A White Paper on Safety and Choice with Integrative Medicine
Proposed Private Sector Answer to Our Health Care Crisis
L. Terry Chappell, M.D. to be presented at the Royal College of Physicians, London, England, in March, 2007
KEY CONCEPTS OF THIS WHITE PAPER
1. Our health care system consists of Consumers, Concentrated Economic Interests, and Government Regulatory Bodies.
2. Our health care system, which is really a disease care system, is collapsing and headed toward backruptcy.
3. There has been little progress in chronic disease care outcomes for 35 years, but costs have increased substantially. The risks of compications from procedures and side effects from drugs is substantial, which decreases the effectiveness of our system.
4. Conventional Medicine as part of CEI has limited its scope to drugs and surgery with a major profit incentive and a disturbing conflict of interest.
5. Much of the evidence used as a basis to support drugs and surgery has been mis-interpreted and exagerated. Safety has not been given proper attention in establishing treatment guidelines.
6. Companies that fund insurance benefits for their workers are a part of CEI and have the greatest opportunity for change. Wellness programs that emphasize lifetyle changes can be enhanced. Integrative Medicine can be embraced and reimbursed. A rational prescription plan can be implemented.
7. Paying for high-impact Integrative Medicine and a rational prescription policy will substantially reduce the number of procedures and costs, reduce disability, improve outcomes, enhance performance, and increase safety. Examples of high-impact IM include prolotherapy, chelation therapy, acupuncture, allergy and immune boosting, and detoxification. A rational prescription policy includes reduced dose, reduced risk, reduced cost, use of generics, paying for selected over-the-counter drugs, and substitution of natural products when possible.
8. Consumer-Driven Health Care with complete Transparency and Integrative Medicine as an option will implement change effectively. Transparency consists of identifying what the evidence really shows, education, and true informed consent.
9. Integrative physicians can work with current primary care physicians and with minor modifications to existing insurance plans to adopt these concepts.
10. Changes in Government Regulatory Bodies are also needed but the Government is painfully slow. We do not have to wait for GRB to act. The private sector can rapidly improve the effectiveness of our health care system, increase safety and reduce costs.
As with most industries in the United States, the health care industry consists of three major components:
1. Concentrated Economic Interest
2. Government Regulatory Bodies
The health care system in the United States features the most advanced technology in the world, which can result in dramatic, sometimes spectacular restorative health benefits. We can transplant organs, manipulate genes, crush arterial plaque, kill cancer cells, destroy dangerous bacteria with a single new antibiotic, replace joints with man-made materials, and save lives of newborns that can be held easily in one hand.
At the same time, compared with other developed countries, our health care system is burdened with high infant mortality, low life expectancy, large numbers of disabled citizens, and many patients under treatment who continue to suffer from chronic degenerative diseases. The Center for Disease Control estimates that 70 million Americans suffer from arthritis or chronic joint pain. According to Carolyn Dean in Death by Modern Medicine, as many as 784,000 people die every year in the US from complications of drugs, medical procedures and hospitalizations. Such complications could be called the leading cause of death. Cancer and heart disease each claim slightly less than 500,000 victims per year.
The widespread use of non-steroidal, anti-inflammatory drugs like ibuprofen has been blamed for bleeding ulcers and kidney failure for many years. Now some of the Cox-2-inhibitors (e.g. Vioxx) have been linked to heart attacks. Bacterial super-bugs are developing resistance to our most powerful antibiotics. A large increase in polluting chemicals in the environment have been linked to a higher incidence of cancer, asthma, autism, and many other diseases.
According to a report by the Institute of Medicine in 1999, there were between 44,000 and 98,000 deaths each year due to medical mistakes in hospitals. This compared to 14,088 deaths from guns in 1998 and 43,400 deaths from automobile accidents. Substantial efforts have been made to reduce such mistakes, but minimal progress has been made to date.
Health care costs are increasing each year. Insurance rates are also rising rapidly, and insurance companies report that they cannot keep up with claims. The number of uninsured US citizens is around 44,000,000 people. Large and small businesses that provide health care coverage are finding the cost to be an uncontrollable part of their budget. Most agree that we are in a crisis. Our health care system is failing. It is headed toward bankrupcy.
The first version of this white paper written in 1999 pointed out that up to 69% of Consumers had chosen to utilize Complementary and Alternative Medicine (CAM), despite considerable resistance from Concentrated Economic Interests and Government Regulatory Bodies. CAM is much safer than Conventional Medicine. The widepread use of CAM has enormous potential to reduce costs and increase effectiveness. The initial white paper was written to stimulate Congress and State Legislatures to reduce the barriers against CAM, which would have caused a fundamental change that would have made the health care system safer, more effective and less expensive.
During the intervening eight years, three new concepts have evolved. First, practitioners trained in CAM have emphasized the concept of Integrative Medicine, which combines the best of Conventional Medicine with the best of Alternatives. Second, Evidence-based Medicine has emerged as a standard for both conventional and innovative approaches. Third, the concept of Transparency has been developed to describe the need for an open health care system in which everyone understands exactly what is going on.
