MANAGED CARE January 2004. ©MediMedia USA
Human beings are not machines, and modern medicine needs to move beyond the repair shop mentality. Could nontraditional services help?
Albert Einstein said that you cannot solve a problem with the kind of thinking that is creating the problem. Modeling our health care system after the machine repair shop has forced us to make difficult choices, where quality, affordability, or both must be sacrificed. Meanwhile, the patients' own inner mental and spiritual resources, along with many modes of prevention and self-care, remain largely untapped.
Some of these resources — notably, complementary/alternative medicine (CAM) — are very inexpensive. Good economic sense tells us that it is time to begin testing them seriously to see which work, and how well — and then to begin using the ones that do.
The organizations that are best equipped to take on these challenges are health plans, with personnel and the means of reorganizing them. They stand to gain much from doing so.
What plans can do
Here are some examples of how health plans might use or support integrative medicine:
Providing work site wellness programs for corporate customers. Such programs include exercise as well as education in nutrition and in mind-body self-care such as stress and pain management. Plans could profit from reductions in claims and from charging fees for the services.
Sponsoring CAM education for practicing professionals and students. Both conventional and CAM practitioners would need training to collaborate effectively. This includes not only education of existing staff and contracted providers but also medical students.
Supporting research into CAM at medical schools and other institutions. Some of our most prestigious medical schools, such as Harvard, Duke, UCLA, the University of Arizona, and UC Irvine, have well established programs for CAM research. At the very least, research could help guide health plans in deciding which forms of CAM should be covered. CAM has no equivalent to the pharmaceutical companies, which routinely fund research as part of product development. Major health plans and government agencies, which would use this research, could help fill this gap.
Health plans have financial incentives to promote wellness. Everyone knows that prevention costs less than cure, and that any insurer profits more from health than from disease. However, medications and surgery, the principal tools of mainstream medicine, are usually more curative than preventive. Optimum health is achieved when prevention and cure are fully integrated.
Many health plans have ready access to CAM providers. Any HMO with a behavioral medicine department has mental health professionals on staff, most of whom know mind-body modalities already. PPOs that cover mental health can easily recruit such people, along with nutritionists, acupuncturists, and other CAM providers, and organize them into teams.
Health plans have the centralized administrative structure to do this. An HMO could do it by fiat; a PPO, by offering incentives.
Common objections
Given these incentives, one would think that health plans would have enthusiastically embraced integrative medicine by now. However, they have not done so on a large scale, and there are some reasons for this reticence. The following objections are understandable, but not ultimately valid.
The scientific evidence to support CAM is insufficient. Opponents often argue that CAM includes remedies that have never been tested scientifically and others that are outright fraud. Studies that validate CAM modalities seldom appear in reputable medical journals.
Reply. The first part of this argument is certainly true. CAM by definition includes all modalities other than drugs or surgery, including most forms of quackery. However, because some modalities, such as certain forms of acupuncture and stress management, have been validated in controlled studies, this is more an argument for testing them than for dismissing them altogether. Only through research can we learn which ones work and how well.
Studies on CAM are excluded by reputable medical journals more by their subject than by the validity of the research. Medical journals omit studies of CAM because the editors don't consider CAM to be medicine. When Hans Selye, for example, introduced the notion of "stress" into medicine in the 1950s, no serious medical journal would publish his work. He had to appeal to the popular culture. Today, stress is recognized as a leading cause of many diseases, including heart disease and cancer.
Health plan management and staff are not trained in complementary medicine. This would vary among health plans, but some retraining will be needed, at some cost.
Reply. There is a definite educational need here, but these costs must be put in perspective. Education is usually cheap when compared to treatment. Which is more expensive, a class on pain management or work ergonomics, or a spinal fusion for back pain?
Some CAM modalities are in fact "scientifically impossible." Especially in academia, it is widely believed that some CAM modalities, such as mind-body medicine, are "scientifically impossible," even in theory. Any evidence supporting them is therefore not worth examining.
Reply. Scientific laws describe what happens. Science can show that certain phenomena are extremely rare or even unheard of, but it cannot prove them impossible — especially if the events in question actually do occur. The fact that bumblebees cannot fly according to known principles of aerodynamics does not prove that bumblebees can't fly.
Integrative medicine entails making radical changes in our health care system. Are the risks involved in these changes worth underwriting? Change is hard and radical change is harder still. CAM and conventional medicine view the human organism in vastly different ways. CAM views it not as a machine but as a system that has internal intelligence. Such a fundamental change in how we conceive the human organism would have profound consequences, creating strategic, tactical, and logistical problems that we may not be able to foresee.
Reply. Interest in CAM shows little sign of disappearing or even diminishing. According to the Stanford Center for Research into Disease Prevention, Americans were spending $18 billion annually on CAM in 1998, up from $14 billion in 1993. Scientific progress itself entails change — and sometimes radical change. Avoiding it is not an option. Doing nothing, in the hope that CAM will just go away, is not managing risk.
It ain't broke, so don't fix it. An often-underrated enemy of integrative medicine is the spectacular success of biomedicine itself, which is unparalleled in medical history. The belief that it is the only solution to health care problems is understandable.
Reply. It is understandable but wrong. First, even if we deny biomedicine's scientific problems, there is no denying its economic ones. The biomedical solution to the problem of an aging population could strain even the most robust economy. The economics alone demand that we at least investigate other viable options. Second, biomedicine's track record is not perfect, e.g., the belief that the immune, endocrine, and nervous systems never interact severely impeded biomedicine's ability to deal with autoimmune and degenerative diseases. Third, the biomedical model of the organism as nothing more than a machine may be very incomplete.
By developing successful integrative medical programs, health plans can revive consumer interest in managed care and regain lost market share. The prognosis for managed care may be better than its detractors think.