Reducing the Cost of Chronic Conditions by chpgroup

Research Paper

Reducing the Cost of Chronic Conditions presented by The CHP Group

Reducing the Cost of Chronic Conditions The burden of disease that attends chronic health problems is a significant cost to society. This cost is borne both in terms of the money spent on healthcare and the social costs of impaired productivity and disability. These costs continue to trend upward due to a growing and aging US population. Great strides have been made in patient care. In the pre-COVID-19 era, modern medicine and effective public health measures had largely eradicated most infectious diseases in the US. Advancing medical technology has made many acute conditions such as severe injury, heart attack, stroke, and cancer survivable for many patients. Despite these advances, the prevalence of chronic diseases have taken their place as the primary driver of healthcare spending. The CDC estimates that over half of the population has one or more chronic health problems1. These chronic health issues are immensely expensive; the CDC estimates that the costs for cancer, heart disease, obesity, diabetes, arthritis, and overuse of alcohol and tobacco is in excess of $1.5 trillion. Ninety percent of the nation’s $3.8 trillion annual healthcare expenditures are for people with chronic and mental health conditions.2

Chronic Conditions: Barriers to Value Cost-effective and high-value management of chronic disease has proven to be elusive. While primary care is considered to be the optimal setting for cost-effective care delivery (compared, for example, to consulting with a specialist), this approach continues to have difficulties in delivering efficient, high-quality, and cost-effective solutions. This may be due to the fact that primary care settings have yet to fully incorporate multidisciplinary teams which may be a more effective way to organize and deliver care for patients with chronic conditions.3

Communication Issues An effective partnership between clinicians and patients, based on open dialogue, is an essential feature in promoting healthy behaviors. Obstacles encountered in the typical primary care practice center on communication issues between the clinician and patient about the patients’ condition and the planned interventions. These communication issues – generally about the scope and nature of the condition and the proposed treatment – can negatively impact the desired patient outcome and Purpose of this Paper their wellness. Bodenheimer observed in his 2007 discusThis research paper examines the areas where integrative healthcare (IH) can sion that physician to patient provide high-value healthcare for the management of patients with chronic communication suffers due to health problems. The scientific and clinical evidence that supports many IH several issues:4 interventions demonstrates that these treatments have a place in both clinical • Clinical practice guidelines often fail to achieve the intended target of educating patients.

protocols and practice guidelines. The growing scientific evidence base for IH is further supplemented by data on the clinical and financial outcomes associated with successful integration of IH in health systems. Health plans and other payers that effectively integrate IH in the management of chronic disease can reduce the cost of care, improve health outcomes, and enhance patients’ experience of care.

• Patients receive evidence-based recommended care only about 55% of the time. • While patients are more likely to succeed in chronic care management in a participatory relationship, clinicians often struggle to engage effectively and to assist patients in incorporating evidence-based advice into their lives. • Up to 50% of patients leave a typical office encounter not understanding what their clinician told them about their conditions and treatments. As a result of these communication issues, patients frequently fail to understand the importance of adherence to medication and lifestyle recommendations.

Non-Compliance Along with communication, non-compliance is a significant issue. Up to 50% of adults do not follow through with long-term medication regimens.5 Lifestyle interventions show similarly disappointing compliance as evidenced by rising rates of obesity; increasing consumption of calorie-dense, high fat and added sugar foods; and insufficient physical activity.6,7 The reasons patients fail to follow-up adequately with long-term care plans are varied and include the costs of medication, undesirable side effects of medication, and a failure to establish a collaborative therapeutic alliance between patients and their doctors.

Care Systems •

Integrative Healthcare (IH)

•

Complementary & Alternative Medicine (CAM)

•

Conventional Medicine •

Integrative healthcare involves bringing conventional and complementary approaches together in a coordinated fashion Aims to enhance overall health, prevent disease, and to alleviate debilitating symptoms which often affect patients experiencing chronic health conditions Characterized by a high level of communication between patient and provider as well as amongst their conventional and integrative healthcare team The popular term for health and wellness therapies that typically have not been part of conventional medicine “Complementary” refers to a group of diagnostic and therapeutic disciplines that are used together with conventional medicine in the management of disease and injury “Alternative” generally indicates treatments that are used in place of conventional medicine A system in which medical doctors and other healthcare professionals – such as nurses, pharmacists, and therapists – treat symptoms and diseases using interventions including pharmaceuticals, radiation, and surgery May also be referred to as allopathic medicine or Western medicine

