Our vision was simple: provide primary care doctors and other practitioners with inspiring and scientifically-sound information about natural, non-pharma options for preventing and treating the common chronic conditions they see in their patients every day. At the same time, we wanted to give the burgeoning dietary supplement and nutraceutical industry a vehicle for bringing its messages to a wider practitioner audience.
The brainstorm for what ultimately became HPC hit me in 1985, when I was a novice medical journalist, fresh out of college, and covering conventional medical specialties for pharma-sponsored publications. My job involved reporting on continuing medical education (CME) conferences, and I quickly noticed that almost all the presentations at these meetings were about drugs, high-tech diagnostics, and invasive surgeries. There was nothing on nutrition or prevention beyond lip service about “diet and lifestyle change,” and rote messages on sunscreens, mammograms, digital rectal exams, and the like.
Yet we already knew, back then, that lifestyle and environmental factors were the major drivers of chronic conditions like obesity, diabetes, cardiovascular disease, inflammatory disorders, and even things like cancer. I was aware of research emerging on the margins of mainstream medicine on subjects like acupuncture, hypnosis, herbal medicine, antioxidant vitamins, Ayurveda, and other “alternative” approaches.
I was equally aware that millions of Americans—myself and most of my friends included—were engaging with “alternative” medicine in some way.
“Why is nobody paying attention to this? Someone ought to create a magazine about holistic medicine for doctors,” I thought to myself, never for a moment thinking that this “someone” was me. I was a writer. What did I know about starting a business?
Putting ‘Health’ in Healthcare
Enter Meg, HPC’s instigator-in-chief, without whom none of this would have happened. She took on the role of publisher, and provided the practical executive skills and financial support needed to translate the HPC vision into reality. Together we undertook a mission with a long arc: to help practitioners put the “health” back in healthcare.
Our fire was fanned by a series of landmark articles in mainstream medical journals, beginning in 1992, with a letter to the editor of the New England Journal of Medicine titled “Physicians and Healers—Unwitting Partners in Healthcare.” In it, the authors, Raymond H. Murray and Arthur J. Rubel, urged their medical colleagues to wake up to the fact that millions of Americans used supplements and sought “alternative medicine.”
Murray and Rubel wrote, “Most physicians are unaware of its popularity, much less that many of their own patients are also being cared for by practitioners of alternative medicine.” They also noted that, “there are good reasons to believe that alternative medicine has many adherents among all social classes.” That’s doctor code for, “Even your friends might be doing it too.”
This was followed, through the mid-90s, by a series of papers by David Eisenberg and colleagues at Harvard Medical School, documenting the widespread popularity of CAM (complementary and alternative medicine) as it was then called.
In 1993, Eisenberg’s group estimated that one-third of U.S. adults were using some form of “alternative” medicine and usually not telling their physicians. In their 1998 follow-up, the prevalence of CAM use had increased to 42%, with total visits to CAM practitioners reaching 629 million and exceeded total visits to primary care physicians. The big brow-raiser was the fact that Americans were spending on the order of $21 billion annually on alternative medicine.
Eisenberg’s group not only chronicled the movement, they helped instigate it. His department at Harvard was arguably the first at a mainstream medical school to host CME conferences on medical alternatives. They continue to innovate, most recently with their Healthy Kitchens, Healthy Lives courses that teach healthy cooking skills to medical professionals.
While Harvard was sounding the wake-up call, Columbia Presbyterian Medical Center hired a brilliant young cardiovascular surgeon who also happened to have an interest in things like Reiki and energy healing, meditation, and nutrition. His scalpel skills were so good that Columbia gave him latitude to pursue research on how these modalities might improve heart disease outcomes. His name was Mehmet Oz.
Meanwhile, the Dietary Supplement Health and Education Act (DSHEA) had become law, passing Congress on a tidal wave of popular support. Though DSHEA is full of awkward compromises, it did lay the regulatory groundwork for vitamin and herb businesses to find their footing as an industry. Big drug companies and consumer packaged goods companies had their eyes on the space, launching a number of high-profile brands, many of which flopped.
The practitioner channel for supplements was still nascent, but brands that sold primarily through practitioners were growing thanks to the emerging naturopathic profession, and a new surge of interest in CAM within the mainstream. The times certainly seemed to be a-changin’; maybe our idea for a publication about holistic medicine for doctors wasn’t so crazy.
Moving the Needle
So, in October 2000, after a year of planning, Meg and I launched HPC. Our hope was that by providing clinicians with high-quality educational content, we would give further lift to the holistic/functional medicine movement and help shift healthcare toward a more sane, humane, and sustainable paradigm. Have we succeeded? Yes ... and No.