Unfortunately, Government Regulatory Bodies have failed to adopt measures to reduce the barriers against Integrative Medicine. There is still a need for such measures. The only way that Government Regulatory Bodies will act is in response to pressure from Consumers who are fed up with a failing system. At the same time, Consumers should not have to wait for a painfully slow governmental machine to respond. Consumers have shown that they are willing to pay for Integrative Medicine regardless of insurance reimbursement because they sense that it is safer and might be more effective than the usual and customary medical care.
Finally, those who fund Concentrated Economic Interests in the private sector are coming to the realization that drastic changes must occur in the health care system. Large and small companies that provide health insurance as benefits are desperately looking for answers. The widespread use of Integrative Medicine has a huge potential to help solve the crisis that we face. The purpose of this updated white paper is to demonstrate how all three of the components of the health care industry can take actions to create an affordable health care system that is much safer and more effective than what we have today. Those that fund insurance coverage are in the best position to implement this change.
Consumers are the recipients of health care. However, the term “health care” is actually a misnomer. In the United States, we actually have a “disease care’ system. Most consumers rely on their insurance to cover most of their medical expenses. In order for medical expenses to be reimburseable, a test or treatment must be connected to a diagnosis. Occasionally, “preventive medicine” in the form of screening tests are covered services, but they are offered for the purpose of detecting illness at an early stage. They do not prevent the illness from occuring.
The online journal, PloS Medicine, defines “disease mongering” as “the selling of sickness that widens the boundries of illness and grows the markets for those who sell and deliver treatments”. Such screening tests as mammograms, PSA’s, cholesterol and other blood tests, circulation testing, and bone density are used primaily for disease mongering. By expanding the boundries of illness, providers of disease care funnel consumers into the disease care system. Sometimes early detection can be beneficial, but not infrequently extensive follow-up testing does not confirm an abnormality. After a confirmed positive screening test, some patients are subjected to high-risk follow-up tests such as angiograms, the latest drugs with prominent side effects, and surgical procedures that have potential complications, occaionally even death. Many of these disease care procedures are not only potentially dangerous, but are also wasteful and expensive. Even that might be justified if they were effective, but evidenced-based medicine has failed to show that many common disease care procedures and medications can prolong life significantly. Our death rate from cancer and heart disease is about the same as it was 35 years ago.
True preventive medicine that sustains health is rarely covered by insurance. Thus, there is no financial incentive to eat healthy, exercise regularly, deal with stress, detoxify the body from pollutants and take care of our environment. These preventive measures are the action plans needed for an effective strategy to avoid illness and minimize contact with the disease care system. Screening tests might be much more acceptable if they were used aggressively to funnel people into preventive strategies, rather than toward conventional medicine’s tests and treatments of dubious value.
The Toll of Chronic Degenerative Disease
Approximately 45% of non-institutionalized Americans have one or more chronic health condition, which in turn increases their risk for premature death or decreased productivity. This accounts for three-fourths of the annual total health care expenditures in the United States. Not only are conventional treatments for these conditions minimumly successful, but most of the treatments have potential risks and complications.
Richard Nixon declared war on cancer in 1971. Conventional medicine has responded with some efforts at early detection, continuation of chemotherapy and radiation as the mainstays of treatment, and little for prevention. The death rates from cancer are essentially the same today as they were in 1971. The only real change we have seen in cancer therapy is expenditures, which have increased greatly and have become a major part of hospital incomes.
Heart disease and strokes are the first and third cause of death from specific illness in the US, with cancer in between. What has happened to the death rates for cardiovascular disease over the last 35 years, with the advent of coronary bypass surgery, cardiac care units, and drug regimens that often cost $500-1000 per month? The death rate has come down a few percentage points. The Institute of Medicine attributes this minimal improvement to lifestyle changes, especially reducing the number of male smokers. These illnesses are still at the top of the death lists.
Most of our cardiac drugs and surgery have no impact on the cardiovascular death rate or the death rate from all causes. The evidence shows that you have to treat 100 patients with either aspirin or high-dose statin drugs in order to save one heart attack. At the same time you risk causing major bleeding episodes from aspirin and debilitating muscle pain from the statins. We perform more bypass procedures than most other first world countries, combined. Our cardiac care, which is based in our hospitals, is built upon a foundation of trivial evidence and disappointing outcomes.
Musculoskeletal problems are the leading cause of expenditures for industrial health care plans. A meta-analysis of 15 studies of chronic, non-malignant pain found an incidence of 15% of all Americans. An FDA advisory committee estimated the same prevalence, with 10% of those having seriously considered suicide as an escape from their pain. Others have estimated that 50 million people in the US are partially or completely disabled due to chronic pain, which makes pain the most common cause of long-term disability.
Nonsteroidal anti-inflammatory drugs such as ibuprofen and Vioxx have fallen out of favor because they have been linked to gastric bleeding, kidney failure and heart attacks. Physicians are afraid to prescribe narcotics to patients even when clearly indicated because some of their peers have faced discipline or loss of license from their medical boards. Ineffective pain treatment leads to longer hospital stays, rehospitalizations, and many, many visits to physicians and other health care providers in their offices. Joint replacements, epidural nerve blocks and back surgeries have moved to the forefront in the treatment of chronic degenerative joint problems. Sometimes these procedures are very helpful, and sometimes they do not help at all or create worse problems.