Ineffectiveness Evidence from the scientific and clinical literature about many conventional medical interventions for chronic diseases show that they are less than fully effective even when adherence to the treatment plan is good. Effectiveness is further compromised by complex delivery systems that are not organized to meet the demands of providing quality, evidence-based, multidisciplinary, and patient-centered care for chronic diseases. The 2001 Institute of Medicine publication, “Crossing the Quality Chasm: A New Health System for the Twenty-first Century” describes current system designs that are organized to respond rapidly and efficiently to an acute illness or injury. The focus tends to be on the immediate clinical problem, its rapid diagnosis, and the initiation of a treatment plan. In this setting, the patient’s role is largely passive and there is little urgency to develop patient self-management skills that are so critical to achieving the best outcomes for patients with chronic conditions. While many practices and health systems continue on this path in the treatment of chronic disease, research argues that the integration of care that incorporates conventional and integrative healthcare may help deliver better outcomes for patients.8 Further evidence of communication barriers include those related to care coordination as highlighted by Elder who suggested, “…Better integration of chiropractors into conventional care spine management algorithms could represent a sensible approach to enhancing patient-centered care for patients with chronic musculoskeletal pain.”9

The Three Dimensions of Effective integration

Administrative integration Clinical integration occurs when patient care is coordinated across all clinicians, sites, and functions to maximize value. This is the most critical component in creating a setting that enhances patient care using the highest-value services.

Clinical integration

Financial integration

Financial integration occurs when all elements of the system work to incentivize the use of the highest value services. 4

Administrative integration occurs when credentialing and contracting are focused on bringing high-quality providers together who are working toward a common goal of patient-centered care. Administrative integration encompasses a common policy infrastructure including industry standard credentialing, quality improvement and utilization management policies.

Integration Creates Value In their 2001 research paper, Wagner, et al., outline six elements of improved health system design that can lead to improving the care and outcomes for chronic diseases.10 Two of the most significant features of efficient and effective chronic disease care are better self-management interventions and better coordination across all caregivers. Better collaboration with patients empowers them to embrace their crucial role in long-term management which has shown to be necessary for a successful outcome. Health system designs that facilitate communication among all caregivers enable patients and their caregivers to make healthcare decisions that are evidence-based, clinically-effective, and more focused on patient satisfaction.

Integrating IH Healthcare approaches which have been developed and practiced outside of conventional medicine have a long and rich history. While the terms used to categorize integrative healthcare interventions are many – alternative medicine, complementary medicine, and CAM – each has sought to differentiate these healthcare approaches from conventional medical care. As these approaches have become more popular and broadly supported by evidence, the goal has been to build therapeutic alignment with other disciplines.

An effective partnership between clinicians and patients is an essential feature in promoting healthy behaviors

In 1991 the Office of Alternative Medicine was established within the National Institutes of Health. In 1998 the Office became The National Center for Complementary and Alternative Medicine (NCCAM). Surveys and other research revealed that true “alternative” medicine use is uncommon: most people who use non-mainstream approaches use them along with conventional treatments. Reflecting this reality, NCCAM was renamed National Center for Complementary and Integrative Health (NCCIH) in December 2014. The current research focus of NCCIH is directed toward seeing how these healthcare approaches can work in combination with conventional care to provide safe, evidence-based treatment; to improve patient outcomes; and to create better value for the nation’s limited healthcare dollars. Effective integration of all forms of healthcare depends on coordinating the best of conventional and integrative healthcare together. There is a growing body of evidence that demonstrates the clinical and cost-effectiveness of this coordinated approach.

High-Value Healthcare and the Role of IH High-value healthcare is evidence-based and delivered via the clinical and scientific evidence regarding the spectrum of treatment interventions. The drive toward high-value care incentivizes patients, providers, and payers to employ treatments that have evidence of safety, efficacy, and effectiveness. 5