There’s no question that things have changed. We’ve seen the emergence of holistic and functional medicine clinics at many of the nation’s top medical centers, among them Mayo Clinic, Cleveland Clinic, and Duke University. Cleveland Clinic’s Center for Functional Medicine, under the guidance of Drs. Patrick Hanaway and Mark Hyman, has set new standards for functional medicine research, comparing outcomes of patients seen at their center against patients with similar conditions treated at other sites within the Cleveland Clinic universe.
Not to be outdone, Mayo clinic has launched a new center for integrative medicine at its Jacksonville, FL, campus. To head the project, Mayo recruited Adam Perlman, who formerly led Duke Integrative Medicine. Late in 2017, Henry and Susan Samueli endowed University of California-Irvine with $200 million for an entirely new College of Health Sciences committed to holistic research, physician training, and clinical care.
With the exception of the University of Connecticut’s program—which announced its imminent closure, all of the other naturopathic medical schools are thriving and growing. Bastyr University, which celebrated its 40th year, recently opened its second campus in San Diego. Southwest College of Naturopathic Medicine, just a seedling when HPC launched 20 years ago, has evolved to become a mighty tree of naturopathic knowledge and research.
If mainstream medicine as a whole has yet to fully embrace holistic concepts and practices, it certainly has become more tolerant of them. I am old enough to remember when mainstream doctors categorically dismissed gluten sensitivity, intestinal permeability, and food allergies as “psychosomatic” or imaginary. Today, institutions like Mayo issue guidelines for improving their diagnosis. It’s one of many concepts once distained as “quackery” that are now acknowledged by mainstream practitioners.
Many more doctors today are willing to recognize the limitations and dangers of pharmaceuticals, and are incorporating holistic modalities into their practices. One shining example of this is Dale Bredesen, MD, a conventionally trained neurologist and researcher specializing in Alzheimer’s disease and cognitive decline. After decades of pharma-focused research that led to one dead end after another, Bredesen became convinced that mainstream medicine’s model of Alzheimer’s was fundamentally wrong. This was not a simple disease caused by one or two age-related biochemical flaws, and fixable by a “silver bullet” drug. It was the net result of complex nutritional, environmental, and behavioral factors. Today, Bredesen’s protocols—which depend on thorough lifestyle assessment, dietary change, and personalized supplementation protocols, are not only preventing Alzheimer’s, they are reversing it.
Similarly, Dr. Terry Wahls—an internist who biohacked her way into reversing her own multiple sclerosis through lifestyle change and supplementation—is now teaching thousands of other MS patients how to do the same. After years of nay-saying from the medical mainstream, Wahls is finally gaining some respect. The University of Iowa, where Wahls is based, is supporting her research, and the MS Society—which once warned her against “spreading false hope,” recently made a $1.5 million grant to her research institute.
The Department of Defense, particularly the Veterans Administration, has been surprisingly receptive to holistic medicine. Under the guidance of Dr. Tracy Gaudet—an early graduate of Dr. Andrew Weil’s University of Arizona integrative medicine fellowship—the VA has instituted system-wide programs for holistic non-pharma approaches to pain and post-traumatic stress disorder (PTSD) management.
The supplement industry has also evolved across the board, from basic and clinical science to analytical testing and quality assurance. While there is still a cadre of mainstream physicians who dismiss all supplements, the majority of doctors are taking, recommending, and in some cases dispensing supplements.
In our 2019 Practitioner Survey, HPC found that 95% of our respondents—one third of whom are conventionally trained MDs—are taking some sort of supplements for their own health, and two thirds dispense products in their office. That’s more than double the number we saw in our first survey back in 2010. Among those that do not dispense, 91% recommend supplements to their patients.
I won’t go so far as to say these stats are representative of all mainstream MDs. But when we break out the MDs from our general cohort, we still find high levels of personal supplement use, clinical recommendation of supplements to patients, and willingness to dispense these products. There’s no question that physician confidence in supplements has grown over 20 years. Holistic Primary Care has chronicled and celebrated these and many other promising developments over the last two decades.
Stuck at the Tipping Point
Yet for all of the progress, much remains frustratingly the same as it was 20 years ago. We know millions of people want this kind of medicine, and thousands of practitioners wish to offer it. Yet, the field seems to be perpetually stuck at the tipping point.
