Tell-A-Vision for the 21st Century
HealthCare_2.0
The Health Assurance Act -- A Vision for the 21st Century
More comprehensive version of HealthCare_2.0: A Transformative Vision
prepared for members of the Coalition for Improving Maternity Services (CIMS)Faith Gibson, LM, CPM
Palo Alto, CA 94301
September 11, 2009I am a conservative Mennonite, parent of three, grandmother, former ER nurse and currently a professional midwife. After many years of working on midwifery legislation I was appointed to the Midwifery Advisory Council of the California Medical Board and I continue to serve as chair of the Midwifery Council.
After working all my adult life as a health care professional and patient advocate, it’s obvious to me that we must pass healthcare reform legislation in this session of Congress. However, that will not be the end of the matter. We also need a long-range vision for fundamentally transforming our current disease-focused system into a health-based model of care. In an earlier period of our history this was referred to as the “healing arts.”
Between the last decade of the 19th century and the first of the 21st century, our 20th century health care (more accurately an illness and injury care) “system”—the 1.0 version—evolved thru a number of distinct stages that have brought us to a place that is both filled with promise and fraught with political and economic danger. In the Chinese language, the word “crisis” is a combination of the characters for “danger” and “opportunity.” Whatever else may be said about our system of care, the word ‘crisis’ surely would apply—a predicament that also provides us with unique opportunities.
When I graduated from nursing school in Orlando, Florida, the Deep South was still racially segregated and it was the norm for both white and black patients not to have health insurance and, true to the long tradition, medical care was still a public service industry. Since then I have personally witnessed health care change from a regulated public service to the deregulated world of high-finance and corporate practice of medicine—investor-owned facilities that order twice as many tests, do twice as many invasive and surgical procedures and have a 20% increase in mortality rates, and health insurance companies that are organized around quarterly reports, shareholder interests and have to put profits before patients as a matter of policy.
As a political activist, I have read nearly all the books on the politics and economics of our healthcare system published in the last 20 years and studied the history of Western medicine back to the time of the ancient Greek physician Hippocrates. Combined with my direct experience in the field of heath care and long academic study of the topic, I believe I have developed an comprehensive overview of the topic. I believe these insights will be a helpful addition to the current debate on health care reform.
The Health Care Reform Debate of 2009
I am pleased to report that the Affordable Health Choices Act of 2009 (HR 3200) is a politically moderate bill that preserves individual choice and would fix many of the most egregious problems with our current system. While HR 3200 is not perfect, it would balance the power between corporate medicine and the public good by providing the tools necessary to the mediate the conflict of interest between corporations and individuals. If passed in its present form, HR 3200 would move us closer to reliably delivering healthcare that is as safe, affordable and cost-effective as any other industrialized country.
The biggest roadblock to a fair and affordable healthcare system is not political—it is a basic and widespread lack of understanding of the system. With rare exception, no one knows the origin of our current medicalized HC system, understands why it is dysfunctional or knows why just throwing more money at the problem will not work. Neither the Administration nor the political pundits and talk show hosts have been able to articulate a vision for transformation—a practical plan that will create a fair and affordable model of health care that can be achieved without taxing the middle class, rationing medical services, limiting the advance of medical science, turning the system over to government bureaucrats or raising the national debt.
The following commentary is offered in honor of Senator Ted Kennedy’s memory. It is a forward-facing vision of what would work and 3 practical steps for a health care system that all Americans could be proud of.
Unofficially I refer to this as the Health ASSURANCE Act.
The Health ASSURANCE Act ~ 2020 vision for the 21st century
America can’t afford not to reform the way we provide and the way we pay for healthcare. In order to fix the long-term budget deficient, we must fix health care. For American business to compete successfully in the global economy, we must fix health care. In order for our own families and friends to be safe, we must fix health care. In order to have personal peace of mind, we must fix health care.Yankee ingenuity took us all the way to the moon, surely these same talents can help us upgrade to a HealthCare _2.0 system. Money being spent unproductively (or unwisely) can be redirected. Forward-thinking reform can introduce science-based change in how health care and medical services are provided and financed, while incorporating the benefits and cost-savings of scientific innovation and new technology.