Evidence-based healthcare is a combination of clinical expertise linked with the best medical evidence and it incorporates the patient’s values in decision-making about healthcare interventions. A recent paper in the Journal of the National Cancer Institute notes that patients often make treatment decisions “based on factors other than medical value.” When patients are presented with objective information and scientific evidence about the costs and expected outcomes of treatment options, they can be empowered to make decisions that are concordant with the goals of high-value healthcare. Evidence-based providers assist in shared decision-making by helping patients understand the evidence supporting the desired outcome and the resources needed to achieve that outcome in both time and dollars.11 The evidence in support of many IH interventions is rapidly accumulating. A systematic review of the literature regarding conventional medical and IH therapeutic approaches have demonstrated that the levels of evidence for both are similar. The Cochrane Collaboration has produced reviews of IH treatments that give evidence that these interventions are safe, clinically-effective, and able to deliver patient outcomes at costs that are both reasonable and often much less than conventional medicine alternatives. Increased recognition that lifestyle should be included in the primary prescription for the leading causes of disease and chronic conditions12 is supported by the practice of integrative healthcare providers who have long included lifestyle medicine/therapies as components to treatment of the whole person; understanding the value of diet, exercise and other health promoting behaviors. One recent study demonstrated the strong association between patients who used IH and the inclusion of lifestyle therapies in their treatment.13 The overlap of integrative medicine with preventive medicine can contribute to health promotion (and reduction in chronic conditions) through lifestyle counseling, dietary guidance, stress reduction techniques, sleep quality improvement interventions, and use of natural products for health promotion.14

Effective IH Integration in the Pacific Northwest The CHP Group (CHP) partners with health plans to provide members access to chiropractic, acupuncture, naturopathic medicine, and massage therapy services. Having IH services integrated into the health plan at the administrative, financial, and clincal level benefits both the health plan and the member. Administrative

As part of this partnership CHP provides administrative services which assist in achieving a measure of incentives for primary care providers to refer and for patients to access IH services.

Clinical

Clinical integration is facilitated by evidence-based clinical and referral protocols for a number of chronic conditions commonly seen by IH clinicians. PCP referrals include chronic musculoskeletal conditions, chronic pain syndromes, nausea, women’s health issues, Irritable Bowel Syndrome, headaches, eczema/atopic dermatitis, and osteoarthritis. Many of these services are integrated into multiple patient populations in the health plan including group health, Medicare and Medicaid, and workers’ compensation. Patient satisfaction survey scores with these providers average 98% over the last 10 years.

Financial

With access to IH providers and care, members can seek advice and treatments that are more cost-effective than expensive imaging or long-term opioid use.

Models of IH Integration Successful models of integrating IH interventions have increasingly occurred in many settings including hospitals, medical centers, and health systems. The Health Forum, a subsidiary of the American Hospital Association, has through surveys of US hospitals, shown a growing trend in access and utilization of IH services in US hospitals. Beginning in 1998, 6% of respondent hospitals said that they offered IH services. By 2001 the number had more than doubled to 15%.15 The 2005 survey revealed just over 26% of respondent hospitals offered at least some IH services. This grew to 37% in 2007 and to 42% in the 2010 survey.16 Memorial Sloan Kettering Cancer Center17, MD Anderson Cancer Center18, and Johns Hopkins Integrative and Digestive Center19 are just a few of the leading medical centers to incorporate IH therapies. In particular, investigators at the Mayo Clinic in Rochester, MN, conducted their own small study of massage for post-cardiovascular surgery patients; the Mayo Clinic now routinely offers massage therapy to colorectal and thoracic post-surgical patients.20 The Veterans Health Administration (VHA), the largest integrated health system in the US, has been expanding access to chiropractic care since 2004. A recent exploration of this trend revealed that the number of patients seen by chiropractors grew from 4,052 in 2005 to 37,349 in Percentage of US Hospitals Offering 2015. The annual number of 42% Integrative Healthcare Options, chiropractic encounters/visits 1998 – 2010 increased from 20,072 in 2005 37% to 159,366 in 2015, a 693% increase.21

Effective IH Integration for Better Outcomes As providers become more focused on delivering highvalue healthcare they will be driven by the evidence about the safety, effectiveness, and lower cost of clinical interventions. In its 2005 report, the Institute of Medicine stated that the successful integration of IH must have the goal of “…

26%

15%

6% 1998

2001

2005

2007

2010

the provision of comprehensive care that is safe and effective, care that is collaborative and interdisciplinary, and care that respects and joins effective interventions from all sources.” The report concluded with the recommendation: “… that the National Institutes of Health and other public and private agencies sponsor research to compare • the outcomes and costs of combinations of CAM and conventional medical treatments and models that deliver such care • models of care delivery involving CAM practitioners alone, both CAM and conventional medical practitioners, and conventional medical practitioners alone. Outcome measures should include reproducibility, safety, cost-effectiveness, and research capacity.”15 In 2010, the IOM’s Roundtable on Value & Science-Driven Healthcare offered a vision “…for a healthcare system that draws on the best evidence to provide the care most appropriate to each patient, emphasizes prevention and health promotion, delivers the most value, adds to learning throughout the delivery of care, and leads to improvements in the nation’s health.” The lofty goal for 2020 is that “90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information, and will reflect the best available evidence.”22

