By Dana Ullman MPH
This article was originally published in the JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE, 5,1, 1999, 65-73. It is reproduced here with the permission of the publisher,
Mary Ann Liebert, Inc.
2 Madison Ave.
Larchmont, NY 10538
tel: 914-834-3100; fax: 914-834-3771.
Managed care presents a challenge to homeopaths and to consumers of homeopathic care. If homeopaths want to be a part of managed care, they will have to organize themselves to a higher level of professional order. Although the vast majority of practicing homeopaths are licensed in one of many conventional health professions, with the medical license being the most common, homeopaths need to develop more clearly defined educational standards and certification programs in the specialty of homeopathic medicine, and they need to have these programs certi.fied by respected, independent agencies. The small number of homeopaths who are unlicensed will either have to become licensed or work with those who are and whose malpractice insurance would cover their care.
This article notes that there is a small but significant body of clinical research and additional evidence that homeopathic care is cost-effective. A recent increase in public and private research monies is leading to a larger body of evidence that homeopathic medicines are effective, and this will help it achieve greater acceptance and recognition from governmental bodies, medical professional associations, and managed care organizations. Reasons are given for why managed care organiza.tions will play a leading role in advocating that consumers learn to use homeopathic medicines for non-emergency self-care ailments as a way to empower them to take greater control over their health and to reduce doctor visits and hospitalizations.
Presently, only a small number of homeopaths practice in a managed care environment, in part because their practices are already active without it and in part because managed care organizations have not considered homeopathic care a legitimate part of clinical care. This situation, however, is changing rapidly.
In the 1980s there were four homeopathic training programs in the United States, but by the mid-1990s there were over 25 (Ullman, 1996). With the growing number of practicing homeopaths, it is reasonable to expect more demands from practitioners and consumers for inclusion of homeopathic care in managed care plans. And there is increased interest from various managed care companies in the field of alternative medicine (Jackson, 1997; Piturro, 1996).
There are, however, various difficulties that homeopathy and homeopaths face in their integration within managed care. First, homeopaths are a disparate group of licensed and unli.censed professionals, some of whom are certified through rigorous examination and most of whom are not. Even among those homeopaths who have a conventional medical licensure, only a minority of them have sought certification in homeopathy. And for those practitioners with certification, there is not as yet any homeopathic certifying agency that has achieved independent accreditation.
In addition to these credentialing problems, administrators of managed care organiza.tions have some doubts about the efficacy of homeopathic medicine, as well as the cost-effectiveness of homeopathic care. Until these important research questions are answered, inclusion of homeopathic care within mainstream institutions, including managed care plans, will remain an illusive goal.
Despite these significant stumbling blocks, there are significant developments in re.sponse to each of these issues, making the inclusion of homeopathic care in a managed care environment a reasonable possibility within near future.
The greatest number of professionals who specialize in homeopathic care are medical doctors. According to the leading directory of American homeopaths published by the Nation.al Center for Homeopathy (Alexandria, VA), 44% are medical doctors or osteopaths, 16% are naturopaths, 15% are chiropractors, 12% are veterinarians, 7% are nurses, 4% are dentists, and 2% are acupuncturists (National Center for Homeopathy, 1998).
This directory is not meant to be complete, as some practitioners feel no need or desire to advertise their services. Also, to be listed in the directory requires membership in the Na.tional Center for Homeopathy, and it is relatively common for homeopaths, many of whom tend to be somewhat iconoclastic, to avoid joining organizations.
This directory also does not list unlicensed practitioners, but according to the North American Society of Homeopaths, the leading organization of unlicensed homeopaths, there are approximately 70 who have completed their rigorous certification process (this number equals 14% of those listed in the National Center for Homeopathy’s directory). In addition to these 70 practitioners who are unlicensed by any conventional licensing agency, there are at least 100 more who practice homeopathy but have not sought any type of certification.