We’re thrilled to witness the growth of Bastyr and SCNM, and the emergence of centers at Mayo, Cleveland Clinic, and so many other mainstream centers; we also lament the loss of many of the field’s pioneering institutions. The University of Arizona’s Center for Integrative Medicine and Beth Israel’s Continuum Center are but two examples of innovative and popular clinics that were shuttered owing to lack of support from parent hospital systems, failure to develop sustainable fiscal models, or both. University of Bridgeport’s naturopathic school—the east coast’s only naturopathic training program—is the latest casualty.
While there’s clearly greater mainstream acceptance, many mainstream institutions still treat holistic and functional medicine like a novelty or a marketing ploy. The economic framework of insurance-based medicine still incentivizes prescriptions and procedures. Despite all the marketing tropes about “patient centered care,” and “wellness,” insurers still provide little incentive for the practice of truly preventive, holistic care.
As a result, many holistic and functional medicine practitioners struggle to keep their practices afloat financially, and too many people cannot access the care they want and need. We frequently get calls from people who assume that Holistic Primary Care is a clinic. They’re seeking holistic physicians for themselves or family members in the hope of getting help for a litany of often serious medical conditions.
After I explain that HPC is a publication, not a clinic, I refer them to websites for the Institute for Functional Medicine, the American Academy of Naturopathic Physicians, or the Academy for Integrative Health and Medicine, where they can use the doctor-search function to find practitioners in their areas. The inevitable next question is, “Do you know if these doctors take insurance?”
The default answer is, “Probably not.” While some would-be holistic/functional practitioners do take insurance for some services, the majority are strictly direct-pay. In our last survey, 43% of respondents were in cash-pay models, while only 28% are fully insurance-based, and 26% are in mixed models.
Membership or “concierge” models seem to work well to support holistic practice, but membership costs put them out of reach for the vast majority of Americans. For the most part, concierge practices are limited to affluent communities. Networks like MDVIP and others generally enroll older doctors with well-established patient bases. Though there are some exceptions like Parsley Health, the concierge practice sector has not provided many new opportunities for younger practitioners, and overall growth of this sector has been stagnant.
The reality is, out-of-pocket practitioner fees—which can be up to $2,000 for initial visits—plus hundreds if not thousands in uncovered testing costs, and monthly supplement bills that can easily top $200-300, put holistic, functional, and naturopathic medicine way out of reach for a majority of the people. And even for those with money, the costs can be a disincentive. These costs are usually additive to, not substitutes for, the premiums, co-pays, and “surprise” bills for conventional care.
While millions of Americans struggle to pay for their healthcare, the CEOs of major insurance plans continue to pay themselves tens of millions each year. As we reported in a 2017 article titled “Doctors vs Insurance CEOs: A Tale of Two Surveys,” the top insurance executives are paid nearly 40 times what the best-paid physicians (orthopedic surgeons and interventional cardiologists) make. Primary care doctors are on the low end of the physician pay scale; nurses, naturopaths, and nutritionists earn far less.
Meanwhile, elected officials continue to play political football with the issue of whether or not health insurance is a right, a privilege, or a burden, while largely ignoring the factors that stoke illness and the interventions that would improve health status.
The lack of insurance coverage for holistic and functional medicine—and the public’s dependence on insurance whether it be public (Medicare and Medicaid) or private—has created a financial bottleneck impeding wider growth of the field. Yet there’s reason to be wary of the third-party payers. They’ve made a mess out of mainstream medicine. There’s no reason to believe they will be any kinder to alternative modes of care.
Despite these major macroeconomic challenges, practitioner-focused supplement companies have collectively built a substantial and rapidly growing sub-industry. With growth rates averaging between 7-9% per year, the practitioner channel has outpaced the growth of the supplements industry as a whole, according to Nutrition Business Journal.
Will that growth continue? There’s certainly plenty of opportunity, as more mainstream institutions that previously dismissed nutrition and supplementation recognize the limitations of pharma-based medicine. But the practitioner channel also faces major challenges. Among them are:
The Aging Practitioner Population: The channel was built largely on solo or small group private practitioners, who began their careers 30 or 40 years ago. They’re now aging out, selling their practices to larger systems, or simply closing their doors and retiring. From what we hear from executives at professional-only brands, those “legacy” practices—which can generate upwards of half a million or more in supplement sales annually—are not easily replaced.
Many younger practitioners have an interest in holistic and functional medicine, but they’re practicing in a very different socioeconomic environment than their predecessors. Private practice is the exception, while employment in large managed care networks is the rule for young physicians. The same holds true for nurses.
