Should "alternative medicine" be incorporated into managed care? Should managed-care organizations be free to decide this for themselves, or should outsiders dictate what gets covered?
"Alternative medicine" has become the politically correct term for questionable practices formerly designated as health frauds and quackery. Some techniques referred to as "alternative" may be appropriately used as part of the art of patient care. Relaxation techniques and massage are examples. But procedures linked to unscientific belief systems have no place in responsible medicine — or managed care.
The biggest problem in discussing this subject is that "alternative" has many possible meanings. The dictionary definition is a choice between mutually exclusive possibilities. Until the late 1980s, in standard medical usage, the word "alternative" referred to choices among effective treatments. In some cases they were equally effective (for example, the use of radiation or surgery for certain cancers); in others the expected outcome differed but there were reasonable tradeoffs between risks and benefits. In recent years, however, the term has been applied to a multitude of unsubstantiated methods that differ from standard (science-based) care. Jack Raso, R.D., who edits the newsletter Nutrition Forum, has catalogued nearly a thousand of these.
The best way to minimize confusion is to classify alternatives as genuine, experimental, or questionable. Genuine alternatives are comparable methods that have met science-based criteria for safety and effectiveness; experimental alternatives are unproven but have a plausible rationale and are undergoing responsible investigation; and questionable "alternatives" are groundless and lack a scientifically plausible rationale.
Whether some approaches are valid depends not only on their methods but how they are used and what claims are made for them. Spinal manipulation, for example, can be useful in properly selected cases of low-back pain. But manipulating the spine once a month for "preventive maintenance" or to promote general health — as many chiropractors recommend — is senseless. Relaxation techniques have a limited but acceptable role in the treatment of anxiety states. But biofeedback for "mind expansion" or meditation for "balancing life energy" are another matter.
Novel doesn't mean nonsensical
Although patient demand is a factor, most managed care coverage is determined by evidence of effectiveness and cost-effectiveness. The program developed by Dean Ornish, M.D., for people with coronary heart disease illustrates how this selection process should work. Ornish's approach includes smoking cessation, stress-management techniques, daily exercise, and a 10 percent-fat vegetarian diet. This program is novel because its dietary fat level is half the lowest level the American Heart Association recommends for people unresponsive to less stringent cholesterol-control measures. Ornish has documented his findings in a scientific manner, using before-and-after measurements of coronary blood flow and publishing his results in peer-reviewed scientific journals. His work is sufficiently promising that Mutual of Omaha is testing whether his approach is an economical alternative to bypass surgery or angioplasty in carefully selected patients. If it is, you can bet that third-party payers will embrace it.
When lobbyists prescribe
Coverage can also be dictated by state or federal laws. Most states have "insurance equality laws" requiring chiropractic coverage under various circumstances. A few require coverage for acupuncture, and the state of Washington recently ordered inclusion of naturopathy and massage therapy as well. The impact of such laws depends on how much service is covered, who provides it, and how the coverage is structured. Many insurance companies forced to cover chiropractic services have been displeased with the results.
Chiropractic leaders misrepresent the significance of workers' compensation studies that have found that patients treated by chiropractors were more satisfied and returned to work sooner than patients treated medically. These studies did not scientifically validate what the chiropractors did and were not designed for that purpose. Although most contain data appearing to favor chiropractic, their authors did not evaluate whether the patients had comparable problems. In addition, the duration and costs of disability and time lost from work are influenced by factors other than effectiveness.
Several months ago the New England Journal of Medicine published a study comparing the cost of low-back pain treatment by family physicians, orthopedists and chiropractors in North Carolina. The median total charges were $545 by urban chiropractors, $383 by orthopedists, $348 by rural chiropractors, $214 for rural primary-care physicians and $169 for urban primary-care physicians. Although chiropractors charged less per visit, their treatment was costlier because they saw their patients about five times as often.
Additional data have been collected at the Group Health Cooperative, a staff-model HMO in Madison, Wis. Dan Futch, D.C., chief of chiropractic practice, has found that the patients he sees require an average of three visits per episode, considerably fewer than the average reported for chiropractors in other settings. Futch is also executive director of the National Association for Chiropractic Medicine, a small group of medically oriented chiropractors and chiropractic students who have renounced chiropractic's unscientific dogma.