One of the obstacles to inclusion of homeopaths into managed care is the legal recogni.tion of this specialty form of health care. Although this is not a problem for the vast majority of homeopaths because they are already licensed in one of the various recognized health pro.fessions, it can be a problem for unlicensed homeopaths.
Homeopathic medicines are recognized in the U.S. federal law, primarily as “over-the-counter drugs,” that is, drugs that do not require a doctor’s prescription (Food and Drug Administration, 1988). Because homeopathic medicines are considered “drugs,” there is a tendency for state medical boards and courts to assume that those people who prescribe them, except for home use, must have a license to prescribe drugs. As such, medical doctors, osteo.pathic physicians, and dentists can prescribe homeopathic medicines, and various physician extenders (physician assistants, nurse practitioners, nurses, etc.) can prescribe them under the supervision of a medical doctor or osteopath.
Thousands of chiropractors have integrated at least some homeopathic medicines into their practice, even though it remains unclear whether they have the legal right to do so in every state. Their licensing laws rarely mention homeopathy specifically, nor do they usually grant them the right to prescribe over-the-counter drugs. Chiropractors rely upon a common sense argument that they are simply recommending drugs that anyone, licensed or not, can purchase homeopathic medicines without a prescription. Whether this is legally accurate or not hasn’t yet been determined.
The definition of medicine is a state’s rights issue, and thus each state has its own medical practices act. Homeopathy is not mentioned in the vast majority of the states’ medical practices acts. Three states (Connecticut, Arizona, and Nevada) have passed laws establishing homeopathic medical boards who recognize medical doctors that specialize in homeopathy (Cohen, 1995). Primarily as a result of earlier harrassment from conventional physicians, homeopaths in these three states were able to get legislation passed that allowed homeopaths to oversee their own practices, rather than be judged by conventional medical colleagues.
In 1995, Nevada passed a law that allows medical doctors who become licensed as “homeopathic physicians” can oversee the practices of “homeopathic assistants” (not more than five unlicensed practitioners) and “advanced practitioners” (defined as licensed health profes.sionals, such as nurses, physician assistants, and chiropractors) (Nevada State Law, 1995). Homeopathic assistants must work in the office of the supervising medical doctor, while advanced practitioners can work in their own offices but must meet with the supervising medical doctor at least four hours per month.
One serious flaw in this Nevada law is that no other licensed health professional can prescribe any homeopathic medicine to a patient except those who are homeopathic physicians, homeopathic assistants, or homeopathic advanced practitioners. This means that the average conventional doctor, nurse, or chiropractor who is not licensed as an “advanced homeopathic practitioner” cannot give any homeopathic medicine to a patient, unless they do so under the supervision of a “homeopathic physician.” Also, while it is common for nurses and physician assistants to have their care supervised by a medical doctor, it is not common for medical doctors or chiropractors, and this will inevitably create certain problems. Other times that homeopathy is mentioned in states’ laws are in the 11 states that li.cense naturopathic physicians. Such laws state that naturopathic physicians are legally allowed to prescribe homeopathic medicines.
The issues surrounding the lay practice of homeopathy are unclear. Although any homeopathic practice can be considered medical care, regulatory and law enforcement agencies are not presently arresting lay practitioners, with extremely rare exceptions. Despite the fact that homeopathic medicines are recognized as drugs, and despite the fact that there are a couple hundred unlicensed homeopaths engaged in active homeopathic practice in the U.S., there has been only three attacks against homeopaths for practicing medicine without a license during the past 30 years, none of which led to any conviction nor to any precedent-setting that would allow unlicensed practice.
The first case occurred in 1976 when Dana Ullman was arrested for practicing medi.cine without a license in Oakland, California. This case was settled just prior to trial, and it allowed the homeopath to continue his practice as long as he didn’t say he was a doctor, that he referred patients to doctors for diagnosis and treatment of any diseases, and that he signed contracts with patients that differentiated between the health care he provided as distinct from medical care (California vs. Gregory Dana Ullman, 1977; Ullman, 1978). In essence, the court allowed Ullman to prescribe homeopathic medicines for sick people but not for specific diseases they may have.