All it takes is a can-do attitude and the right expenditure of our plentiful resources. Two trillion a year is more than enough money to treat everyone and meet every genuine medical need.
Health ASSURANCE as a system of care can be achieved without taxing the middle class, rationing medical services, limiting the advance of medical science, turning the system over to government bureaucrats or raising the national debt.
Health ASSURANCE plans will not cost more than 10% of a family's income, refuse coverage because of a pre-existing condition, drop you when you get sick or need surgery, bury you under ever-escalating co-pays or impose a yearly or lifetime limit on benefits.
As a fair and affordable business model, it doesn't make any difference if assurance coverage is public or private, as long as these plans assure timely and effective access to necessary health care. However, the company policies of private plans must put patients before profits, which means that basic medical coverage—sickness insurance for acute and chronic illness and serious injury must be non-profit. Wall Street's prime directive for investor-owned businesses identifies a fiduciary responsibility to shareholders as primary concern of each for-profit business. Primary fiduciary responsibility to shareholders doesn’t work for basic medical services any more than it would for the fire department, EMS, the police or the military.
We must have universal access to a basic medical insurance plan that is non-for-profit and covers those who develop an acute or chronic illness or serious injury. However, successful models used in Europe (particularly Switzerland) confirm plenty of profit to be made by insurance companies who sell comprehensive health insurance plans, supplemental plans and plans that cover the elective use of health care services and medical treatments.
Upgrading to HealthCare_2.0 starts with a forward-facing vision:
Luckily for us, failure is not an-going option. The rest of the developed world has already figured out how to make health care work. We are a smart, capable and innovative people—surely we can figure out how to do the same. What we need is a transformative vision for how we can upgrade to a HealthCare_2.0 system. In keeping with the idea that fools rush in where angels fear to tread, we boldly call this transformative vision “HealthCare_2.0.”
It's often said that the military is always fighting the last war—that is, they are trying make sure that whatever happened last time doesn't happen again.
So far, the debate over health care has also been hampered by its focus on the past and immediate present, with an assumption that the future will be more of the same, only more expensive because of the demographic bulge of aging baby-boomers, combined with unstoppable health care inflation. Politicians are trying to figure out how to fix a dysfunction system based on the way thing are now, but all we can count on is that they will be different in 10 years.
An order of magnitude transformation in the biological and technological sciences is well underway and will be as dramatic and far-reaching in the 21st century as the germ theory of disease and the discovery of antibiotics were in the early 20th century. Innovations in genomics, DNA-based diagnosis, and the new science of epigenetics (how genes are turned on and off) will dramatically reduce future health care costs through early detection and improved treatment. Gene-splicing and yet-to-be invented treatments will eliminate many previously fatal or chronically debilitating diseases at far less expense than our current system, which includes decades of lost income and costly drugs and medical services for desperately ill people.
Diagnostic technologies and imaging tools will continue to improve, and new ones will be invented, that are better and more cost-effective. The miniaturization of medical equipment to test, monitor and treat patients, and cell phones used as information stations, are already making it possible for people to benefit from technologies that a decade ago were only available in big city hospitals. Examples are iPhone applications like the 5-minute clinical consult for primary care providers that have criteria for differential diagnosis and treatment for 750 medical conditions, including H1N1 (swine) flu. A miniaturized device, also used with cell phones, now allows a practitioner to do laboratory tests in the field to make a diagnosis or monitor the effectiveness of ongoing drug therapy. It is already being used in developing countries.
The combination of miniaturization, information stations, and on-line access to specialists makes high quality care available in neighborhood clinics, by EMTs in the field, and in home-based health care programs. Many communities are already using an out-of-hospital system based on a new version of the old-fashioned “house call,” only in this case, the doctor comes fully equipped with 21st century technology and online access to specialized knowledge. Scheduled and emergent house calls by general practice physicians and non-physician practitioners save money by preventing unnecessary hospitalization and by allowing discharged patients to be sent home days sooner while receiving the same high quality follow-up. Healthcare economists are convinced the 21st century house call will not only improve patient care but literally also save billions of HC dollars every year.
