8 de septiembre. La Natividad de la Santísima Virgen. "Hoy ha nacido la Virgen María, de la estirpe de David, por quien vino a los creyentes la salvación del mundo y cuya vida gloriosa llenó de luz toda la tierra" Profecía de Miqueas 5,1-4a. Así dice el Señor: «Pero tú, Belén de Efrata, pequeña entre las aldeas de Judá, de ti saldrá el jefe de Israel. Su origen es des
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Members.ziggo.nlPatients whose GP knows complementary medicine tend to havelower costs and live longer Received: 15 November 2010 / Accepted: 27 May 2011 / Published online: 22 June 2011Ó The Author(s) 2011. This article is published with open access at Springerlink.com and longer lives are unlikely to be related to differences in complementary and alternative medicine (CAM) as an area selection (e.g. people with a low taste for medical inter- of research, although both clinical experiences and several ventions might be more likely to choose CAM) and better empirical studies suggest cost-effectiveness of CAM.
practices (e.g. less overtreatment, more focus on preventive and curative health promotion) by GPs with knowledge of compared with conventional medicine.
complementary medicine. More controlled studies (repli- A dataset from a Dutch health insurer was used cation studies, research based on more comprehensive data, containing quarterly information on healthcare costs (care cost-effectiveness studies on CAM for specific diagnostic by general practitioner (GP), hospital care, pharmaceutical care, and paramedic care), dates of birth and death, genderand 6-digit postcode of all approximately 150,000 insurees, for the years 2006–2009. Data from 1913 conventional GPs were compared with data from 79 GPs with additionalCAM training in acupuncture (25), homeopathy (28), and anthroposophic medicine (26).
Results Patients whose GP has additional CAM training have 0–30% lower healthcare costs and mortality rates, depending on age groups and type of CAM. The lower costsresult from fewer hospital stays and fewer prescription drugs.
Complementary and alternative medicine (CAM) has been largely ignored by health economists as an area of research.
controlling for confounders including neighborhood spe- That fact is possibly related to the low esteem of CAM in cific fixed effects at a highly detailed level, the lower costs Defining CAM is difficult, because the field is very broad and constantly changing. According to the NationalCenter for Complementary and Alternative Medicine P. Kooreman (&)Department of Economics, Tilburg University, (NCCAM), CAM is a group of diverse medical and Warandelaan 2, 5037 AB Tilburg, The Netherlands healthcare systems, practices, and products that are not generally considered part of conventional medicine The Cochrane Collaboration definition of complementary E. W. BaarsDepartment of Care, University of Applied Sciences, medicine is that it includes all such practices and ideas that Zernikedreef 11, 2333 CK Leiden, The Netherlands are outside the domain of conventional medicine in severalcountries and defined by its users as preventing or treating illness, or promoting health and well-being. These prac- Department of Healthcare and Nutrition, Louis Bolk Institute,Hoofdstraat 24, 3972 LA Driebergen, The Netherlands tices complement mainstream medicine by satisfying a demand not met by conventional practices and diversifying Anthroposophic medicine, acupuncture, and homeopa- the conceptual framework of medicine .
thy are three main streams of CAM. One of the core fea- Patients around the globe are increasingly embracing tures of CAM is its orientation on preventative and curative CAM as a contributor to health. A recent study by the US health promotion as an additional approach to a more National Institute of Health shows that 4 out of 10 Amer- conventional fighting disease approach. Anthroposophic icans used some form of CAM in 2007. Another study on medicine is an integrative diagnosis and therapy concept, Switzerland reported that almost 11% of the population had developed from 1921 onwards and practiced today in over used one of five CAM streams (anthroposophic medicine, 60 countries. It combines mainstream scientific medicine homeopathy, neural therapy, phytotherapy, and Traditional with Rudolf Steiner’s anthroposophy. Anthroposophic Chinese Medicine) in 2002. The CAM doctors in that study medicine considers a human being as a whole entity— treated patients that tended to be younger, female, and body, mind, soul, and individuality. It aims to stimulate the better educated. These patients also tended to have a self-healing forces of the body, restoring the balance of favorable attitude toward complementary medicine and to bodily functions, and strengthening the immune system, exhibit chronic and more severe forms of disease. The rather than primarily relieve the symptoms of disease.