The second case happened more recently (July, 1996) and did not involve a lay practi.tioner. Helen Healy, a licensed naturopathic physician, was given a cease and desist injunction from practicing medicine without a license because in Minnesota, where she was practicing, there is no formal recognition of naturopathy. The public and media support that she received was so significant that the medical board choose to settle the case in a way that allowed her to practice naturopathy (and homeopathy) as long as her patients sign a statement that acknowl.edges that she is not a medical doctor, that she sends a postcard to the patient’s medical doctor or chiropractor informing them that the patient is being seen by her for naturopathic care, that does not diagnosis disease, and that her records are at random reviewed by a physician (Set.tlement agreement, 1996).
In 1997, a lay homeopath in Atlanta was given a cease and desist order, though this order was never acted upon. Despite this near absence in arrests of unlicensed homeopaths, one can predict an in.crease in investigations in the future as homeopathy gains more attention.
At present, there is not much incentive for homeopaths who are conventionally licensed to obtain additional specialized certification in homeopathy. As interest in providing homeo. pathic care from managed care organization increases, there will be new incentives for certifi.cation. This development will benefit consumer and practitioner alike.
Of the 500-1,000 medical doctors and osteopaths who presently specialized in homeopa.thy in the U.S., only about 100 have sought separate certification as a homeopath. Approxi.mately 400 students graduate every year from the four recognized naturopathic colleges, and about 25% of these students choose homeopathy as their specialty. Despite these numbers, less than 100 naturopaths have sought certification from the Homeopathic Academy of Naturo.pathic Physicians.
The Council on Homeopathic Certification (CHC) is a new certifying body that con.ducts a rigorous examination and that also evaluates five case histories from a practitioner with six month follow-ups before certification is achieved. The CHC will allow licensed and unli.censed individuals to apply for certification. As of 1998, they have certified almost 200 homeopaths, granting them a Certifiation in Classical Homeopathy (CCH).
Certification alone does not necessarily grant the right of unlicensed homeopaths to engage in homeopathic care of patients, though it may provide a meaningful measure for man.aged care companies to assess if a practitioner, licensed or not, has a recognized level of knowledge in the field of homeopathic medicine.
Certification is not only useful to managed care companies. Physicians may want or demand those who practice homeopathy under their supervision to obtain certification, and consumers can likewise learn which practitioners have achieved a certain level of expertise.
Malpractice insurance is also essential in order for care from homeopaths to be inte.grated within managed care because it is an integral part of the credentialing process. Al.though malpractice insurance is not a problem for the vast majority of practicing homeopaths who are already licensed in one of the many conventional medical licensing bodies, malprac.tice insurance is not common today for the small number of homeopaths who are unlicensed. Homeopaths who do not have malpractice will have to do something about this if they have any interest in working within a managed care framework.
Those practitioners who are licensed have access to malpractice insurance, but those who aren’t licensed generally don’t have this access, except for practitioners in Canada and England, where Lloyds of London provides such coverage. Considering the relative safety of homeopathic medicines, it is not surprising to note that the cost of malpractice insurance for homeopathic care is quite minimal.
Malpractice insurance for unlicensed practitioners in the United States is a different matter because it can be construed that homeopathic care is the practice of medicine, and insurance cannot cover illegal actions. Possible ways to accomodate unlicensed practitioners might be the inclusion of a rider on a physician’s malpractice, but such riders could only be possible if the unlicensed homeopath is being directly supervised by the physician, an occa.sional but still somewhat rare practice today. Unlicensed homeopaths might also be able to work in institutional settings under an institution’s malpractice coverage, though as yet, there are no models for this occurence.
Another factor that will greatly influence the inclusion of homeopathic care within managed care is the scientific evaluation of homeopathic practice. There is a growing body of evidence that suggests that homeopathic medicines are effective, as two comprehensive meta-analyses have shown (Kleijnen, et al., 1991; Linde et al. 1997). The most recent meta-analy.sis evaluated 89 placebo-controlled and/or randomized trials and found that patients given a homeopathic medicine were 2.45 times more likely to experience a therapeutic benefit than those given a placebo.