The United States spends twice as much on health care on a per capita basis as most European countries and three times as much as Japan. Incredibly, when health results are quantitated, the US ranks between 15th and 31st compared to other countries. US Consumers are certainly not getting their money’s worth. One of the leading causes of personal bankruptcy in the US is unexpected health care costs for people who have health insurance. General Motors pays more for worker health care than it does for steel. There can be no doubt that health care costs are rising at an unsustainable rate. At our current rate of growth, health care costs by 2099 will absorb 100% of our economy.
Opacity and Transparency
Transparency consists of identifying what the scientific evidence really shows, education of Consumers, and true informed consent provided by health professionals so Consumers can choose the type of health care they feel is best for them.
Consumers are currently faced with opacity in their health care system. If they want to be reimbursed for their health care, they have virtually no choice as to what that care will be. They are not informed about the strength of the evidence to support the tests and therapies that are presented to them. They are not offered alternatives. They are not given broad informed consents. They are kept totally in the dark about how decisions are made as to what procedures and therapies are covered by their insurance. They know little about the risks and costs of the medications. They do not know the extent of the benefits that they might achieve by taking a particular drug or submitting to a surgical procedure. They do not know about conflicts of interest or publication bias. They do not know the relative benefits and risks of lifestyle changes compared to those of medications or surgeries.
Opacity is created by physicians who demand compliance with the least amount of information about options, often within the shortest possible amount of time. Compassion is not in great supply, even when the proposed procedures might be looked upon as violent (cutting with surgery, poisoning enzyme systems with drugs, burning with radiation). The patient is not the decision-maker, although the physical body and mental well being are his own.
There is no surprise that a growing number of patients are seeking complementary and alternative medicine (CAM) to be integrated into their health care. Many patients intuitively distrust the opacity that they trying to deal with. They seek transparency and reasonable options, despite the authority of their doctors and their inferior position of power. Most important, they fear the hazards of the disease care system. They know that drugs have the potential to hurt them as well as help them. Surgery can go terribly wrong and even take their lives. They know that people die in hospitals. They have friends and relatives that have benefitted from Integrative Medicine. They know that the latter carries much less risk than conventional medicine. They are aware of unnecessary surgeries and the dangers of polypharmacy. By improving function and restoring balance, Integrative Medicine can encourage the body to heal itself, which makes a lot of sense to those who can feel their bodies not working properly. They are willing to spend their own funds to get this type of health care, within limits of course. If their insurance company encouraged the use of Integrative Medicine, its use would skyrocket.
CONCENTRATED ECONOMIC INTERESTS
Just as Eisenhower warned the nation about the Military-Industrial Complex, others have expressed concern about the Medical-Pharmaceutical Complex. Concentrated Economic Interests in the medical field includes interactions among drug companies, organized medicine, hospitals, medical schools, businesses and industry that fund insurance, and insurance companies themselves, especially managed care.
Guidelines for Therapy
The component groups that make up Concentrated Economic Interests have peer-review activities that have created an accepted body of knowledge and practice loosely based on scientific evidence. Guidelines are sometimes published and sometimes kept secret. However, CEI do not hesitate to ignor their own guidelines, especially if a therapy is generally accepted for other purposes. For example, they set guidelines for the appropriate indications for coronary bypass surgery and then perform many procedures that do not meet those guidelines. Insurance companies pay for the unnecessary procedures and medical schools depend on the revenues. The companies that fund insurance for their workers depend upon conventional physicians to police the system with peer review. Those doctors represent the system with a major financial conflict of interest. The guidelines used to approve coverage are written by a profession that depends on the payment of expensive procedures for its income. Whenever a hospital and its doctors have the ability to do a lucrative procedure like bypass surgery, they want to use that skill as often as possible in order to justify having it available.
Two recent books have revealed that the Medical-Pharmaceutical Complex has misinterpreted the published scientific evidence to provide Concentrated Economic Interests with a set of guidelines that is costly and based on flimsy evidence. In Overdosed America, Abramson meticulously examines study after study that justify the mandated use of expensive and dangerous drugs. The actual evidence in the studies show minimal benefits at best and sometimes even show harm. By looking at relative risk reduction comparing one drug to another as opposed to absolute risk reduction, which defines the true outcome of an intervention, physician authors are able to completely distort their conclusions to affirm their intended purpose. Instead of scientific research seeking to find unbiased answers, we are given distorted statistics to support a premise and achieve a profit.
Kaufman’s book Malignant Medical Myths explores the scientific basis for many common perceptions in the medical profession and finds an apalling lack of evidence to support them. In fact an unbiased interpretation of data sometimes proves just the opposite. Furthermore, the number of patients who suffer complications is often comparable to the number who show any benefit. Naturally, distorted conclusions reached by Conventional Medicine greatly increase the cost of care to Consumers.