majority of alternative medicine users appear to have Specific anthroposophic approaches include anthropo- chosen CAM mainly because they wish to undergo a cer- sophic medicinal products, massage therapy, art and music tain procedure; additional reasons include desire for more therapy, and speech and movement therapies [ comprehensive treatment and expectation of fewer side Homeopathy is a form of alternative medicine, first effects In a referendum in Switzerland in 2009, two- proposed by the German physician Samuel Hahnemann in thirds of the voters were in favor of a wider coverage of 1796, that attempts to treat patients with heavily diluted CAM by public health insurance. In January 2011, based substances. These substances that cause certain symptoms on the positive outcome of a national referendum, the in healthy individuals are given as the treatment for Swiss authorities decided that five main streams of CAM patients exhibiting similar symptoms. The appropriate (anthroposophic medicine, homeopathy, neural therapy, homeopathic medicinal product aims to stimulate the phytotherapy, and Traditional Chinese Medicine) will be body’s inherent forces of self-recovery ].
covered by the mandatory health insurance for a period of Acupuncture is one of the main forms of treatment in Traditional Chinese Medicine (TCM). It involves the use of In many cases, the effectiveness of CAM has not been sharp, thin needles that are inserted in the body at very proven in clinical trials However, lack of proof of specific points. This process is believed to adjust and alter effectiveness is obviously not the same as proof of inef- the body’s energy flow into healthier patterns and is used to fectiveness. Clearly, the status of a treatment can change treat a wide variety of illnesses and health conditions [ from CAM into conventional medicine once scientific In their review, Herman et al. ] report that some evidence on effectiveness becomes available. Two exam- studies indicate that CAM therapies may be considered ples of CAM treatments that have become (more) accepted cost-effective compared with usual care for various con- by conventional medicine are St. John’s wort and acu- ditions: acupuncture for migraine, manual therapy for neck puncture for specific indications. St. John’s wort, for more pain, spa therapy for Parkinson’s, self-administered stress than 90 years used in anthroposophic medicine, has management for cancer patients undergoing chemotherapy, become part of the conventional guidelines for the treat- preoperative and postoperative oral nutritional supple- ment of depression, based on scientific evidence from mentation for lower gastrointestinal tract surgery, bio- randomized controlled trials Hopton and McPherson feedback for patients with ‘functional’ disorders (e.g.,  conclude on the basis of a systematic review of pooled irritable bowel syndrome), and guided imagery, relaxation data from meta-analyses that acupuncture is more than a therapy, and potassium-rich diet for cardiac patients. A placebo for commonly occurring chronic pain conditions.
systematic review of randomized clinical trials on the use In addition, in her thesis, van den Berg recently dem- of so-called natural health products shows evidence of onstrated positive effects of acupuncture on obstetric health cost-effectiveness in relation to postoperative surgery but problems (breech presentation). Also, Servan-Schreiber not with respect to the other conditions assessed [ presents a series of recent examples of the transition from Studer and Busato [demonstrated that general practi- CAM to conventional medicine in depression treatment.
tioners who have completed certified additional training in Some of the methods described by Servan-Schreiber have CAM after obtaining their conventional medical degree been practiced for centuries, cannot be patented, and are (GP-CAMs) (n = 257) compared with general practitio- available at low costs. These findings underscore the fact ners who have not (GPs) (n = 174) have equal costs per that methods that are considered CAM today could be patient per year, but significantly lower costs per doctor effective and have a large cost-saving potential.
(29%) per year, although GP-CAMs take more time per patient. A NCCAM study in 2007 demonstrated that CAM analyses. Azivo is a former Ziekenfonds (sick fund) foun- costs were 11.2% of total out-of-pocket expenditures on ded in 1895. It merged with health insurer Menzis in 2008 but keeps operating as ‘‘Azivo’’ in the Hague region. Its GP care varies between European countries in terms of share in the market for basic and supplementary health structure, working methods, and responsibilities. In the insurance in this region is about one quarter.
Netherlands, GPs are the central gatekeepers for reference The dataset contains quarterly information on the to the rest of healthcare, like specialists and paramedics.
healthcare costs of all Azivo insurees for the years 2006 up Dutch general practitioners generally receive a quarterly to 2009. In addition, it contains the date of birth of the fixed fee per patient plus a fee-for-service per consultation insuree, date of death (if applicable), gender, and 6-digit and per drug prescription. There is no difference between postcode of the insuree’s residence. For each insuree- the financial incentives faced by GPs and GP-CAMs. In the quarter combination, information on the costs of four dif- Netherlands, purchasing basic health insurance is manda- ferent types of care is available: care by GP, hospital care, tory for all citizens. In addition, citizens are free to pur- pharmaceutical care, and paramedic care (like physical therapy). The dataset does not contain information on the Since there is a lack of cost-effectiveness data of CAM supplementary insurance status of insures; the cost infor- in the Netherlands, in this paper, we compare the perfor- mation is the sum of expenses covered by both the basic mance of general practitioners who have completed certi- and (if applicable) supplementary health insurance.
fied additional training in CAM after obtaining theirconventional medical degree (GP-CAMs) with general practitioners who have not (GPs). More specifically, weconsider GP-CAMs with additional training in anthropo- The dataset also contains the names and addresses of the sophic medicine, homeopathy, or acupuncture (about 1% general practitioners who have patients who are insured by of GPs for each of these CAM types).