Evidence for Cost-Effectiveness of IH Interventions From a health plan or purchasers’ perspective, the idea of adding a benefit for IH as a cost savings rather than an increased cost, may seem counterintuitive. However, the number of studies that explore the cost effectiveness of IH interventions is growing and demonstrate that the addition of integrative healthcare benefits can instead LOWER the cost of care by moving members from high-cost, low-value care to lower-cost, high-value care: • A recent review by Hermans, et al, found “emerging evidence of cost-effectiveness and possible cost savings in at least a few clinical populations.” Cost savings accrue from several potential sources including a focus on prevention of chronic conditions, better patient engagement and compliance with treatment, inclusion of lower cost IH therapies in combination with conventional treatments, reduction of complications from shortened hospital stays, and improved patient follow-through with self-management strategies.23 • A 2014 study of high cardiovascular risk postal workers found that naturopathic medicine interventions significantly reduced the risk of a cardiovascular disease event (heart attack, stroke, death), resulted in net savings of $1,187 (2008 Canadian) to employers, and saved $1,138 in societal cost primarily due to reduced presenteeism.24 • IH users have been shown to significantly lower their use of prescription drugs.25,26 In an analysis of over 70,000 member months in a health plan, IH users had 60% fewer hospital admissions, 62% fewer outpatient surgeries, and 85% lower prescription drug costs when compared to non-users.27

• An internal study by Blue Shield of King County (WA) found naturopathic physician-managed chronic disease lowered costs of chronic and stress related illness by up to 40% as well as lower costs for specialist utilization.28 • A study from the University of Washington that evaluated the effects of IH use among patients with a number of chronic conditions (back pain, fibromyalgia, menopause) found that IH users “had lower average expenditures than nonusers. (Unadjusted: $3,797 versus $4,153, p = 0.0001; beta from linear regression -$367 for CAM users.) CAM [i.e. IH] users had higher outpatient expenditures that which [sic] were offset by lower inpatient and imaging expenditures. The largest difference was seen in the patients with the heaviest disease burdens among whom CAM users averaged $1,420 less than nonusers, p < 0.0001, which more than offset slightly higher average expenditures of $158 among CAM users with lower disease burdens.”29 • A comparative analysis of health plan members with and without insurance coverage for chiropractic care (700,000 with coverage, one million without) showed lower total overall annual cost by about $200 per member per year (PMPY). Further analysis of members with back pain showed these members had fewer imaging studies (X-ray, MRI), hospitalizations, and back surgeries.30 In making the case for “The Low Risk, High Return of Integrative Health Services,” in the November 2015 HFM Magazine, Ruthann Russo and colleagues observed that IH interventions are, “Patient centered approaches that address the full range of physical, emotional, mental, social, spiritual, and environmental factors affecting individuals…These modalities embody concepts related to patient-centered care and shared medical decision making…”31

Safety and Effectiveness of IH Treatments for Chronic Pain Conditions The medical and social costs of chronic pain are staggering. The Institute of Medicine (IOM) estimates the healthcare cost of chronic pain at $261 to $300 billion in the US. Even greater than the cost of medical care, the costs due to lost productivity adds another estimated at $297-336 billion to the economic

IH Users vs Non-User Comparison of IH users vs non-IH users over 70,000 member months by health plan

60% fewer

62% fewer

85% lower

hospital admissions

out-patient surgeries

prescription drug costs 9

burden of chronic pain.32 The clinical and scientific literature on IH for chronic pain conditions is rapidly expanding. The Cochrane Collaboration and others have developed systematic reviews of this literature for many commonly available treatments. Comparisons of the outcomes between IH and conventional medical treatment in these reviews often show equivalent levels of strength of evidence as well as the evidence of effectiveness. While not intended to be a comprehensive summary, the following information presents examples of chronic pain conditions for which IH can meet the goal of high-value healthcare.

