By: Molly McMullen Laird, M.D.
LILIPOH: Can you tell me briefly about the community supported medical initiative that you and Quentin Mc Mullen, M.D. have started?
Molly McMullen Laird, M.D.: The driving force behind our Patient Organization, and the unique economic form that we use, came through looking at anthroposophical medicine as a whole and incorporating not just physician care but everything that should be included in that whole task of taking care of someone over a long period of time. This includes things like prevention, education, nursing care, therapies, getting patients to use more healthful body care things, over-the-counter and home-care remedies and products. What you see in a conventional fee-for-service model, is that people wait until they are sick to go see the doctor and be taken care of. The prevention aspects get ignored until something catastrophic happens, and then they seek help. We all know people do better if they take care of things at the beginning, like change their diet and stay educated about health, so we emphasize a preventive approach.
Another reason we began working in this way is that certain anthroposophical procedures and medicines are not covered by insurance. So people end up, just on purely economic grounds, being forced into this conventional system. We wanted to find a way that a community could support a group of like-minded individuals who want access to these therapies. We saw it as establishing a practice and a center where services could be available in the best way that we can make them available. The members of the group would support it by a monthly contribution. Then when someone was ill, they could come as much as they needed to come without any concern or economic problem. In January 1998 the organization was founded with 37 memberships.
When we started out, because we didn’t have a physical office at the time, we were renting space in the Steiner House. A couple of volunteers organized the schedule; they did it by scheduling appointments by e-mail. We lived along with that method for a little while but it was quite cumbersome. Then we found an office space in the summer of 1998. The Patient Organization members helped us move in and transformed the space very beautifully. People brought pieces of furniture – it was kind of like a barn raising. It was a nice feeling. We had an open house and I remember looking around the office thinking, so and so brought that, so and so brought that. It wasn’t a sterile medical office – but instead was a homey, comfortable space from the beginning. People comment when they walk into our office about how comfortable they feel. And I think some of that has to do with the process in which the office was started. It was not like hiring a company to outfit the office or set up the paperwork.
In the first year we had numerous meetings to consider what kind of legal form and bylaws we should adopt. We had lawyers as board members helping to make sure we were doing everything in the right way, so that we would be, from a legal standpoint, on the up and up, and be able to stand up in the world and be proud of what we are doing. This is a very important value for Quentin and I. That has been our signature all along in our practice. It was amazing that people stuck to it, attending meetings every month. They were difficult meetings, trying to figure things out, not exactly like having tea and crumpets. We were hammering things out that were very complicated.
We settled on $50 a month to begin with, and, amazingly, for the first couple of years it would hit the budget right on the nose. We would track the services and then track the contributions. We also have some patients that pay for services. At the end of the year we have a business meeting to see how much was the dollar amount of the services rendered, and what was the dollar value of the contributions. We have had a couple of years where we’ve fallen behind by a couple thousand dollars. But generally we are pretty close. We have now raised the minimum amount. We also have a sliding scale, and we now have a family membership and an individual membership. The family membership is $90 to $65 dollars. Individual memberships at this point are $55 to $35. So people can tick off whatever their level of member ship is, and they write a check for every month of the year, and they get a renewal letter at the end of the year.
The PO meets every other month. We have educational presentations during the meeting, or we have social activities, such as a gardening day.
LILIPOH: How many members are there now?
MML: We leveled off at over a hundred members. That covers about 250 people.
LILIPOH: Could you say a little bit more about how it works for a patient?
MML: The Patient Organization is one entity under Community Supported Anthroposophical Medicine (CSAM). CSAM has a number of different mandates or goals, including education, training, service, research, inpatient activity, Patient Organization. There is a therapy group of anthroposophic therapists who work for CSAM, and the physicians are part of the therapy group. We are employees of CSAM. The Patient Organization is an entity underneath CSAM, but is actually its own governing body. It belongs to itself and is governed by itself. There is a contract negotiation between the Patient Organization and CSAM for services. The Patient Organization moneys are given to CSAM in exchange for services. We are basically selling services to the Patient Organization. The criteria of the Patient Organization is to use CSAM employees. The Patient Organization does not pay for a patient to go to “X” therapist somewhere in the community. It only pays for things that are in-house. The therapies or nursing care are supervised and prescribed by the physician. The patient can’t just call up and say to the receptionist, I need an appointment with the nurse. The physician has to have a conversation with the patient: “This is something that I think you should have. Do you agree with it? This is something the Patient Organization will pay for.” That is how it works, it is initiated by the physician. Because otherwise, the potential would be rampant in terms of cost. Theoretically someone could call every day, “I need massage therapy three times a day.”