Azivo, which allows us to distinguish between conven-tional GPs and GP-CAMs. We defined a general practi-tioner as anthroposophic GP-CAM if his or her name appears in the list of general practitioners with additionaltraining in anthroposophic medicine as provided by their professional association [GP-CAMs with homeopathy] and GP-CAMs with acupuncture [are defined We analyze costs at the patient level using linear and log- linear regression analysis. While the linear specification ismore common, the log-linear specification can be argued to be more appropriate given that costs are nonnegative andcost distributions typically have long tails. Given the large Significance of coefficients is tested using t tests, with average differences in health and healthcare needs across clustering of standard errors at the level of the insuree.
age groups, the cost analysis has been performed separately Calculations were made using StataSE 10.0.
for the age groups 0–24, 25–49, 50–74, and 75?. In all costregressions, the explanatory variables are gender, age(linear, within each age category), dummies for each quarter, dummies for anthroposophy, homeopathy, andacupuncture, and 6-digit postal code fixed effects.
Effects on mortality rates are analyzed using a Logit model with fixed effects at the 4-digit insuree postcode level.
The dataset contained information on 151,952 insurees Given the relatively low proportion of deaths (less than 3% of with a mean age of 38.4 (SD = 22.6); 53% are women.
insurees died during our sampling period), fixed effects at These patients live in 21,902 different 6-digit postal codes.
6-digit insuree level are infeasible. To check for robustnessagainst functional form specification, we also analyze mor- tality using fixed effects linear probability models.
The dataset contained information from 1992 GPs: 1913 Dataset on healthcare costs and demographics conventional GPs and 79 complementary GPs (GP-CAM)(anthroposophy: 26, homeopathy: 28, acupuncture: 25).
A dataset from health insurer Azivo, active primarily in the The number of patients insured with Azivo is highly city of Hague and its wider vicinity, was used for the unevenly distributed across GPs. For example, 5 out the 26 anthroposophic GPs in the dataset account for more than large for patients aged 75 and above with an anthropo- 95% of the claims by patients with anthroposophic GP.
sophic GP-CAM (1,000 Euros on an annual basis) This is because Azivo has a relatively large market share (about one quarter) in the Hague region and a very low The analyses also demonstrate large demographic dif- market share in most other regions. The average number of ferences between patients with a conventional GP versus Azivo patients with these 5 anthroposophic GPs is about patients with GP-CAMs (Table ). GP-CAMs have a larger 570. The corresponding figures for the other GP types are fraction of female patients than conventional GPs and 850 (conventional), 150 (homeopathy), and 360 (acu- fewer patients from disadvantaged neighborhoods. Clearly, puncture). The differences can be due to variations in the the cost differences reported in Tables and are partly size of the total practice as well as in variations in Azivo’s due to differences in the demographic composition of the market share across the four groups of patients.
various groups of patients and therefore difficult tointerpret.