Although some studies have been successfully replicated two times (Papp et al., 1998), three times (Reilly et al., 1994), and even 11 times (Wiesenauer et al., 1996), other replica.tions have not shown consistent efficacy (GRECHO, 1989; Walach et al., 1997; Whitmarsh et al, 1997). Of those studies that have shown some consistent positive results, only one has been replicated by separate and independent bodies of researchers (Papp, 1998). Replication of research is absolutely necessary for homeopathy to be taken seriously, both by conventional physicians and by managed care organizations.
One of the few studies that compared homeopathic treatment versus conventional medical treatment was recently published in an AMA journal (Weiser, 1998). This study compared results in the treatment of vertigo, with half of the subjects given a homeopathic medicine (a combination of four homeopathic medicine mixed together) and half given a conventional drug (betahistine). The study showed that those given the homeopathic medicine experienced at least as good results as those given the conventional drug, though the homeo.pathic medicine was considerably safer and less expensive.
Besides studies that verify the efficacy of homeopathic medicines, there is also a need for more studies evaluating the cost-effectiveness of homeopathic care. Of the studies that have already been conducted, there is presently positive evidence indicating that homeopathic care is more cost-effective than conventional and other alternative care, though more rigorous work is needed in this area as well.
One study conducted by the French government in 1991 showed a significantly reduced cost from homeopathic care versus conventional medical care (Social Security Statistics, 1991). The totality of costs associated with homeopathic care per physician was approximately one-half of the totality of care provided by conventional primary care physicians. However, because homeopathic physicians, on average, saw significantly fewer patients due to the more labor intensive tendency of homeopathic care, the overall cost per patient under homeopathic care was still a significant 15% less. It is also interesting to note that these savings appear to increase the longer a physician has been using homeopathy. A follow-up study in 1996 con.firmed these results (Caisse Nationale de l’Assurance Maladie des Travailleurs Salaris, 1996).
This survey also noted that the number of paid sick leave days by patients under the care of homeopathic physicians were 3.5 times less (598 days/year) than patients under the care of general practitioners (2,017 days/year). These figures suggest further benefit and savings to the homeopathic approach to care.
Homeopathic medicines are reimbursable under the French health care system, in part because they cost considerably less than conventional drugs (on average, the cost of a homeo.pathic medicine is 7 French francs versus 23.00 French francs for conventional drugs). Al.though homeopathic medicines in France represent 5% of all medicines prescribed by physi.cians, they represent only 1.2% of all drug reimbursements due to their lower cost per pre.scription.
Another study in Seattle, Washington, which compared the utilization and cost of homeopathic, naturopathic, and acupuncture services found that homeopathic care was the least costly and that patient visits to homeopaths were less than to other alternative care profession.als (this study, however, did not concurrently compare or evaluate patient visits or costs for conventional medical care) (Jacobs and Smith, 1996; Jonas and Jacobs, 1996).
The Royal London Homeopathic Hospital conducted an audit of a sample of their pa.tients during a three-week period (Sharples and van Haselen, 1998). A total of 541 question.aires were handed out, 506 returned, and 499 were analyzed. This survey found that 63% of patients had their complaint for more than five years. Of the patients who were on conven.tional medications when they initially sought homeopathic care, 29% had stopped and an addi. tional 32% had decreased their medication, while only 4% increased their medication. Sixty-two percent indicated that their main complaint had moderately or very much improved compared to their status before treatment at the homeopathic hospital.
This study, like others before it (Jonas and Jacobs, 1996), indicate that the vast majori.ty of complaints seen by homeopaths are for chronic, long-term illness. Because these studies showed significant improvement in patient health and in reduction of medication, this data is of special interest to managed care companies.