Three Practical Steps to HealthCare_2.0:
1. Developing a health-based rather than disease-focused system
The primary purpose of health care is to preserve, protect and maintain the health of the already healthy, reduce the incidence, duration and severity of disease, and to prevent suffering and prolong healthy function during the normal human lifespan. The secondary purpose of health care is to treat disease and injury when it occurs.
What we call health care in the US is only the second part of that equation—we have a medical system developed to intervene in the course of an already-established disease. Only after a patient’s health has seriously deteriorated—enough to trigger a doctor's visit or if a medical crisis occurs—does this system of medical intervention come into its own. When that happens, the system of medical intervention can be life saving. This is the kind of care that causes people to declare: “Why, we have the best health care in the world!” As a former ER nurse, I can attest to how amazingly effective (and appreciated!) our crisis-intervention model is. Nonetheless, it isn’t organized around the preventive model of ‘health’ care as used in other developed countries, which get much better outcomes, at much less cost.
While Western medicine offers some forms of preventive care, such as ordering mammograms and prescribing cholesterol-lowering drugs and the like, neither the many years of medical training nor the reimbursement structure for an MD’s services are organized around the preservation of health or prevention of disease.
Frankly stated, we neither teach nor pay MDs to provide ‘health’ care.
The current economic structure of our dysfunctional system makes illness and injury (instead of health) the profit center of a money-driven medical model. This has created an unsustainably medicalized health care system that currently accounts for 1/6 of our entire GDP —17% in the US, compared to under 10% in those countries that have the best measures of wellbeing and longevity. 24
When crisis-intervention medicine is compared to the top 5 categories of mortality in the US, it is easy to see the unproductive expense and other problems caused by not having a health-based model of care. In America the top 5 categories of pathology* (underlying cause of death) most frequently associated with fatalities are all preventable diseases or avoidable accidents associated with:
1. Smoking (emphysema, lung cancer & heart disease)
2. Alcoholism (liver disease, gun violence, and auto fatal accidents)
3. Obesity and its many complications (diabetes, heart disease, poor surgical risk)
4. Drug abuse (overdose, violent crimes, murder)
5. Toxic substances and poisons, including exposure to air and water pollution (fatal asthma attack, carbon monoxide poisoning, and death from acute or chronic toxicity)
[*List composed by Jan Garavaglia, M.D., chief medical examiner for the District Nine Medical Examiner’s Office, Orange-Osceola County, Florida]
A measure of the medical costs of untreated mental illness comes from a study of 120 homeless alcoholics living on the streets of Boston, who collectively chalked up a staggering 18,000 EMS ambulance calls and emergency room visits and 900 hospital admissions over five years—150 per alcoholic. Costs to the county for emergency medical and hospital services were estimated at $26,000 each year for each alcoholic, but until such a time as these alcoholics get liver disease or hit by a car, that $26K worth of repeat ER visits did nothing to successful treatment of their addiction and other mental health problems. However, it did add over $3 million to the ‘health’ care bill sent to the taxpayers of Massachusetts or $15 million over the 5-year course of the study. [NPR story, 08-04-09]
One doesn't have to be a rocket science to know that it is cheaper and more humane to prevent hip fractures that it is to hospitalized the frail elderly and surgically repair their broken bones. Similarly, public health programs that turn back the tidal wave of obesity makes a whole lot more sense than having nearly half the population sick with diabetes and its complications. At present, the single biggest item in our healthcare budget—one-third of every healthcare dollar—is spent on the treatment of diabetic complications. This frequently preventable disease is also the number one cause of all blindness, limb amputations and kidney failure. Data from Medicare on kidney dialysis shows an annual patient cost for end-stage kidney disease ranges from $65,496 to $488,360—or an average of $129,090 per patient per year. We are hemorrhaging red ink on preventable complications of a frequently preventable disease.
That’s the really bad news. The even worse news is that only 8% of care provided by our current system is treating diabetes effectively as judged by patient longevity and prevention of complications. If state-of-the art scientific principles of prevention and treatment already in use by the VA system were widely applied to the public health issue of diabetes, it could reduce the complications of diabetes by 80%. That’s a ten-fold reduction in the horrifying, disabling and expensive conditions of blindness, amputations and end-stage kidney disease.