After controlling for these demographic differences by means of regression analyses, we find that for patients in The costs of patients with a GP-CAM are 7% lower the age group 25–49 with a GP-CAM with acupuncture, compared with conventional GPs, which amounts to total costs are 66 Euro lower per quarter (Table left 140 Euros per patient annually. However, this difference in panel). Secondly, for patients aged 75 and above with an raw means of total costs is significant only for anthropo- anthroposophic GP-CAM, total costs are about 400 Euros sophic GP-CAMs. The lower total costs result from lower lower per quarter. The magnitude of this difference is large, hospital and pharmaceutical costs. Patients with a GP- about one-third lower. The separate regressions for the CAM have slightly higher costs for paramedic care, but this costs components show that these lower costs come from difference is small. When the costs are compared by age lower hospital and lower pharmaceutical costs. The results group, in absolute terms, the differences are particularly for the log-linear specification show a somewhat different Table 1 Descriptive statistics on patients with GPs and GP-CAMs Incidence of costs of healthcare (0/1) (per quarter) ***, **, * indicate a statistically significant difference with conventional GP at the 1, 5, and 10% level, respectivelya Costs of healthcare are in Euros per quarterb Based on a government list of most disadvantaged neighborhoods in the Netherlands (‘‘Vogelaar-wijken’’). These neighborhoods are uniquelyidentified by their 4-digit postal code Table 2 Costs of healthcare; by type of GP and insuree age category ***, **, * indicate a statistically significant difference with conventional GP at the 1, 5, and 10% level, respectivelya Costs of healthcare are in Euros per quarter pattern. Homeopathic GP-CAMs have about 15% lower we find that patients with a GP-CAM have significantly costs in all three age categories below age 75. The lower lower mortality rates (Table ). For all three types of costs for patients aged 25–49 who have a GP-CAM with CAM, the effect is significant for some specifications, but not for all specifications. The magnitude of the effect again It is important to note that 6-digit postal codes in the Netherlands are highly detailed, representing 16 house-holds on average. Within such a code, households are highly homogeneous in terms of socioeconomic status.
Given that we have controlled for 6-digit postal codes in There are four types of explanations for the differences the regressions, the results are unlikely to be due to dif- reported in the previous section. First, the differences could be due to selection on unobservables in patients’ GPchoice. For example, patients who are healthier and more health-conscious or patients with a strong preference tominimize exposure to medical interventions might be more In the present dataset, the only information available on likely to choose a GP-CAM. In both cases, costs will be health outcomes is mortality in the years 2006 up to and lower due to lower demand for healthcare. A standard including 2009. For the population of insurees in our data, approach to control for selection on unobservables is to use the mortality rate was approximately 3%. After controlling instrumental variables. A potential instrumental variable for demographics (including age) and 4-digit postal codes, (IV) in this case is the distance between a patient’s home Table 3 Effects of complementary care on costs per insuree age category ***, **, * indicate a statistically significant difference with conventional GP at the 1, 5, and 10% level, respectivelya Costs of healthcare are in Euros per quarter. Each row is based on two regressions with either costs (left panel) or the natural logarithm of costs(right panel) as the dependent variable. Explanatory variables are gender, age (linear, within each age category), dummies for each quarter,dummies for anthroposophy, homeopathy, and acupuncture; the table reports the coefficients on the latter dummies. All regressions control for6-digit insuree postcode fixed effects; standard errors clustered at the insuree level and the various GPs. However, the distance measures same time, these patients report fewer adverse side effects would be perfectly correlated with the 6-digit postal code of treatments and higher patient satisfaction (e.g., [ dummies. As a consequence, this IV would only work if we These findings combined with the results in this study would control for less detailed neighborhood information, provide some indication that undertreatment by GP-CAMs like 4-digit postal codes. However, since socioeconomic is unlikely. Firmer conclusions require more data on differences within a 4-digit postal code are typically large, this would not be a credible approach for identifying a Thirdly, the results could be due to better practices of CAM due to a stronger focus on preventive and curative Second, the results could be due to undertreatment by health promotion and less overtreatment. For example, a GP-CAMs. In the present dataset, we were only able to GP-CAM might try a low-cost CAM treatment first. As analyze mortality and found that patients with a GP-CAM mentioned, the primary professional orientation of CAM tend to have lower mortality rates. A number of studies doctors is to strengthen the self-healing capacity of the have reported that patients seeking anthroposophic or body and the self-management of the patient. This homeopathic care have longer lasting and more severe approach is associated with prescribing fewer conventional health problems than patients in conventional care. At the pharmaceuticals, tests, and operations.
Table 4 Effects of complementary care on mortality Dependent variable: death in 2006, 2007, 2008, or 2009 The table is based on models with the following explanatory variables: gender, age, dummies for anthroposophy, homeopathy, and acupuncture(dummy for complementary in the last column); the table reports the coefficients on the latter dummies LPM regression controls for 4-digit insuree postcode fixed effects ***, **, * indicate a statistical significance at the 1, 5, and 10% level, respectively Fourthly, the lower costs could be related to the fact that effectiveness. Missing information includes costs distin- patients interested in CAM might have higher out-of- guished by basic and supplementary insurance, out-of- pocket expenses since CAM is not included in the basic pocket expenses, morbidity, work absence, subjective health insurance package. On the other hand, patients interested in CAM are more likely to buy supplementary Consequently, a large number of issues remain for future insurance that covers CAM. This would imply that the research. We mention three of them specifically. First, marginal out-of-pocket expenses for these insurees are replication studies based on similar datasets are needed to lower than for insurees with a conventional GP, leading to confirm the present results. Secondly, further research is more consumption of healthcare (recall that the Azivo data needed to determine to what extent selection on unob- contain costs covered by basic health insurance plus costs servables and causal effects explain the lower costs and covered by optional supplementary health insurance). Yet, lower mortality rates of patients with a GP-CAM. Thirdly, we find that the costs of patients with a GP-CAM are lower.