Many chiropractors believe that after a painful condition is resolved, patients should continue indefinitely for "maintenance care." Many also believe that every spine should be examined and adjusted monthly or weekly throughout life. No evidence exists that either of these approaches benefits patients. Managed care can limit overutilization by excluding chiropractors who practice unscientifically and setting limits on the rest. But rather than raising their standards, most chiropractors are filing lawsuits and asking legislators to break down managed care barriers.
Can oil and water mix?
Dr. Futch's experience demonstrates that scientifically oriented chiropractors (a tiny minority of practitioners) can be integrated into managed care. What about acupuncturists, homeopaths, naturopaths, and unscientific chiropractors?
Acupuncture involves stimulation of the skin at designated points. Traditional practitioners claim to balance the body's "life force" by inserting needles (or using other modalities) where imaginary horizontal and vertical lines ("meridians") meet on the surface of the body. These points are said to represent various internal organs (some of which are nonexistent). Some practitioners reject the pseudoscientific trappings and postulate that pain relief occurs through mechanisms such as the production of endorphins. I do not believe that acupuncture is cost-effective for any purpose or influences the course of any organic disease.
Homeopathy is based on the notion that symptoms can be cured by taking infinitesimal amounts of substances that, in larger amounts, can produce similar symptoms in healthy people. Homeopaths also claim that the more dilute the remedy, the more powerful it is. Some "remedies" are said to be so dilute that no molecule of the original substance remains, only an "essence" that cures by bolstering the body's "vital force." I do not believe that practitioners who prescribe only placebos deserve support.
Naturopathy is based on the belief that diseases are the body's effort to purify itself and that cures result from enhancing the body's ability to heal itself. Naturopathic treatments can include "natural food" diets, vitamins, herbs, tissue minerals, cell salts, manipulation, massage, exercise, diathermy, colonic enemas, acupuncture, and homeopathy. Like some chiropractors, many naturopaths believe that virtually all diseases are within the scope of their practice. I don't see how practitioners involved in so much nonsense can fit into a science-based health-care team.
The all-important spine
Chiropractic encompasses a broad spectrum of practices related to the false premise that spinal misalignments ("subluxations") are the cause, or underlying cause, of most ailments. Chiropractic's founder postulated that the body's "vital force," which he termed "innate," expresses itself through the nervous system. Chiropractors who cling strictly to this notion allege that subluxations cause most illnesses by interfering with the flow of "nerve energy" to body organs. Most chiropractors acknowledge the importance of other factors in disease but tend to regard mechanical disturbances of the nervous system as an underlying cause. Many of them engage in unscientific diagnostic procedures, prescribe inappropriate food supplements and utilize homeopathic remedies. Small percentages denounce chiropractic's basic dogmas, spurn its unscientific practices and confine their practice to musculoskeletal problems. Thus, while virtually all chiropractors manipulate the spine as their primary method of treatment, their rationale and techniques vary considerably. Many homeopaths, naturopaths and chiropractors are lukewarm about or opposed to immunization.
Can unscientific practitioners be subjected to utilization review and other quality-control measures? Can practitioners immersed in "vital forces," "subluxations" and similar concepts provide high-quality care for their patients? Should practitioners who oppose proven preventive measures be permitted to practice within a managed care setting? (Even worse, should they be permitted to be their own gatekeepers?) If treatments are ineffective, is there any evidence that allowing subscribers to use them will reduce the overall cost of their health care?
My answer to each of these questions is no.
For further information
Zwicky JF, Hafner AW, Barrett S, Jarvis WT. Reader's Guide to "Alternative" Health Methods ($32.50). American Medical Association, Chicago, 1993.
Barrett S, Jarvis WT, editors. The Health Robbers: A Close Look at Quackery in America. ($26.95). Prometheus Books, Amherst, N.Y., 1993.
Barrett S, Herbert V. The Vitamin Pushers: How the Health Food Industry Is Selling America a Bill of Goods ($26.95). Prometheus Books, Amherst, N.Y., 1994.
Magner G. Chiropractic: The Victim's Perspective. ($25). Prometheus Books, Amherst, N.Y., 1993.
Copies can be ordered from LVCAHF, P.O. Box 1747, Allentown, PA 18105. Add $2.50 postage for the first book and $1 for each additional one.