Additional evidence of good results of successful and potentially cost-effective treat.ment with homeopathic medicines was shown by the Glasgow Homeopathic Hospital which conducted an audit of 100 consecutive patients. They found that 81% had a condition for which conventional medical treatment was not effective and for which 47% had seen a special.ist. After one year, 60% experienced significant improvement in the condition about which they were most concerned, 49% had a sustained improvement in their quality of life, and 37% managed a sustained reduction in their conventional medications (HomInform, 1997). Other smaller studies have also confirmed the cost- effectiveness of homeopathic care.
One pilot study in Great Britain suggested that doctors practicing homeopathic medicine issued fewer prescriptions and at a lower cost than their conventional medical colleagues (Swayne, 1992), while another pilot study in Germany evaluated a single homeopathic dentist’s practice and suggested that it was more cost-effective than conventional dental care (Fedlhaus, 1993).
One other example of a cost benefit to homeopathic care was witnessed in a small study of the homeopathic treatment for infertility (Gerhard et al., 1991). This study showed that homeopathic care for infertility was 30 times less expensive per successful delivery than the match comparison group given conventional care.
Despite these various large and small studies, managed care organizations tend to remain unfamiliar with these investigations, and even when they become knowledgeable of them tend to demand more evidence.
Even when clinical and cost-effectiveness studies suggest benefit from homeopathic medicines, some managed care executives may still remain skeptical until basic science inves.tigations posit compelling evidence on how homeopathic medicines work. Although there has been work in this area too (Lo, 1996; Lo, 1996a), nothing is yet conclusive. Despite the prob.lem of not knowing with certainly how homeopathic medicines work, it is quite possible that this present lack of understanding will not seriously diminish the acceptance of homeopathy, just as many medical treatments today have been readily accepted even though physicians still remain unaware of how or why they seem to work.
While managed care organizations have helped to reduce medical care costs by trim.ming the “fat” from the medical care system, the cost reductions have been less and less re.cently, suggesting that there may not be much more fat to trim. Perhaps what is needed is a more significant change in how medicine is practiced. Professional homeopathic care provides one viable alternative.
For instance, a child with otitis media may receive round after round of antibiotics and may even have eartubes inserted at a significant cost of several thousand dollars. And yet, it is extremely common for children with otitis to receive homeopathic medicines and not experi.ence another ear infection. One study showed that 70.7% of children with otitis medica showed that those given an individually chosen homeopathic medicine experienced no recurrent ear inflammation and 29.3% had a maximum of three relapses, while 56.5% of children given a placebo were free of relapses and 43.6% had a maximum of six recurrences (Friese et al, 1996).
Presently, managed care organizations have kept homeopathy and homeopathic practi.tioners at arm’s length. Such organizations are usually run by business people and physicians who have tended to defend the conventional medical paradigm and its practices at all costs (and it usually has been at all costs).
At the same time, licensed and unlicensed homeopaths have not actively sought to become a part of managed care plans, in part because the vast majority of these practitioners have had successful private practices and have not needed to bolster their patient loads with managed care consumers and in part because homeopaths work within a different paradigm of health and healing that can make communication with some other health professionals difficult.
However, a recent growth in homeopathic training programs is beginning to create increasing numbers of graduates, some of whom will want to or need to interface within man.aged care practices. Because there are not many homeopaths who are doing this work at present and because most managed care companies have tended to be resistant to homeopathic care anyway, there has been little common ground between these two groups. This lack of communication, however, is temporary because managed care ultimately will benefit from the inclusion of homeopathic care, and homeopaths will benefit from becoming a part of main.stream medicine and reimbursed healthcare. The additional incentive for this communication to take place is that consumers are increasingly demanding comprehensive health care that includes homeopathic medicines.