Grayboys has reported on a clinic at Harvard Medical School that offers second opinions for those who have had diagnostic angiograms and bypass surgery recommended. He demonstrated that 80% of angiograms and 75% of bypass procedures were found to be unnecessary according to published clinical guidelines. Obviously, the guidelines put into practice were far different than those based on the published evidence.
For patients 65 years of age or older who suffer a myocardial infarction, the New England Journal of Medicine reports a much higher use of cardiac procedures such as angiograms, angioplasty and bypass surgery in the United States than in Canada, which resulted in no significant difference in long-term death or disability rates. A group of Mayo Clinic cardiologists looked at sex differences in the evaluation of unstable angina and found that the use of cardiac procedures was significantly lower in women. To their surprise, when all factors were taken into account, the neglected women were fortunate because they had better outcomes. The men had a 21% more risk of subsequent cardiac events than the women.
The American Medical News reported on a survey published in the Archives of Internal Medicine in which 58% of internal medicine specialists felt it was appropriate to lie to insurance companies about the severity of a patient’s condition to achieve insurance reimbursement for bypass surgery, when the patient in actuality did not meet the guidelines for such surgery.
The latest ploy in the insurance system is pay-for-performance. The idea is to pay bonuses to physicians who can demonstrate that they have given quality care to their patients. So far, the computer programs used are clearly not good enough to analyze the data accurately. However, the main problem with this initiative is that the measurement of quality uses surrogate end-points based on flawed evidence, such as achieving a certain blood pressure, cholesterol level, or flu shot rate. The standard of care is not necessarily based on the most effective treatments. If performance were based on improved quality of life, reduced death rates, fewer heart attacks, less days of work missed due to influenza and improved disability, that would make a lot more sense. Very soon, doctors would realize that they could get more bonus money if they used Integrative Medicine in their practices.
Funding of Research
Abramson points out that in the late 1980’s and early 1990’s the Reagan administration cut the funding for the National Institutes of Health. As a result there was a huge shift from public funding of research to the private sector. Pharmaceutical companies pay medical schools and private groups to do research on their new drugs. If the results are negative, they are usually not published. If they are positive, the statistics are arranged in the best possible light for publication.
When their drugs are approved by the FDA, drug companies promote them vigorously to physicians by drug representatives and by placing prominent advertisements in the journals of organized medicine and often in the public media. The revenues from these ads are a large part of the income for the professional journals, which is a major conflict of interest. Insurance companies and their funding partners in industry are pressured by the marketplace to provide the latest drug therapies, which are almost always more expensive than previous treatments, even if improved benefits are questionable. Insurance companies raise their rates each year to accommodate the increase in costs. The businesses that provide insurance benefits to their employees have to follow suit. Everybody gets financially squeezed, especially the business community. This is a major reason why our system is headed toward collapse.
Procedures for Profit
Patients used to go to hospitals to receive intensive nursing care at the direction of family doctors with the occasional help from specialists. Over time, they would recover and be sent home. Technology has advanced, and physicians have become more skilled at doing complicated procedures. As insurance has evolved from financial aid for emergency and catastrophic illness to coverage of most medical care, codes had to be developed to submit claims. The American Medical Association seized that opportunity and developed an ongoing system of codes that is used exclusively by the Medical-Pharmaceutical Complex. This has proven to be a major source of income for the AMA, because they sell these code books with yearly updates.
The majority of the AMA’s membership is made up of physicians who have specialized. Specialists found that they could earn more money by doing procedures than by talking to patients. Medical payments through insurance and the codes that drive the insurance are heavily weighted toward procedures. Even family doctors nowadays would have a hard time paying their overhead if all they did was talk to patients and give them advice.
Hospitals depend on procedures for their livelihood. Can you imagine how many hospitals would remain open for business if it were not for bypass surgery and joint replacements, each of which bring in $40,000-100,000 per procedure?
The Shocking Truth about Drug Prices
In the September, 2006 issue of Life Extension, the actual cost of the raw materials for prescription drugs was reported. The mark-up was astronomical, as noted by the few examples in the table below. The article also pointed out that generic drugs can also have an incredibly high mark-up. Abramson in Overdosing America documents that the implementation of rational prescribing habits can save a huge amount of money.
DRUG RETAIL/100TABS COST MARKUP
Celebrex 100mg $130.27 $0.60 21,712%
Lipitor 20mg $272.37 $5.80 4,696%
Prozac 20mg $247.47 $0.11 224,973%
Zestril 20mg $89.89 $3.20 2,809%
The Good and the Bad about Concentrated Economic Interests
The marketplace in the United States has produced a disease care system that is capable of spectacular results. Students and residents come from all over the world to study here. Rich international patients come for treatment in our most prominent medical centers. Some of the research performed is of the highest quality. Our scientists receive many Nobel prizes.
However, Concentrated Economic Interests in our disease care system have been successful in limiting competition and promoting high-tech procedures and patented drugs to create profits. They have controlled the flow of information with a huge conflict of interest. They have misinterpreted data and reached faulty conclusions. Thus our progress against chronic degenerative diseases has been minimal and our system is in deep financial trouble.
