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Herbal Medicines Can Reduce Costs in HMO.
Oklahoma is not known as the hotbed for complementary-alternative medicine (CAM). At the first Harvard course on Alternative Medicine, three years ago, I persuaded another doctor to join me, but at the last two courses I have unfortunately been the sole physician representing the State of Oklahoma. It is with this as a backdrop that I would like to share the experience of introducing herbal medicines into a very conservative HMO practice.

I am the chairman of an Ob-Gyn Department that is part of a 47 multi-specialty group that has the contract to take care of 60,000 members of an HMO. I have been using herbals in my practice for about five years with good success. I was anxious to get on me monthly staff meeting agenda to discuss the topic of herbal medicine with the rest of the medical group. It seems that there was never enough time or interest and so my request for time to discuss herbal medicine was always put off.

Then came the yearly meeting when the medical group and the HMO administrators met to discuss ways of holding down cost. I was asked to sit on the task force whose mandate was to discuss the more expensive drags on the formulary and look for ways of reducing costs. This was also about the time that the Journal of Geriatric Psychiatry and Neurology put out a supplement devoted to the discussion of an herbal anti-depressant called St. John's Wort (Hypericum perforatum L., Clusiaceae). The data showed that this herb was as effective as many of the other drags on the market for depression, but with fewer side effects. The working dose was 300 mg three times daily of Hypericum standardized at 0.3 percent of one of the presumed active compounds, hypericin.

I developed a handout summarizing the information from the journal article, which clearly showed that this herbal was prescribed just as any other traditional anti-depressant drug. I then presented data that showed that a month's supply of Prozacr was $72.00 whereas Hypericum cost less than $9.00 for a month's supply. The HMO spent nearly $1 million a year on anti-depressants for our membership and the data showed that if St. John's Wort was only effective in 25 percent of the patients, then this would save over $250,000 a year. I felt this was a very conservative estimate but in a conservative environment you tend to make conservative estimates.

Suddenly, there was great interest in herbal medicines and it was obvious, given today's financial climate, that the proverbial "foot-in-the-door" that I needed was cost savings. I would like to think that my colleagues were motivated by patient demands or the safety of these herbal medicines but as a pragmatist, I knew that wasn't true.

I was then asked to work up an herbal medicine presentation at the next month's meeting. As the time drew near to give my talk, I found myself becoming apprehensive about how I would be received. Would my credibility be ruined? Would my referral base disappear because I would be seen as the "quack" physician?

I presented the following herbals and the medicines that they could replace along with the cost savings that could be realized. I chose ten herbs that I felt had some of the strongest data to support their clinical use:

1. Ginger root (Zingiber officinale Roscoe, Zingiberaceae) as an anti-emetic

2. Garlic (Allium sativum L., Liliaceae) as a hypolipidemic

3. Nettle leaf (Urtica dioica L., Urticaceae) as an anti-histamine

4. Ginkgo biloba (Ginkgo biloba L., Ginkgoaceae) as a treatment of tinnitus and intermittent claudication

5. Feverfew (Tanacetum parthenium (L.) Schultz-Bip., Asteraceae) as a treatment and prevention of migraines

6. Valerian (Valeriana officinalis L., Valerianaceae) as a minor tranquilizer and sleep aid

7. Cranberry (Vaccinium macrocarpon Aiton, Ericaceae) to prevent recurrent bladder infections

8. Saw palmetto (Serenoa repens (W. Bartram) Small, Arecaceae) as a treatment and prevention of benign prostatic hypertrophy

9. Milk thistle (Silybum marinum (L.) Gaertn., Asteraceae) to treat chronic liver disease and toxic liver damage

10. Peppermint oil (Mentha x piperita L., Lamiaceae) as a treatment for irritable bowel syndrome (enteric-coated capsules).

The potential of direct savings in yearly drug costs was between $500,000 and $750,000. The indirect savings would be in the area of fewer emergency room and clinic visits for urinary tract infections, acute migraines, or overdosing on prescription medication, just to name a few. What would be the cost benefits of using Echinacea if patients got back to work after the flu two days sooner?

I was surprised to find that many doctors came up to me after the presentation and in confessional tones stated that they had wanted to use herbs but did not for fear of professional condemnation or for the lack of knowing where to get reliable information on herbal medicine. Now, I would like to say that all of these herbal medicines were well received and now in common use but doctors do not easily let go of proven therapies or move on to treatments which are foreign to them. We do carry St. John's Wort, Valerian and Feverfew in our pharmacy and physicians are writing prescriptions for these herbals as they would for any other recognized medicine. I have also given a grand rounds on herbals at the medical school and have two more talks planned for local medical societies. I have also had more physicians ask about herbal medication in the past year than in the previous five years.

There seems to be a movement that is slow growing here in Oklahoma City and a group of physicians and the complementary-alternative providers in the community are now meeting on a regular basis to develop a network. In the words of Bob Dylan, "the times they are a changin'..."

To date our pharmacy has dispensed herbals to 175 patients. It is not a giant step towards the reintegration of herbal medicine but it is a step. I have found that to be heard, you must speak the language of those to whom you are speaking. In today's managed care environment, the language is that of "cost savings." It is here where the potential of integrative therapies of including the use of herbal medications can make significant advances.

Article copyright American Botanical Council.


By Larry Kincheloe