Based on a current rate of $2.2 trillion a year on medical care, successful prevention and effective treatment programs for just this one common disease could save half a trillion dollars a year. These estimates don't factor in technological innovations, such as epigenetics, which may soon figure out how to turn on protective genes or turn off the ones that make so many of us vulnerable to the systemic ravages of abnormally high blood sugar.
Just ponder for one moment how much we’d save on medical bills if we had an innovative health-based system of preventive care that addressed the spectrum of health concerns up-front, preventing many diseases, reducing the severity of many others and prolonging the functional years of the human life span.
2. A system built on "best practices"—Analyzing models and methods of health care and medical treatments, devices and products for comparative effectiveness
The Problem: Current standards of care do not require that medical treatments or surgical procedures be the most clinically effective or “best practice” or that patients be informed whenever the actual effectiveness of a recommended treatment is unproved. Standard treatments also do not have to be cost-effective. A large percentage of medical treatments and regimens used in American health care pre-date the idea of evidence-based medicine. As a result, only about 10% of customary medical practices have compelling evidence of their safety, effectiveness or a positive cost-benefit ratio.
The post-modern idea of evidenced-based medicine has never been broadly applied to the American model of health care. People wrongly assume that that every action of every medical provider represents the “best practice” as defined by the latest scientific research. In an age of the Google Internet search, with virtually instant access to scientific data on-line, everyone is surprised to find out that this is not the case. The bulk of evidence-based medical research is narrowly focused within conventional methods of treatments—for example, contrasting a particular cholesterol-lowering drug to one made by a different company or given in a different dose, or a new surgical technique will be contrasted to an older form of surgery. This kind of research compares a few similar drugs or treatments against one another, and then provides a scientific opinion as to which is the evidenced-based choice among of this pre-determined set of options. It often misses the forest for the trees and at times, this micro focus of this type of research is carried away with the bark and misses the entire issue of comparative effectiveness.
Since there is no profit to be made from therapeutic methods that do not directly relate to medical procedures, products or professional services, the idea of EB medicine often breaks down when it comes to overarching models of practice—for example, contrasting outcomes for the physiological management of normal childbirth, as compared to the standard set of obstetrical interventions routinely used on healthy women.
Historically, medical care was built on the authority-based practice of medicine, which is the two-thousand year-old system that can be traced back to the Greek physician Hippocrates, who is also known as the Father of Modern Medicine. In this system, a medical “expert” (i.e., authority) determines the way something is done and that becomes the standard until it is superseded by another ‘authority’ who introduces a new and supposedly, a better idea. The contemporary difference between authority-based medicine and evidence-based practice is that evidence-based science informs a physician’s choice between two different drugs or surgical procedures, while authority-based medicine grants him or her the right to decide whether to or not prescribe a drug (or perform surgery).
The great bulk of the way things are currently done by the medical profession reflects the authority-based tradition of medicine, which means that customary practices continue to be used even though they may lack a contemporary proof of efficacy (safety, plus cost-effectiveness). This does not automatically mean a treatment isn't beneficial, just that nobody really knows if it is as effective as assumed or if it is the safest or best choice among other effective options. For instance, the success rate of prescription pharmaceuticals in controlled trials is attributed the placebo effect 33% of the time—that is, inert “sugar pills” were as effective as the chemically-active compound in 1/3 of the cases, but without the side-effects and expense. The message is that an activity or substance assumed to be causal can in fact be merely co-incidental—in other words, the treatment had nothing to do with the cure, as the patient would have gotten better anyway.
Unlike randomized controlled trials for drugs, the majority of medical practices in the US remain unevaluated (one source identified this to be as high as 90%), with little incentive to fund research in this area. Changing the status quo has no perceived benefit or financial advantage to the health care industry, which finds the current system quite profitable.
This traditional pattern of medical practice includes billing patients for clinically untested treatments, which are then paid for by insurance companies and Medicare because the law requires "customary care" ordered by a medical doctor to be reimbursed. However, the legal definition of 'customary' is whatever is customarily done by the medical profession. A medical treatment, or course of care, becomes the "standard" simply because it is routinely used, not because a scientifically conducted comparative analysis identified it as the most effective choice.