Naturopaths, nutritionists, and other non-MDs are largely excluded from mainstream systems, so many are in private practice. But they often struggle to find and develop loyal, committed patient bases on which to build thriving long-term practices.
The chiropractic niche, a mainstay for some supplement brands, is also experiencing an age-out, as older DCs feel the impact of decades of physically demanding work and seek retirement. While the profession has had success getting insurance reimbursement for certain services, this is increasingly under cost-cutting scrutiny.
Across the board, practitioner-patient relationships have become more transient and transitional. Many people in the 20-40 age bracket have never had a steady physician—or if they did, it was with a pediatrician and it ended when they turned 18.
In short, the practice model on which the channel was built—well-established private practices with longstanding, loyal patient populations—is no longer the norm. The future growth of practitioner channel companies will depend on their ability to adapt to a more fluid, transient, convenience-oriented healthcare landscape, and to connect and communicate with young practitioners.
The Amazon Effect: As I’ve written several times here in this column, the unauthorized resale of practitioner-only brands on Amazon and other online retail platforms has had a detrimental effect on the practitioner channel. Fundamentally, it erodes the channel’s core value proposition: highest quality products available only through medical professionals, and ideally used under medical guidance.
Unauthorized resale—typically at discount prices—is corrosive in two ways: it cuts the practitioners out of the loop by making the products available directly to patients, and the discount prices make practitioners look like they’re gouging their patients.
Some companies have gone to great expense to try and keep their products off Amazon, or at the very least to force resellers to comply with suggested retail prices. Others have tried to develop systems that link would-be purchasers with practitioners and discount codes to encourage the patient-practitioner relationship.
Whatever the strategy, this has proven to be a costly and intractable issue. It is very hard to argue with the public’s desire for convenience. And there’s nothing convenient about having to go to a doctor’s clinic to buy supplements.
The solution here—and it is one that practitioners and brand leaders will have to figure out together—is how to create added value and then communicate that added value to patients. It can be difficult to overcome the allure of convenience. But it is clear that people will go out of their way and pay more for experiences and products they perceive to be beneficial, enjoyable, or both.
Mainstream Pushback: Broader acceptance of non-pharma natural medicine within the mainstream has provoked pushback, an inevitable consequence of its growth. The latest struggle is happening in the realm of continuing medical education. The Accreditation Council for Continuing Medical Education (ACCME), which sets the national education standards and governs all organizations offering AMA category 1 CME credits, has recently taken a strong stance against accreditation of conferences that teach “unproven or experimental” modalities.
That stance has had direct impact on a number of organizations and institutions in our field that have lost or are in the process of losing CME accreditation for conferences and programs that until recently offered credits. ACCME has no legal authority to stop the conferences, but the absence of CME credits makes these events less appealing to some physicians. Further, it signals a demotion and a re-marginalization of holistic and functional medicine by the mainstream.
Google’s Algorithm Changes: As I described in detail in the December 2019 edition of Nutraceuticals World, Google has made major changes in its search algorithms aimed at limiting public exposure to information about “speculative and/or experimental medical treatments.” Depending on how those terms are defined, that could cover a broad swath of holistic, functional, and naturopathic medicine. But who’s defining these terms? To what end? For whose benefit?
Google claimed the moves are intended to protect the public by filtering out fake news, bogus claims, and fraudulent products and services. While one need not look too far to find egregious examples of misleading medical information online, Google’s broad-stroke approach has squelched many websites and organizations providing credible information about useful though unconventional modalities and products.
The implications of having a for-profit company like Google as the prime arbiter of medical information has vast social implications, and direct impact on our industry. We should not turn a blind eye to this.
We will be exploring these and other issues in depth at our upcoming Practitioner Channel Forum, April 22-24, at the TWA Hotel in New York City. The Forum is right after SupplySide East (we’ll be running shuttles from the Meadowlands to the TWA), and we’ve got a great line-up, including Mayo Clinic’s Adam Perlman, Southwest College’s Paul Mittman, a dynamite legal and regulatory panel, and a deep dive into digital survival strategies in the age of Google. We hope you’ll join us to put some jet fuel into your practitioner-focused business development strategies, and to celebrate HPC’s 20/20 foresight. Learn more at www.TPCForum.com.
Holistic Primary Care
Erik Goldman is co-founder and editor of Holistic Primary Care: News for Health & Healing, a quarterly medical publication reaching about 60,000 physicians and other healthcare professionals nationwide. He is also co-producer of the Practitioner Channel Forum, the nation’s leading conference focused on opportunities and challenges in the practitioner segment of the dietary supplement industry.