Furthermore, disease care when it is urgently needed and the limited successful preventive measures that we have adopted into our system are too often not available to our citizens because they do not have health insurance.
GOVERNMENT REGULATORY BODIES
Government Regulatory Bodies have been created to protect our citizens. To some degree they perform this function well. We do not want our health care system to be frought with dangerous drugs, false claims, fraudulent charges and impaired physicians. However, once established, governmental power tends to be excessively utilized. And our Government Regulatory Bodies draw upon the expertise of Concentrated Economic Interests to the detriment of Consumers.
The Federal Drug Administration has regulatory authority for the safety of both medications and dietary supplements. In regard to medications, the FDA has been criticized because it has had to recall many medications that the agency had approved (due to deaths and complications) and also because the drug approval process has been so slow, expensive and cumberosome. In recent years, the time interval for drug approval has been reduced by half. “Phen-phen” diet pills and Vioxx were withdrawn due to cardiac complications. Another non-steroidal anti-inflammatory drug, Duract, relieved pain but led to such severe liver damage that several patients required liver transplants. Seldane, a popular non-sedating anti-histamine caused fatal arrhythmias. The calcium-channel blocker, Posicor, increased the side effects and toxicity of many other drugs.
The FDA also has full statutary authority to approve claims for dietary supplements. Congress passed the Dietary Supplement Act of 1994, which required the FDA to approve reasonable claims. The FDA refused to comply. In 1999 the Court of Appeals determined that the FDA’s restrictive health claim rules were unconstitutional and a violation of the Administrative Procedures Act. Still, the FDA refuses to encourage truthful information to be disseminated about dietary supplements, which if allowed would increase transparency, increase usage, and improve safety of these products.
Despite a huge number of scientific studies on the benefits of oral vitamin and mineral supplements, the FDA has approved only a handful of claims related to their use. With two or three exceptions these supplements have proven to be extremely safe. Consumers have not suffered serious side effects while taking them. The FDA continues to block the availability of reliable nutritional information to consumers, perhaps in part because of their connections to Concentrated Economic Interests through the giants of the pharmaceutical industry. It is likely that pharmaceutical companies are concerned about competition from natural products. The FDA appears to spend almost as much effort in limiting the use of safe nutritional products as it does in detecting the dangers of prescription medications.
The Federal Trade Commision has two roles, consumer protection and anti-trust. In recent years, the FTC has filed complaints for several professional societies who teach and advocate CAM. The FTC’s strategy is to find a claim made at some time by the society and charge them with false advertising, with huge potential penalties. The FTC then seeks consent orders from these organizations. No matter how strong the defense arguments, none of these organizations have had the financial resources to combat the deep pockets of the government. Several have signed consent orders, simply because they have run out funds to pay the legal fees required to pursue their cases in court.
The Federation of State Medical Boards is a private group of Medical Board members, who license medical doctors and osteopathic physicians throughout the US. Following the guidance of Conventional Medicine, the FSMB has labelled nearly all CAM as ‘questionable”. The FSMB works with the Association of State Attorneys General, the individual Medical Boards, and Administrative Law Judges, whose salaries are usually paid from Medical Board budgets, to regulate physicians who offer CAM to their patients. A disproportionate number of CAM doctors have been brought before Medical Boards, even with no patient complaints and no concern about causing harm to patients. In this way Conventional Medicine has indirectly discouraged physicians from offering Integrative Medicine to their patients. Despite this threat, more and more physicians are learning about integrative techniques, as they seek new and safer ways to help their patients. Medical students, residents and practicing physicians have asked for more information in Integrative Medicine. Courses are now taught at most medical schools, and there is an abundance of continuing education courses in the field.
Similarly, Conventional Medicine has asked Pharmacy Boards to severely limit compounding drugs because such preparations are often prescribed by integrative physicians. Such a regulation would essentially eliminate the basis of the pharmacy profession, which goes back to the days when all therapies were compounded from a pharmacist’s stock of raw materials. These efforts have failed, and there are compounding pharmacies throughout the United States who are an essential part of Integrative Medicine.
Medicare has acted as a Government Regulatory Body by refusing to pay for Integrative Medicine. Those doctors who provide Integrative Medicine are also in a bind because there are few codes for their natural therapies in the Current Procedures and Terminology text, which all doctors must use. The code book is published by the American Medical Association and its sale is a large portion of the AMA’s revenues. Even though the AMA represents only about 30% of physicians in the United States, it has a monopoly on the coding system. If a integrative doctor participates in Medicare, he or she must choose the closest code to describe what service was provided. If Medicare determines that the doctor chose the wrong code, it can fine him or her over $100,000 or even threaten the doctor with prison. As a result, many integrative physicians have opted out of Medicare. With the projected Medicare fee reductions over the next few years, many conventional doctors cannot afford to see Medicare patients and are opting out of the system as well.