There is also a need for cooperation between the various groups in homeopathy as managed care companies, with some exception, seek to eliminate reimbursement for every.thing except conventional medical care (Chapman, 1995). Although licensed and non-licensed homeopaths will probably each be striving for different types of recognition and levels of reimbursement, there is an overriding need to work together to educate various managed care companies, public and private insurers, and health policy experts about homeopathy and homeopathic care. This work is necessary to increase the chances for inclusion into preferred provider groups, for reimbursement for homeopathic treatment from various insurers, and for decreasing the antagonism and discrimination against homeopathic care and homeopathic prac. titioners from orthodox providers.
However, it will not be workable for homeopaths to be included in reimbursement plans if homeopaths were reimbursed at levels of funding that are similar to other providers who on average spend 5-10 minutes per patient. A serious inequity would result because the first patient visit to a homeopath usually lasts 60-90 minutes, and follow-up visits usually last 20-30 minutes. If the reimbursement issue is not equitable, this problem would discourage homeopaths from seeking inclusion in reimbursement programs and would be a backhanded way to impair the ability of homeopaths to participate in managed care.
There is an effort in America to attain specialization status for homeopathic medical doctors so that they will be reimbursed at levels commensorate with the greater amount of time that they spend with patients, compared to the average family physician visit (Chapman, 1995a). In the same way that psychiatrists are reimbursed at a rate corresponding to longer patient visits, efforts need to be made to seek a similar status for board certified homeopaths. As yet, efforts to attain specialization status have not been successful. In the meantime, it is relatively common for licensed homeopaths to be reimbursed by insurers for “extended” or “comprehensive” visits.
Although many homeopaths may not “need” to become involved in managed care programs because their private practices are already full, a growing number of consumers want inclusion of homeopathic care in their insurance coverage so that they will not have to pay out of pocket for health services that they consider basic to primary care.
Once homeopaths become involved in managed care, those provider organizations will need to develop guidelines for managing homeopaths. Most conventional health policy ana.lysts have no experience with homeopathy and will probably, at least initially, seek to fit homeopaths into conventionally defined categories. Once again, a cooperative effort will be necessary to inform health policy decision-makers about homeopathy, not just as having a different medicines, but about the distinct paradigm of health and health care that homeopathy embodies.
Many homeopaths are pessimistic about the ability of most conventional physicians and managed care administrators to understand and accept homeopathy. There is, however, good reason to be optimistic. While there certainly will be difficulties integrating homeopathy within managed care settings and inevitably there will be many setbacks along the way, it is reasonable to assume that homeopathy will achieve considerably greater acceptance, recogni.tion, and respectability within the next 10 years. This confidence is based on the following trends:
1) The trend in research that has been showing efficacy of homeopathic medicines will contin.ue (Kleijnen et al., 1991; Linde et al., 1997; Bellavite and Signorini, 1995).
2) There is new evidence to show that homeopathic microdoses are, in fact, biologically active (Lo, 1996; Lo, 1996a). This work may generate considerably more research interest in this field.
3) Sales of homeopathic medicines have been growing at a 20-25% annual rate consistently since 1990 (“Herbals Hot; Homeopathics Fare Well, 1996”). The growing demand for homeopathic care and self-care homeopathic products will continue and will inevitably influ.ence managed care organizations.
4) As of 1995, 30% of medical schools and 23% of residency programs in family practice now have coursework in alternative medicine (Carlston et al., 1997), and this trend is rapidly in. creasing. A 1998 survey showed 64% of American medical schools had courses in alternative medicine (Wetzel et al., 1998). Although no survey has yet carefully evaluated the content of these courses, it is reasonable to assume that their inclusion in medical training programs is creating increasing acceptance and respect for alternative medicine, including homeopathy.
5) A recent survey showed that 49% of primary care physicians who are members of the A.M.A. want training in homeopathy (Berman et al., 1997).
In addition to these significant trends, a recent survey of English directors of public health who make decisions on what health care is covered by the National Health Service discovered that they placed safety data and randomized clinical trials as a tied number one priority (Fisher and van Haselen, 1998). This survey suggests that modalities such as homeo.pathic medicine will be a leading priority for major purchasers of health care if the evidence from randomized clinical trials continues to grow. It is, however, uncertain how American executives in managed care organizations would answer a similar survey.