This irrational premise also applies to the way the US regulates and prescribes drugs. A paper in the October, 2008, Archives of Internal Medicine states: “FDA approval does not require that a drug be compared with alternative treatments; it only has to be safe to use and better than a placebo. Nor ... does a pharmaceutical company have to show that a drug’s effectiveness justifies its price.” [More Bang for the Buck? Randal Stafford, MD, PhD, Stanford Prevention Research Center; Agency for Health Research and Quality; published in the Archives of Internal Medicine 10-27-2008] PREFER STANDARD CITATION—are there others??
The final act in this self-defining Catch-22 system is the defensive practice of medicine, which mandates that physicians and hospitals continue to use these customary practices to successfully defend themselves in case of a lawsuit. Doctors complain bitterly about high insurance premiums, but defensive medicine is the cash cow of the medical business. The same internally generated feedback loop applies to the legal theory of ‘standard’ care as to the legal setting of ‘customary’ fees—whatever doctors choose to do (for example, routine use of continuous electronic fetal monitoring on all healthy laboring women) becomes ‘customary’ and the customary becomes the ‘standard’ and failure to use the ‘standard’ become the legally indefensible ‘substandard’ care—i.e., malpractice.
Instead of a science-based analysis of effectiveness and evidenced-based medicine determining the standard of care, physician preference or ‘custom’ fuels the accelerated use of expensive diagnostic testing, drugs and medical-surgical procedures. Each year more technological abilities are added to the previous 20th century medical ‘customs,’ There is no end in sight for this perpetual-motion money machine—defensive medicine continues to be a runaway train on a downhill slope.
As a result, there has been much less political appetite for ‘fixing’ the problem of medical malpractice suits than one would expect. While the medical profession and politicians publicly blame malpractice litigation on trial lawyers, the legal profession is not stopping the medical profession from fixing the non-scientific standard of care issue, which is at the heart of the ‘defensive’ practice of medicine. The lucrative practice of defensive medicine goes on unabated because it good for business and Wall Street likes it this way.
This fundamentally irrational system, multiplied through the practice of defensive medicine, is making basic health care so expensive that people who have health insurance are being forced into bankruptcy and those without insurance are dying. What to do?
The Answer: A HealthCare_2.0 system is built on “best practices” by scientifically analyzing all health care models, methods of management, medical interventions, invasive and surgical procedures, medical devices and products and ranking each one for clinical effectiveness, safety and cost-benefit ratio in comparison to other models or modes of care for the same mental or physical condition. This is a naturally inclusive process that would also evaluate all the forms of care provided by non-physician primary care practitioners, such as nurse practitioners, physician assistants and professional midwives, and non-allopathic health care disciplines such as Chinese medicine, naturopathy, chiropractic, etc and the physiological management of normal childbirth in healthy childbearing women (70% of all births).
The systematic evaluation of 21st century health care will be a historical “first” making up for what didn’t happen in the first decade of the 20th century, when practices were adopted without first establishing either safety or effectiveness. When a 21st century state-of-the-art analysis of comparative effectiveness (ACE) is combined with evidence-based medicine, it will give healthcare providers the tools they need to ‘ace’ the system in every way—a win-win solution for professionals, patients, payers and the health care industry itself. When it comes to 21st century health care, ACE should be the American standard of care. 44
3. The other pillar of HC_2.0—high-quality, multi-disciplinary primary care as the hub of the health care wheel
Problem: Last, but not least, is recognizing and repairing the mismatch between the “heroic” nature of allopathic medicine, which mainly focuses on specialty medicine (75%), and the routine, non-urgent forms of everyday care that most people need most of the time. While emergency medical and surgical interventions are life-saving in the case of acute illness and injury, this accounts for only about 10% of doctor-patient encounters. In particular, the specialty practice of medicine does not and cannot address the issue of health-focused preventive care. Preventing disease will always to be more humane and cost-effective than having to treat painful, expensive and debilitating illnesses. The very best way to lower the bill for prescription drugs is to prevent the diseases and disabilities that require people to take expensive medication. That is where primary care comes in. 45
Answer: A robust primary care system is the engine of a prevention-focused HC system, providing clinically effective care that improves health outcomes and lowers cost by preventing the incidence of disease, reducing the health impact of chronic illness and by extending a healthy lifespan. High-quality primary care is where prevention begins and the systematic overuse of drugs and surgery is stopped. 46
In 2008, there were 902 million doctor’s office visits in the US, the vast majority for routine healthcare needs. Approximately 90% of all medical appointments are for self-limiting conditions and other types of non-urgent or preventive care. Self-limiting conditions include mild illnesses, minor injuries and other conditions that resolve by themselves without needing or benefiting from drugs or surgery. Preventive care consists of routine checkups, school physicals, vaccinations , health education, lifestyle issues such as diet, exercise, and questions about sexual topics, normal pregnancy and healthy newborn monitoring, routine GYN visits, prescription refills, concerns associated with normal aging, and support for people with stable chronic diseases.