The Health Insurance Portability Act of 1996 extended fraud and abuse charges to insurance claims. The act classified unintended clerical errors in coding as potential felonies, with major penalties. By providing financial incentives for patients to report their doctors for fraud, the act also disrupted the patient-physician relationship. Although all doctors are affected, integrative docs are more vulnerable to attack than their conventional colleagues due to the same difficulty in finding an appropriate code.
The American Board of Medical Specialties has consistently refused to recognize specialties in Integrative Medicine, even if those specialties have functioning Boards of Examiners that offer written and oral examinations of high quality. In turn Medical Boards and elements of Concentrated Economic Interests such as insurance companies do not recognize specialties not listed by ABMS. Thus, despite their attempts to achieve and document a high standard of excellence, integrative specialists have been kept out of the official health care network, and Consumers have been forced to pay for their services out of pocket.
Government Regulatory Bodies have been resistant to change, unless the change comes through traditional channels, such as Medical Schools, the National Institutes of Health, and Big Pharma. Most of CAM has come from traditional medicine dating back 5000 years, from individual physicians and other practitioners, and from smaller organizations that teach these modalities. The time has come for these approaches to be integrated for the benefit of Consumers.
In his 1961 book High Level Wellness, Halbert Dunn provided a definition for choosing health, which turns out to be a good description of what we now call Integrative Medicine:
Choosing health means:
“ viewing a person and his/her wellness from every possible perspective, taking into account every available concept and skill for the person’s growth toward harmony and balance. It means treating the person, not the disease. It means using mild, natural methods whenever possible. For the person, it means engaging in a healthier lifestyle to enjoy a higher level of wellness. The holistic approach promotes the interrelationship and unity of body, mind and spirit. It encourages healthy, enjoyable activity on all these levels of existence. A holistic approach differs from simply following an
‘alternative’ therapy. It is not an alternative to conventional medical practice. Rather, it includes judicious use of the best of modern Western medicine combined with the best of health practices from East and West, old and new.”
In a nutshell, Conventional Medicine is what licensed medical doctors and osteopathic physicians put into practice based on what they were taught in medical or osteopathic school and the continuing guidelines published in major medical journals. Conventional medical care is essentially “disease care”. “Preventive medicine” is a misnomer, which in actual practice becomes screening for disease at an early stage.
Wellness programs are a big step forward. They emphasize diet, exercise and stress control. Spirituality and improving self-concepts are often included. These measures can be helpful in treating innumerable diseases. They also can be influential in preventing many chronic degenerative diseases.
Integrative Medicine embraces the concepts of Wellness and the best, safest and most cost-effective parts of Conventional Medicine. It goes beyond that, as described above by Dunn. High-impact integrative techniques can build structure and strengthen ligaments (prolotherapy), improve circulation (chelaton therapy), normalize the immune system (anti-fungal and allergy treatment), improve energy fields (acupuncture), increase endurance (subclinical thyroid and adrenal supplementation) and detoxify from pollutants (various oral supplements, IV’s, sauna and colon hydrotherapy). Integrative Medicine enhances normal function and restores balance.
The harmful effects of pollution in our environment have been reported widely in the news media. In the October 2006 issue of National Geographic, David Duncan documented that we have many toxic chemicals in our bodies even without direct exposure in the home or workplace. Some of the most dangerous chemicals commonly found, such as mercury and lead, have been closely tied to autoimmune problems, allergies, cancer, asthma, heart disease, autism and other chronic diseases. Except for children who have eaten lead-based paint that can sharply reduce their IQ’s, Conventional Medicine has pretty much ignored detection and treatment for these chemicals. Some of the most effective techniques in Integrative Medicine are to remove toxic metals with chelation and to desensitize the body with environmental medicine.
Integrative Medicine gets the best results when all health advisors for a patient are work together in harmony. A heart patient might have a cardiologist monitor a couple of carefully chosen cardiac medicines, the family doc controls the blood pressure, a wellness coach helps maintain healthy lifestyle choices, and an integrative doc provides chelation therapy and shows how red yeast can work just as well as Lipitor at less than half the cost and without the usual muscle aching from the drug. There is no question that the patient has the potential to get better results with an integrative approach than with Conventional Medicine alone. By avoiding cardiac catheterizations and surgeries, a heart patient could save a substantial amount of money for himself and/or his insurance company.
COST SAVINGS WITH INTEGRATIVE MEDICINE
Cost savings can be achieved by reducing the need for procedures, both diagnostic and therapeutic, by shifting from drugs to nutrients, and by improving function, which lessons disability and enhances productivity.
The most expensive conditions in the working age population are joint disorders and cardiovascular conditions. Both involve high-tech assessments, such as MRI’s and coronary angiograms. Both also are treated with very expensive surgeries, namely joint replacements and bypass/angioplasty. The evidence is not extensive, but what we have appears to indicate that by utilizing prolotherapy for joint problems and chelation therapy for cardiovascular diseases, we could prevent surgery and some of the diagnostic procedures that accompany surgery in up to 75% of the cases treated. At $40,000-100,000 per surgical procedure, these savings add up quickly.