Condition: Chronic Low Back Pain Low back pain is the most common chronic pain problem that causes patients to seek out IH providers. One study of primary care patients with chronic low back pain found chiropractic and massage therapy treatments to be the most widely used followed by acupuncture, meditation and Tai Chi.33 Summaries of the evidence supports that chiropractic, acupuncture and massage therapy are of the same quality as those which supports conventional medicine. A 2017 clinical practice guideline from the American College of Physicians makes recommendations for non-invasive treatment of low back pain. After a thorough review of randomized controlled trials, and systematic reviews the ACP concluded that clinicians and patients should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation for low back pain.34

Common Treatment Interventions Intervention

Intervention Evidence

Chiropractic & Acupuncture

A 2017 clinical practice guideline from the American College of Physicians makes recommendations for non-invasive treatment of low back pain. After a thorough review of randomized controlled trials, and systematic reviews the ACP concluded that clinicians and patients should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation for low back pain.35

Pain A 2017 systematic review and meta-analysis of 35 randomized placebo-controlled trials Relievers (NSAIDs, by Machado and colleagues concluded that while NSAIDs are effective, “…the magnianalgesics, opioids) tude of the difference between the intervention [NSAIDs] and placebo groups is not clinically important. At present, there are no simple analgesics that provide clinically important effects for spinal pain over placebo.”36 An editorial in the Journal of the American Medical Association highlighted the lack of evidence of effectiveness of opioids as a conventional medical treatment for low back pain. “Despite widely held views about the efficacy of opioids for pain control, systematic reviews have not found sufficient evidence that long-term opioid use controls non-cancer [e.g. spine] pain more effectively than other treatments.”37 Surgery

One of the largest trials of surgery vs. non-surgery treatment for lumbar disc problems concluded that both treatments provided relief over a two-year period. Surgery proved helpful more quickly, but in the out-years, there was little difference between the surgical and non-surgical groups, except for higher cost in the surgical group.38

Condition | Neck Pain Neck pain is the third most common chronic pain condition in the US and the fourth leading cause of disability worldwide.39 In the United States according to the National Health Interview Survey in 2015, 38.9 million adults reported neck pain and 61% of those individuals reported their neck pain as chronic.40 According the Dieleman et al, low back and neck pain constitutes the third highest cost health condition, at $87.6 billion. The increase in spending for these two conditions between 1996 and 2013 was larger than almost all other areas of healthcare.41,42 There is increasing evidence in the scientific literature supporting patients seeking chiropractic care when dealing with chronic spinal conditions. There is need for a safe, low-cost alternative for chronic pain management which includes chiropractic care. As a non-invasive treatment, chiropractic – including manipulation, mobilization, and exercise – and other multi-modal approaches such as manual therapy, massage, and patient education are evidence-based recommendations for chronic neck pain.43

Common Treatment Interventions Intervention

Intervention Information

Chiropractic

There is moderate quality evidence that spinal manipulation/mobilization combined with exercise is effective for chronic non-specific neck pain.44 Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate, intermediate, and long-term follow up.

Massage Therapy

While few clinical trials are focused specifically on neck pain and massage therapy, there is some evidence that indicates that massage therapy can be an effective treatment for neck pain.45

Acupuncture

In a 2017 paper, Yin Fan, et al. state that “acupuncture stands out as the most evidence-based, immediately available choice” to fulfill the call for non-pharmacological treatment options for pain.46

Exercise

Often included as a core component of IH treatment for most conditions, the use of specific strengthening exercise for chronic neck pain is supported by moderate quality evidence.47 Using specific strengthening exercises as a part of routine practice for chronic neck pain especially focused on the neck, shoulder and shoulder blade region may be beneficial in reducing pain and improving function.

Radiofrequency denervation (RF)

There is limited evidence that RF offers short term relief for chronic neck pain of zygapophyseal joint origin.45

Condition | Chronic Headache/Migraine The 2012 National Health Interview Survey (NHIS) found about 14% of adults report “migraine or severe headache” in the previous three-month period. Headache is a leading cause of hospital and emergency department utilization.48 A survey of American Headache Society physicians and behavioral specialists compared short- and longterm cost associated with pharmacologic interventions and cognitive behavioral therapy (CBT) interventions. While inexpensive prophylactic medication was less expensive than CBT in the first six months, a behavioral approach was less costly after that.49 This is particularly important in the management of this sometimes life-long affliction.

Common Treatment Interventions Intervention

Intervention Information

Acupuncture

A randomized controlled clinical trial involving over 3,000 patients found that patients with headaches treated with acupuncture in addition to routine care showed clinically relevant and persistent benefits with significant improvements in symptoms and quality of life.50 Additionally, while acupuncture added cost to overall treatment, the quality of life outcomes (quality-adjusted life year or QALY) showed that acupuncture met threshold values for cost-effectiveness for treatment of headaches.51 The available evidence suggest that acupuncture is effective for treating frequent episodic or chronic tension-type headaches.