more research is needed with regard to the cost-effective- Clarifying the role of out-of-pocket expenses is an empir- ness of CAM for specific diagnostic categories.
ical issue that requires additional data.
Several studies that compare the health status of patients We thank health insurance company Azivo, for providing the data, and Paul de Beer, Katie Carman, Patrick Hullegie, treated in CAM and in conventional medicine in primary Tiemen Woutersen, as well as three anonymous referees for helpful care settings find that patients treated in CAM practices suffer more often from severe and chronic illnesses (e.g.,[This suggests that if we could control for severity This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which per- and chronicity of illnesses (with additional data), the esti- mits any noncommercial use, distribution, and reproduction in any mated cost differences might be larger.
medium, provided the original author(s) and source are credited.
Another result of this study is that GP-CAMs have a larger fraction of female patients than conventional GPsand fewer patients from disadvantaged neighborhoods.
Similar findings have been reported for the US [and forSwitzerland ].
The major limitations of this study concern the limited 2. Manheimer, B., Berman, B: Cochrane complementary medicine field, about the Cochrane Collaboration (Fields) 2008, Issue 2.
dataset. First of all, the dataset is from only one insurer in one specific Dutch region, and the data reflect the behavior of only a small number of GPs with additional training in CAM. This challenges the generalizability of the results.
3. Wapf, V., Busato, A.: Patients’ motives for choosing a physician: comparison between conventional and complementary medicine Secondly, the dataset does not cover all the information in Swiss primary care. BMC Complementary Altern Med 7(1), 41 needed to perform an optimal comparison of cost- 14. Kennedy, D.A., Hart, J., Seely, D.: Cost effectiveness of natural health products: a systematic review of randomized clinical trials.
5. Singh, S., Ernst, E.: Trick or Treatment The Undeniable Facts about Alternative Medicine. W. W. Norton & Company, New 15. Studer, H.P., Busato, A.: Ist a¨rztliche Komplementa¨rmedizin 6. Linde, K., Berner, M.M., Kriston, L.: St. John’s wort for major 16. Nahin, R.L., Barnes, P.M., Stussman, B.J., Bloom, B.: Costs of depression. Cochrane Database of Systematic Reviews 2008, Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007. National Health Statistics Reports 18. Available at: 7. Hopton, A., McPherson, H.: Acupuncture for chronic pain: is acupuncture more than an effective placebo? A systematic review of pooled data from meta-analyses. Pain Pract 10(2), 94–102 8. Van den Berg- Lange, de, C.: The contribution of acupuncture 20. Esch, B.M., Florica, M., Busato, A., Heusser, P.: Patient satis- and moxibustion to healthcare, an evidence-based approach.
faction with primary care: an observational study comparing Thesis Erasmus University, Rotterdam (2010) anthroposophic and conventional care. Health Qual. Life Out- 9. Servan-Schreiber, D.: Healing without freud or prozac: natural approaches to curing stress, anxiety and depression. Rodale 21. Marian, F., Joost, K., Saini, K.D., von Ammon, K., Thurneysen, A., Busato, A.: Patient satisfaction and side effects in primary care: an observational study comparing homeopathy and con- ventional medicine. BMC Complementary Altern Med 8, 52 13. Herman, P.M., Craig, B.M., Caspi, O.: Is complementary and 22. Ness, J., Cirillo, D.J., Weir, D.R., Nisly, N.L., Wallace, R.B.: Use alternative medicine (CAM) cost-effective? A systematic review.
of complementary medicine in older Americans: results from the BMC Complementary and Alternative Medicine 5:11 (2005) health and retirement study. Gerontologist 45, 516–524 (2005)
Maruti Suzuki India Ltd In line with expectations Result Update Maruti’s 4QFY08 operating performance was in line with our estimates, adjusting for 28tH April 2008 MTM loss provision on its forex derivatives and the one time expense of Rs 545 mn, representating compensation to dealer. The MTM provision is with respect to forward cover for its European exports (commenc