Naturopathic Practice - A Comparison to Conventional Primary Care

A new article was recently published that described naturopathic practice at 4 of the 8 accredited North American naturopathic academic institutions ^[1]. The study includes an analysis of over 300,000 patient visits over 5 years, making it the largest study of its kind. It is unavoidable that the public asks: what is the difference between a Naturopathic Doctor and a Medical Doctor? The MD is certainly the more common medical degree and treatments are generally covered by the government or through insurance. So it is worthwhile to go see a Naturopathic Doctor? Should care be provided in addition to conventional primary care, or is it a viable competing alternative? There are plenty of similarities and differences between both MD and ND care and it's important to remember that there is not necessarily a right or wrong answer to these questions. Each field is unique and offers distinct benefits to patients and to medicine as a whole. There are many who believe that Naturopathic Doctors are the answer to doctor shortages and increasing healthcare costs. This may be true in some areas more than others, since healthcare is implemented differently in different areas of North America. Naturopathic Doctors are licensed in 18 US states and 4 Canadian provinces, the District of Columbia, and Puerto Rico ^[1]. The majority of the scope of practice in these locations is very similar to conventional primary care, in that Naturopathic Doctors engage in assessments, diagnostics, and treatments.

The Association of Accredited Naturopathic Medical Colleges (AANMC) was established in 2001 to advance the naturopathic medical profession by actively supporting the academic efforts of accredited and recognized schools of naturopathic medicine ^[2]. According to their analysis, the curriculum, courses, and credits of both MD and ND schools are extremely similar. Due to the ND philosophies, the ND curricula also includes certain areas of study not covered conventionally, including clinical nutrition, homeopathic medicine, and psychological counseling. However, NDs receive very similar biomedical and diagnostic training compared to MDs ^[2]. In the later years of study, the educations begin to differ more. Post-graduation, MD residencies are mandated and regulated by the medical schools, so there is a wide variety of opportunities available. However, naturopathic residencies are not required or funded by the federal government, so only 5-10% of NDs participate. In terms of generalists vs. specialists, the ND curriculum is built to train primary care physicians, not specialists, so this is another area that differs.

In the large published study, data was collected from some of the academic clinics that are among the largest facilities providing naturopathic care and are involved in the preparation and training of NDs. The main objectives of the study were to develop an integrative database with the 5 years of patient visit, including patient, lab, and prescription data; to analyze healthcare utilization in these clinics; and to compare the characteristics to conventional medicine using the National Ambulatory Medical Care Survey (NAMCS) dataset from the Centers for Disease Control and Prevention (CDC). This article will examine some of the data that was captured by the study, including what the patient demographics are for naturopathic care, how patients pay for service, and what the most frequent diagnoses are and how they compare to conventional primary care.

 Naturopathic Patient Characteristics

During the 5 year period where data was collected, 52,129 patients were seen in the four clinics. New patients accounted for approximately half of all the patient visits. The percentage of female patients was 69% and for male patients it was 31% ^[1]. There are many studies that look at gender differences in terms of healthcare-seeking behaviour. It appears that there is a strong assumption that women seek more healthcare than men, but the evidence suggests that the amount of healthcare sought may actually depend on the symptoms experienced. Even then, associations tend to be weak and inconsistent ^[3]. Seen in this light, this would suggest that Naturopathic Doctors are possibly able to better address conditions that are more common or unique to women, or that at least this may be the public perception. The average patient seen was 39 years of age, with almost half the patients being between the ages of 35 and 64, so the majority of patients seen by NDs are adults. Kids under the age of 15 were only seen 7% of the time and elderly over the age of 65 were only seen 9% of the time. The proportion of pediatric and geriatric cases seen in conventional primary care are both higher. This may be in part due to how treatments are paid for. In Canada for example, a large part of naturopathic care is covered by private insurance through work benefits. This means that both kids and the elderly are far less likely to have coverage and therefore may be unable to pay.

Fee For Service

ND visits can be covered by private insurance, they can be obtained at a discount, or the patient can pay directly in cash. During the study period, ND visits in the United States were not covered by Medicare or Medicaid, as opposed to conventional care. Private insurance was used to pay for 24% of ND visits, 26% of visits were discounted, and 50% of visits were paid for in cash directly by patients. Based on the data, it's possible that naturopathic academic clinics are serving an unrecognized role as part of a public health safety net by providing care for the uninsured. It's unclear how many patients transition from the low fees of an academic clinic to NDs in private practice, where fees are more expensive. The CDC reported in 2009 a visit frequency of less than 2 per person per year for conventional primary care physicians. In the same year, the ND clinics studied here saw over 4 visits per person per year, suggesting more face-to-face time between NDs and patients ^[1]. This may reflect the fact that visits were occurring in a learning environment and it may also reflect the differences in the types of conditions that are treated.

Conditions Treated

In the study, only the primary International Classification of Disease (ICD-9) code was used in the case of multiple diagnoses for a visit. There was a 32% overlap between the ICD diagnoses of NDs and in NAMCS primary care (and for community health clinics, the overlap was higher at 44%) ^[1]. 4 of the top 6 diagnoses in conventional primary care were found in the top 25 for ND diagnoses, but only 1 of the top 6 ND diagnoses are found in the NAMCS list. This might suggest that NDs are functioning both as primary care practitioners, but may also be addressing otherwise unmet medical needs. The conventional primary care visits saw more routine examinations and infectious conditions, whereas the ND visits saw more chronic conditions, especially musculoskeletal pain and fatigue. Also high on the list for ND categories were general symptoms and ill-defined conditions (fatigue, malaise) as well as digestive disorders and mental disorders (such as anxiety and depression). These results are consistent with previous studies. Many ND therapies are founded on diet and lifestyle modification. It is possible that these therapies are more appropriate for the top ND complaints. It is also possible that the conventional medical system is more equipped to handle acute or emergent care, as oppose to chronic conditions, when compared to ND care.

Conclusion

As awareness of naturopathic medicine increases, it is inevitable that the public seek clarification on how NDs differ from MDs. The AANMC suggests that the curriculum and education of MDs and NDs is very similar, but starts to diverge near the later years. The newly published study is the largest of its kind and captured data from 5 years and a tremendous number of patient visits. Overall, the data suggests that two-thirds of naturopathic patients are female and that the majority of patients are adults. Half of ND visits were paid for directly by patients. Approximately one-quarter of visits were covered by private insurance and the last quarter were discounted visits. The types of conditions seen by MDs and NDs overlap as much as 44% of the time. Many of the top diagnoses seen by MDs are also seen by NDs at a high frequency, but only 1 of the top 6 ND diagnoses are also seen commonly by MDs. Unsurprisingly, conventional primary care sees more routine examinations and infectious conditions. NDs appear to be seeing more chronic conditions, especially fatigue, musculoskeletal concerns, digestive concerns, and mental health concerns. As the demand for patient-centered care increases, we will likely see a shift in patient behaviour. MDs and NDs both provide high-quality care and each provide unique advantages. Hopefully, both practitioner types will work together to provide more options for patients and to ensure that patient goals remain at the forefront.