Healthy Lifestyle Options, LLC is a consulting group that helps companies improve outcomes, increase safety, and save costs by implementing a rational drug program and supplementing employer health plans with an Integrative Medicine option. They estimate that with a rational program on drugs combined with effective integrative health care, they can save employers at least 30% in annual drug costs and medical claims for their workers. The HLO progam results in a large reduction in procedures by having the employer self-insure for integrative treatments instead of surgery.
Conventional medicine is not highly successful in treating stress-related conditions such as fatigue, fibromyalgia, spastic colitis, and frequent headaches. Integrative Medicine gets much better results with safer therapies. Workers with these conditions, as well as mental health problems, autoimmune diseases, and frequent infections would very likely improve work attendance and productivity by implementing a shift toward Integrative Medicine. Low back pain is one of the most common complaints of workers, and research has shown that integrative therapies do at least well if not better than conventional therapies, usually at a much lower cost.
WHAT CAN BE DONE, BY WHOM
Consumers have already demonstrated that many want integrative care strongly enough that they are willing to pay for it themselves without relying on insurance coverage. Many more would utilize the safer, “life-changing” integrative therapies that appear to be so successful, if their insurance would provide the necessary coverage. Increasingly, consumers are given the option to choose Consumer-driven Health Care (CDH), as in health savings accounts, whereby the consumer can spend the first $1000-2000 per year of his or her health care for whatever he or she chooses, with a high-deductable base policy as back-up.
With or without the help of a Wellness coach, Consumers must take charge of their own health. Diet, exercise, dealing with stress, and minimizing pollutants are habits that ultimately must be chosen by a consumer, if disease, disability and premature death are to be avoided.
Transparency about the goals and techniques of the health care system is mandatory. Then the Consumer has to put forth an effort to really learn about important health concerns. He or she must be convinced of the connection between the effort he or she puts into an integrative health program and achieving high level wellness.
One cannot expect Concentrated Economic Interests to expend a strong effort to cut costs. Their financial incentives are exactly in the opposite direction. A hospital will lose a lot of money if bypass surgery and joint replacement costs are reduced. In fact many hospitals would not survive if the reductions are substantial. Invasive cardiologists are the highest paid non-surgical specialists. Every catheterization they do not perform is one less trip to the bank. In fact most doctors who rely on doing procedures will see a drop in their income if Integrative Medicine is adopted on a wide scale.
Pharmaceutical companies have been doing everything they can to obstruct the availability and use of natural products because they achieve much greater profits from selling drugs than herbs and vitamins, which are not patentable. As the saying goes, follow the money.
One of the main reasons that organized medicine is “organized” is to protect the financial interests of the medical profession. Thus conventional medical doctors through the AMA have established the rules, codes and guidelines for payment of services provided. This protects hospitals and practicing physicians alike. Conventional doctors are the ones selected to do peer-review for Government Regulatory Bodies. They interpret the data in published scientific studies. But more important for the threatened survival of our health care system, they serve on the panels for insurance companies that decide what is paid for and what is not. Regardless of the specific outcome for individual patients, only Conventional Medicine is reimbursed. Even if the competition in the form of Integrative Medicine is highly successful, it will not be a covered service.
The only part of Concentrated Economic Interests that does not eventually benefit from rising medical costs are those that fund insurance coverage for their employees. Large and small companies that provide health care coverage have blindly accepted the expertise of conventional and organized medicine through insurance companies and subcontracted peer-review agencies to provide the ‘best’ possible health care at the lowest available price. The companies have trusted Conventional Medicine to establish a standard of care based on correctly interpreting the scientific evidence and approving the safest and most cost-effective therapies. Unfortunately, that trust has been betrayed. What is actually approved is “usual and customary” treatment, which can be hazardous, costly, and not necessarily supported by the evidence.
Companies have pressured insurance companies to reduce costs. Some minor cost savings have resulted from such initiatives as generic drugs, managed care and higher deductibles. Insurance companies have been squeezed as tight as possible under the current system. They report that there is little else that can be done to save money.
Insurance companies have even resorted to unethical ways to ration care. They insist that physicians take a large portion of their valuable time to talk to someone from the insurance company to get tests and therapies pre-approved before they can be performed. They routinely reject legitimate claims by policy holders, oftentimes blaming the provider without any basis. The purpose of creating obstacles is that many doctors and patients simply give up when faced with them. A good deal of legitimate claims are not paid, simply because of this red tape.
The companies that fund insurance as a benefit for their workers, however, have powerful options available to them. They could establish independent panels to correctly determine the impact of therapies, based on a thorough examination the evidence. Panels must include representatives from Integrative Medicine. All of the evidence must be evaluated, not just expensive randomized clinical trials, which are often not available for integrative modalities. The information needed is the absolute effect of a therapy, not the relative effect. We need to be very clear about the side effects and risks of each therapy. We need to know how many people need to be treated with each therapy to avoid one adverse outcome. If an expensive drug lowers the cholesterol 21% better than another expensive drug but the cardiovascular death rate is unchanged, we probably should not be using either drug. We need to know the cost of each treatment and the cost of the side effects if they occur. All therapies should be included, especially those that are reasonable substitutes for the high-risk conventional therapies of drugs and surgery. Integrative Medicine should be given priority, because it is often safer, comparably effective, and cheaper than conventional treatment protocols.