LILIPOH: This is one of the key aspects of your work that is so unique. This is part of the uniqueness of anthroposophic medicine, the physician having these other therapies as tools to help the patient.
MML: Exactly. These are medical treatments that are meant to be regarded as remedies, something really specific for that patient. There is a conversation between the therapist and the physician to diagnose, and a plan and a time frame.
LILIPOH: You not only have a unique model for paying for it, but a model for how a true anthroposophic medical practice would look like. You are bringing the ideal into the world.
MML: I feel that – no matter what the resources are, each are to be handled with respect. That is one of our values throughout our work. We don’t just use resources without consciousness, and I feel like there is a certain tendency in the alternative world to have over-treatment, over-therapy in the search of something healthy. Things get overdone. People tell me things like, Monday they go to an acupuncturist, Tuesday they go to a reiki person, Wednesday yoga, Thursday massage. How much can one take in? Let’s be respectful to the organism. It would be like in biodynamics, taking a farm field and every day giving it some other treatment. This creates confusion, chaos. Things should be planned. The patient may not be in the best position to make that plan. They may not be able to see the context of the illness, what is needed for them to make a plan that is prudent, that also has a chance to settle. We have certain guidelines in anthroposophical medicine about things like external treatments, eurythmy, the frequency of doing these things. It should be done with a certain amount of pause in between for the organism to take it in, and in a certain length of time.
One tricky thing with patients has been a control issue, the utilization of resources. It is hard, as the physician, to be the gatekeeper and the person in control of utilization of resources. Given the wide continuum of human beings, we have some who come too much, and some who do not come enough. We try to find a balance. It’s hard to train people not to come too much or to come often enough.
Because we have taken away the economic incentives, we have taken off a certain brake, that now needs to be controlled from a different standpoint. We’ve had some very good experiences with people who really needed a lot of education about how to handle things with their families, especially children. If the mothers are educated, they don’t have to come as much. So we save resources for the PO. We can move those resources to a cancer patient who might need more support.
Imagine that you are looking at this line of people. For whatever reason, the destiny of serious illness will hit a certain number of those folks, in the course of two or five years or whatever. We want to be there and have the resources to take care of those who have a really devastating illness and to carry that burden as a community. It’s a really gratifying thing to hear the comments from the patients who are very ill and see their gratitude in knowing that they are being taken care of by this much larger group of people, some of whom they don’t even know.
We feel what the farmer feels when we belong to a CSA, and we share in the farmer’s success or failure, in the variability of the harvest. When you belong to CSAM, same idea but for medicine, you are taking it into a different time and a different resource realm. Because you may never use those resources. Then what you say is, there but for the grace of God go I – that is the motto. If you don’t use the therapies it means that you are healthy. These poor folks who are not healthy are using the resources. That is the thing we have to remind people of all the time – they are doing a deed by belonging to a PO, they are doing a deed that is bringing human evolution a tiny step further. This is not a payment plan – not the budget method of getting anthroposophical medical care. The reason for the PO to exist is for the community and the group. It’s a small little thing we have here, a speck, a grain of sand, what we are doing is so miniscule. But for a physician it’s very encouraging to be part of this, and hear these stories of gratitude from people who are very ill. It’s also very gratifying to be in the relationship with the patient. A fee-for-service relationship has a different feel to it. Our PO members are not exchanging money when they come to see us, except that they pay for their medicines. They are not paying for the services, they are using the services and resources and they have a sense about that. We are trying to use the right amount of services so that we stay healthy. We do not have the idea that there is an infinite amount of resource available.
Which is what I see out there in conventional medicine. Someone says, my knee hurts, I want an MRI. My wife says I’m snoring and I need a sleeping aid. I am not so happy – give me an antidepressant. Every one of those things has a price tag attached. If you told someone, okay, take out your checkbook and pay for the MRI, they’d say, “Oh I don’t think I need an MRI. Why would I spend $1500 on that?”
LILIPOH: When someone becomes a member of the PO, the relationship that the patient has to their own health changes. It’s a whole other way of looking at your own health.
MML: In this materialistic world, we have really taken a lot of those concepts into the medical relationship. You hear all the time, somebody gets sick, they are in the hospital, they get the bill, a copy of the hospital bill which was maybe $30,000, and what they say is: “Well, I’ve been paying into this insurance for 30 years.” They don’t look at the bill and say, my God, why do I have to pay $15 for a box of Kleenex? Next time I’ll bring my own!
People feel entitled to health care, they feel entitled to the red-carpet treatment, single room, the best surgeon, a lot of things. Who is looking at balancing the checkbook in this country? Nobody is looking at that. I don’t know if we are making a difference with our group of people, but we have this idea that we are.