Chiropractic

There is a growing body of evidence that supports the use of spinal manipulation therapy (chiropractic care) for headaches including cervicogenic headaches. In a 2018 paper, Hass, et al. said, “... there has been no other intervention shown to be superior.”52

Paracetamol (acetaminophen) e.g. Tylenol

The outcome of being pain free at two hours was reported by 24 in 100 people taking paracetamol 1000 mg, and in 19 out of 100 people taking placebo, meaning that only 5 in 100 people benefited because of paracetamol 1000 mg.53

Naproxen, e.g. Aleve

Naproxen is statistically superior to placebo in the treatment of acute migraine, but the NNT (number needed to treat) of 11 for pain-free response at two hours suggests that it is not a clinically useful treatment.54

Conclusion Integrative healthcare is designed to treat the patient, not the disease or condition and it includes a wide variety of evidence-based healthcare practices which work together to provide the most effective care. Chronic conditions represent the most significant burden to society in terms of healthcare costs, impaired productivity, and disability. As the population grows and ages, the impact becomes more stark. Integrative healthcare has the potential to add a high-value healthcare solution for patients with chronic health conditions. As the growing base of scientific evidence is incorporated into clinical protocols and practice guidelines, IH services will provide more value where there is greater integration into conventional healthcare systems. Including collaborative, patient-centered, evidence-based IH services for the management of chronic conditions delivers value in both lower cost and better outcomes.

Integration of IH into conventional healthcare systems facilitates communication between caregivers and enables patients to make the best healthcare decisions for their needs

At CHP we view integrative healthcare as a collaborative approach to care delivery that is characterized by a high level of communication between patients and their providers. We also see the value of better communication between the conventional and integrative healthcare providers. This philosophy of communication and collaboration puts the patient at the center of the healthcare delivery system, offering them the opportunity to actively participate in their care management. Patients get the highest quality and most beneficial integrative healthcare from licensed providers who have a proven record of delivering effective, safe, and evidence-based care. We recognize the vital nature of the patient-provider relationship and provide the framework for supporting providers to work collaboratively with other providers – conventional or IH – that their patients may be seeing.

When IH providers and their clinical interventions are integrated into the broader healthcare system the benefits are many. As evidence increases for IH treatments for chronic conditions, the therapeutic incentive exists for patients to use – and conventional medical providers to recommend – IH services. As the use of these cost-effective services increases, the benefits experienced by the patient, the provider, the payer, and society as a whole continues to expand. We believe a more comprehensive collaboration between integrative healthcare and conventional healthcare systems creates real value for all stakeholders in the management of chronic conditions.

Endnotes 1

Centers for Disease Control and Prevention. https://www.cdc.gov/chronicdisease/. Accessed March 9, 2019.

Centers for Disease Control and Prevention. www.cdc.gov/chronicdisease/about/costs/index.htm. Accessed February 22, 2021.

Bodenheimer T, Chen E, Bennett HD. Confronting the growing burden of chronic disease: can the U.S. health care workforce do the job? Health Affairs 28, no. 1 (2009): 64-74; 10.1377/hlthaff.28.1.64. Accessed June 11, 2018;

Bodenheimer T. A 63-year-old man with multiple cardiovascular risk factors and poor adherence to treatment plans. JAMA. 2007;298(17):2048-2055. doi:10.1001/jama.298.16.jrr70000.

Marcum ZA, Sevick M, Handler SM. Medication Nonadherence: A Diagnosable and Treatable Medical Condition. JAMA. 2013;309(20):2105-2106. doi:10.1001/jama.2013.4638.

World Health Organization. Diet, nutrition and the prevention of chronic diseases. Report of the joint WHO/FAO expert consultation. WHO Technical Report Series, No. 916 (TRS 916).

World Health Organization. Global Strategy on Diet, Physical Activity and Health. http://www.who.int/dietphysicalactivity/pa/en/ . Accessed June 11, 2018.

Singer J, Adams J. Integrating complementary and alternative medicine into mainstream healthcare services: the perspectives of health services managers. BMC Complement Altern Med. 2014; 14: 167 10.1186/1472-6882-14-167. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4048459/.

Elder D, DeBar L, Ritenbaugh C. Comparative effectiveness of usual care with or without chiropractic care in patients with recurrent musculoskeletal back and neck pain. J Gen Intern Med. 2018; published online: 15 June 2018: http://dx.doi.org/10.1007/s11606-018-4539-yAccessed June 11, 2018.

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