We need to insist on Transparency with all available information, and offer patients consumer-driven health care. If Consumers are given the information, a choice of therapies, and the financial support needed, many of them will choose the safer, more enjoyable, less invasive and less expensive options from Integrative Medicine. Integrative doctors can guide the programs and work with each patient’s family doctor to coordinate care. Specialist care is certainly needed in some circumstances, but those that perform expensive procedures have a major conflict of interest, and therefore should not be making the ultimate decisions, unless there is an emergency.
National health insurance has been proposed as an answer to our health care crisis. Certainly, some equitable measures must be found to make health insurance available to everyone. However, national health insurance would mean a single payor tied to the failing system that has been created by the Medical-Pharmaceutical complex. The only way to provide coverage for everyone under a Government Regulatory Body would be to ration care, and lower everyone’s health care to the lowest common denominator.
A much better idea is not to ration legitimate care by putting up obstacles, but to change the type of care that is paid for by closely examining the evidence, embracing Integrative Medicine as much as possible, offering a transparent system, and enlisting Consumers to make the choices. Conventional procedures will still be done when indicated, but many of them will be avoided.
The first white paper on this subject offered a comprehensive agenda for Government Regulatory Bodies to greatly increase safety and be sure that Consumers have a choice about the type of health care they receive. I explained how these measures would move us toward solving the health care crisis. I suggested passing the Access to Medical Treatment Act, establishing federal guidelines for certification of integrative physicians, increasing funding for CAM from NIH, preventing the abuse of anti-fraud statutes so that they apply primarily to integrative doctors, and protecting compounding pharmacists. In addition, I asked state legislatures to pass health freedom legislation to protect integrative doctors, to put at least one integrative physician on each medical board, and to require informed consents to include all therapies, not just those approved by Conventional Medicine.
Eight years later, the health care crisis has become much worse, and all of these proposals are still on the table. They have not been adopted. A possible exception is that NIH has slightly increased funding for CAM. The government moves slowly. Like Concentrated Economic Interests, Government Regulatory Bodies are guided by those in organized medicine, who have difficulty seeing beyond their obvious conflicts of interest. A new point of emphasis and action plan is needed, which has been explained in this white paper. Those that fund insurance coverage for workers in the United States are in the best position to create the fundamental change that is needed.
Safety and Choice are the essential ingredients of a health care system that works. The key to safety is to utilize less dangerous therapies. Integrative Medicine is frequently safer than offering nothing more than drugs and surgery. The key to effectiveness is to enhance normal function and restore balance whenever possible, not to rely primarily on blocking actions in the body, which is the mechanism of action of most drugs. The key to an affordable health care system is to reduce the number of procedures by offering Consumers the choice to try Integrative Medicine before expensive, high-tech diagnostics and surgery, as long as a transparent look at the evidence shows no worse absolute risks and a reasonable chance for good outcomes. Multi-million dollar clinical trials are not needed to gather comparative outcomes evidence. Each company can gather its own with a little help from a statistician.
We have come to the point where change is urgently needed. Our health care system is in trouble and cries out for fundamental change. Consumers and Government Regulatory Bodies need to act. But the ones that have the ability to change most rapidly and effectively are those who control the flow of money, those that pay the bills in the private sector. They can determine what really works in medical care, and how to achieve optimal results with minimal costs. They can save themselves a great deal of money in the process.
Integrative Medicine includes high quality wellness programs and true preventive medicine. Lifestyle changes are strongly encouraged and reinforced. We need to reduce the number of sick people, not simply expand their numbers with early detection programs that are disguised as preventive medicine. We need a rational prescription program. We need to provide Consumers with Safety and Choice, and transparency with informed consent. The best way to do that is to offer them the choice of high-impact Integrative Medicine, which will improve health outcomes, enhance productivity, reverse disability, and reduce costs substantially.
1. Chappell, LT. Safety and Choice in Medicine—A White Paper. The Townsend Letter: 1999.
2. Jaffe R, Dayton M, Nash RA, et. al. Healthcare Transparency: Opportunity or Oxymoron? In press, 2006.
3. Abramson, J. Overdosed America. Harper Perenniel, New York, 2005.
4. Kauffman JM. Malignant Medical Myths. Infinity, West Conshohocken, PA, 2006.
5. Recommended web sites: www.HLOptions.com, www.icimed.com, www.getprolo.com, www.aaem.com, www.apma.net, www.acam.org,
ABOUT THE AUTHOR, WITH DISCLOSURES
L. Terry Chappell, MD, is a Board-Certified Family Physician who is in private practice in Bluffton, Ohio. He is Medical Director of Healthy Lifetyle Options and President of the International College of Integrative Medicine. He serves as an advisor for the American Board of Clinical Metal Toxicology and is a member of the American Academy of Environmental Medicine, the American Association of Health Freedom, and the American College for Advancement in Medicine. He is a clinical investigator for the NIH-funded Trial to Assess Chelation Therapy.