It is reasonable to hypothesize that managed care organizations may play a major role in supporting the homeopathic revolution. Just as managed care organizations are presently educating their patient populations about specific health promotion and disease prevention strategies in order to reduce unnecessary doctor visits or hospitalizations, managed care organ.izations will encourage their constituencies to consider taking a homeopathic medicine as a potentially useful treatment method for common non-emergency acute ailments. Such educa.tional efforts will not simply be in the interests of the consumer but also in the interests of the managed care company.
The risk vs. benefit ratio to using homeopathic medicines at home is so strikingly in favor of the use of homeopathic medicine that this fact will further strengthen the support that homeopathy will receive from managed care organizations.
And if the practice of homeopathic medicine is as cost- effective as the evidence present.ly suggests, some managed care organizations may even go as far as encouraging physicians and other health care providers to become trained in homeopathy.
A challenge presently exists for both those people involved in homeopathic medicine and those involved in managed care organizations. It may be time to create pilot projects to evaluate both the efficacy and cost-effectiveness of homeopathic care. On one hand, managed care administrators must consider investing in investigating homeopathy, and on the other hand, homeopaths and others who are committed to the field must cooperate with such investi.gations and even make proactive efforts to substantiate the value of homeopathic care.
There has been a tendency of those who are involved in homeopathy to feel their ener.gies must be focused on developing knowledge and experience in homeopathy to become better clinicians. While this is certainly vital, individual advocates of homeopathy and homeopathic organizations must also look for useful ways that homeopathy can grow through recognition of the profession within mainstream institutions and through inclusion within various managed care programs.
Bellavite P, Signorini A. Homeopathy: a frontier in medical science. Berkeley: North Atlantic; 1995.
Berman B, Hartnoll SM, Singh BB, Krishna Singh B., Homoeopathy and the US primary care physician.” British Homoeopathic Journal. July 1997;86:131-138.
Caisse Nationale de l’Assurance Maladie des Travailleurs Salaris, 1996 study of 130,000 prescriptions.
California vs. Gregory Dana Ullman, Municipal Court Oakland Piedmont Judicial District, 98158, March 29, 1977.
Carlston M, Stuart MR, and Jonas WB. Alternative medicine instruction in medical schools and family practice residency programs. Family Medicine, October, 1997, 29:559-562.
Chapman E. Homeopathy: Moving towards the mainstream in a changing health care system. Journal of the American Institute of Homeopathy. 1995;88,4:172-178.
Chapman E. Coding for homeopathic procedures. Journal of the American Institute of Homeopathy. 1995a;88,3:117-119.
Cohen MH. Legal ramifications of homeopathy. Journal of Alternative and Complementary Medicine. Winter, 1995;1,4:393-398.
Feldhaus H-W. Cost-effectiveness of homeopathic treatment in a dental practice. British Homoeopathic Journal. January, 1993;82,1:22-28.
Fisher, P, van Haselen, R., Evidence influencing British Health Authorities’ decisions in purchasing complementary medicine. JAMA. November 11 1998;280,18:1564.
Food and Drug Administration, Compliance Policy Guide, Conditions Under Which Homeo.pathic Drugs May be Marketed, 7132.15, 1988.
Friese K-H, Kruse S, Moeler H. “Otitis media in children: a comparison of conventional and homeopathic drugs.” HNO (Head and Neck Otorhinolarynology). 1996;44:462-466.
Gerhard I, Reimers G, Keller C, et al., “Weibliche fertiltitasstorungen. Vergleich homoopa.thischer einzelmittel–mit konventioneller hormontherapie.” Therapeutikon. 1991;7:309-315.
GRECHO, “Evaluation de deux produits homeopathiques sur la reprise du transit apres chirur.gic digestive: un essai controle multicentrique.” Presse Med 1989;18:59-62.
HomInform, Homoeopathy: The Guide (CDRom), (June 1, 1997).