By 2025, the number of primary care visits in the US is expected to increase by 42%, making relationship-based primary care ever more important. The growth in the US population includes an increased proportion of children, retired baby-boomers and patients with chronic diseases—the very categories of patients that benefit most from the coordination and continuity of care provided by primary care practitioners. [Am College of Physicians’ White Paper 2008 www.acponline.org/pressroom/primary_shortage.htm] Reducing the rate of obesity, diabetes, osteoporosis and many other chronic and costly diseases, eliminates the great volume of expensive and invasive procedures currently driving up the cost of medical care.
What each of these conditions and health concerns share is that they are not medically complicated. However they are frequently time-consuming and certainly take more than the 6 to 10 minutes allotted for the typical non-urgent medical appointment. What people seeking non-urgent health care most want and need is a relationship with an unhurried primary-care practitioner who is able and willing to be empathetically present, to listen, talk, ask questions, sympathize and make helpful suggestions. Primary care practitioners help each person they see stay healthy, become healthy or lessen the impact of a chronic disease. They achieve this important goal by taking the time to educate the patient (or parent/guardian) in the best strategies for managing their health or that of their child or aging parent. This personalized form of care reduces the need for expensive testing and invasive procedures while improving patient outcomes. [ibid]
These successful, but time-intensive strategies, are out of sync with the reality of doctor-patient interaction as it relates to making accurate diagnosis and providing effective care in our current, expensive high-pressure system. Studies show that the average patient takes approximately 2 minutes to give a full account of his symptoms and yet the average busy MD cuts the patient off after only18 seconds. As a result of these truncated conversations, the physician makes an off-the-cuff decision about the patient’s medical condition that typically is never reconsidered, even when lab work or other criteria don't fit the original diagnosis or the patient doesn't respond as expected to the therapy. [How Doctors Think by Jerome Groopman, MD] In addition to the patient’s personal frustrations, the process of medical evaluation often sends the patient on a medical wild goose chase for months or even years that includes expensive, painful and unnecessary tests. Any and all failures of communication damage the doctor-patient relationship, put the patient at risk for iatrogenic harm and the physician at risk for a malpractice suit.
Our current high-stakes HC system offers nearly every aspect of medical treatment and technology known to humankind except for the unfettered time of the physician. Since the physician’s time is the most expensive element in the medical care equation, it's often easier or more profitable to order an another blood test, CAT scan or write a prescription, than sit down and ask detailed questions and then spend additional time quietly listening while the patient describes his symptoms or concerns.
Fixing the Mismatch—the Right Practitioner for the Right Problem
For the last century, our medicalized model of health care has been spending the incredibly expensive time of MDs to provide routine primary care that actually does not require the education of an MD to accomplish safely and efficiently. Since most primary care visits are for problems that don’t need or benefit from medical technology, drugs or surgery, this is an unfortunate mismatch of resources.
While time-intensive primary care is absolutely vital to the health and wealth of the nation, we do not, and cannot compensate MDs for this at the level their education and training demands. From the patient (and taxpayer’s) standpoint, the ‘right use’ of an MD’s time is in places that benefit from their medical training and talents.