“Herbals Hot; Homeopathics Fare Well,” OTC Market Report. June, 1996. Nicholas Hall.
Jackson S. Alternative medicine: not so alternative anymore. Business Week. June 2, 1997.
Jacobs J, Smith N. Charges, utilization, and practice patterns from a pilot insurance program covering alternative medical services. American Public Health Association Conference, New York City, November 18-21, 1996.
Jonas WB, Jacobs J, Healing with homeopathy. New York: Warner, 1996.
Kleijnen J, Knipschild P, ter Riet G, “Clinical trials of homoeopathy.” British Medical Jour.nal. February 9, 1991;302:316- 323.
Linde K, Clausius N, Ramirez G, et al., “Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo- controlled trials,” Lancet. September 20, 1997;350:834-843.
Lo S-Y, “Anomalous state of ice,” Modern Physics Letters B. 1996;10,19:909-919.
Lo S-Y, Lo A, Chong LW, et al., “Physical properties of water with IE structures.” Modern Physics Letters B. 1996a;10,19:921- 930.
National Center for Homeopathy, 1998 Directory, Alexandria, VA.
Nevada State Law, Chapter 630A. 1995;15051-15080.
Papp R, Schuback G, Beck E, et al., “Oscillococcinum in patients with influenza-like syn.dromes: A placebo-controlled double-blind evaluation,” British Homoeopathic Journal. April 1998;87:69-76.
Piturro MC. The alternative mainstream: managed care beginning to embrace non-conven.tional medicine. Managed Healthcare News, June, 1996.
Reilly D, Taylor M, Beattie N, et al., “Is evidence for homoeopathy reproducible?” Lancet. December 10, 1994;344:1601-6.
Settlement agreement between Helen Healy and the Minnesota Board of Medical Practice, September 18, 1996.
Sharples F, van Haselen, R, Patients perspective on using a complementary medicine approach to their health: a survey at the Royal London Homoeopathic Hospital NHS Trust (no date, but first made available in 1998).
Social Security Statistics. CNAM (National Inter-Regulations System) 61, French Government Report. January 1991.
Swayne J, The cost and effectiveness of homeopathy. British Homoeopathic Journal July 1992;81,3:148-150.
Ullman D., Implications of a court case, Holistic health handbook. Berkeley: And/Or, 1978.
Ullman D., Consumer’s Guide to Homeopathy. New York: Jeremy Tarcher/Putnam; 1996.
Walach, H, Hausler, W, Lowes t, et al. “Classical homeopathic treatment of chronic head.aches. Cephalalgia 1997;17:119-26.
Weiser M, Strosser W, Klein P. Homeopathic vs conventional treatment of vertigo: A random.ized double-blind controlled clinical study. Archives of Otolaryngology–Head and Neck Sur.gery 1998;124:879-885.
Wetzel MS, Eisenberg, D, Kaptchuk T. Course involving complementary and alternative medicine at US medical schools. JAMA. September 2 1998;280:784-787.
Whitmarsh TE, Colestron-Shields SM, Steiner TJ. “Double-blind randomized placebo-con.trolled study of homoeopathic prophylaxis of migraine. Cephalalgia 1997;17:600-04.
Wiesenauer M, Ludtke R, “A meta-analysis of the homeopathic treatment of pollinosis with Galphimia Glauca” (a review of 11 annual studies). Forsch Komplementarmed. 1996;3,230-234.
My thanks to Randall Neustaedter, OMD, Edward (Ted) Chapman, MD, John Weeks, Monica Miller, Michael Cohen, Jennifer Jacobs, MD, and Doris Milton, RN, PhD. for their comments on the article.
Key words: Homeopathy, Managed care, Alternative medicine, Cost- effectiveness, Legal status, Consumer rights
No grants or financial support were used in writing this article.
Various homeopathic organizations provide training programs and general information:
National Center for Homoeopathy
801 N. Fairfax #306
Alexandria, VA. 22314