Experts estimate that we need an additional 16,000 MD-general practitioners just to maintain the current level of primary care services. According to Atul Grover, MD, PhD, chief lobbyist for the Association of American Medical Colleges (an arm of the AMA), the answer is a 30% increase in medical school enrollments, to produce 5,000 additional new doctors each year. However, neither of these 'solutions' actually addresses the mismatch between the high-cost of an MD's time and what patients most need and want and benefit from—the unhurried attention of a skill primary care practitioner.
Would it be impolite to suggest the obvious? Primary care for self-limiting conditions and preventive health services should be handled by someone other than a medical doctor. The most appropriate and cost-effective choice for the 90% of patients seeking routine primary care are physician assistants, nurse practitioners, professional midwives and naturopathic physicians, etc. Integrating currently trained non-physician practitioners and non-allopathic physicians into the present primary care system is a far better use of their time and talents—and our health care dollars. The educational time and money that would have gone into training 5,000 additional MD-GPs every year can be reserved to improve specially medicine for MDs and to train future non-physician practitioners. 55
Why we don’t already have multidisciplinary healthcare?
The tension between allopathic medicine and all other 'healing arts' disciplines is a historical problem going back to the early 1900s. Prior to 1910, healthcare in the United States was not formally organized, that is, there was no single philosophy or profession or body of laws that legislated health services or defined medical practice. This naturally inclusive model known was known as the “healing arts”. The title of many state medical practice acts still use the words ‘Healing Arts’.
In 1900, health-related care in America was provided by ‘regular’ MDs, naturopathic physicians, osteopaths, homeopaths, midwives and a category MDs known ‘eclectics,’ who created a hybrid form of care by taking what they believed to be the “best practices” from each of the different healing arts. While health care included medical doctors and classic treatments such as drugs and surgery, it was not limited to MDs or allopathic principles. The result was a broad-based, free market process that offered patient choice and controlled costs thru competition across a spectrum of healthcare disciplines. In 1900, there were three or more non-allopathic physicians (not counting midwives) for every practicing MD, and professional fees for physician services were low compared to other professional occupations. Medical education was likewise inclusive, with most medical schools teaching a basic curriculum of general medicine, combined with specialized training in each of the 'healing arts' disciplines. The only exception was midwifery. Medical schools typically didn't take women students, so midwives were trained in totally separate programs.
In 1905, a decision was made by the AMA to eliminate the traditional multi-disciplinary pool of practitioners and replaced it with a reduced number of allopathic physicians in an MD-centric system. This plan included closing half of all medical schools and purposely making medical education longer and more expensive. [Minutes from the 1908 meeting in New York City between a representative of the AMA and Henry S. Pritchett, President of the Carnegie Foundation; Carnegie Foundation Bulletin #4 (Flexner Report) 1910] As a result, the pool of students was drastically reduced, which allowed the remaining medical schools to be more selective in their admission policies. After 1910, the demographics for US medical school students were predominantly native English-speakers who were male, white and wealthy.
All of the traditional healing arts, including midwifery, were officially dismissed as unscientific quackery. On threat of losing their AMA academic accreditation, the remaining medical schools were prohibited from including any of the traditional healing arts in the schools’ curricula. The decision to eliminate all non-allopathic physicians (naturopaths, homeopaths, etc.) and non-physician practitioners (midwives, acupuncturists, herbalists) was an expression of 'authority-based' medicine. It also occurred before any of the other disciplines of the healing arts were organized, before women had the right to vote and at a time when the US was still a legally segregated country.
It was generally assumed that medically-educated doctors knew things the rest of us did not know and were not able to understand. Organized medicine convinced legislators that the lay public was not qualified to make decisions in the area of medical practice or any other aspect of their health care—the literal origin of the expression "the doctor knows best." The result was the passage of laws by all state legislatures that created an exclusively allopathic system in which every patient had to first see an MD before any other aspect of health care could be accessed. This MD-centric choke point has been the salient feature of the American healthcare system ever since.
Eliminating the traditional multi-disciplinary forms of the 'healing arts' in 1910 was not the result of evidence-based studies or any scientific analysis. No scientific research has ever identified MD-only care to be a superior choice for all aspects of normal biology and all the health-related needs of human beings. No comparative analysis ever definitively proved other health care disciplines—naturopathy, osteopathy or midwifery—to be inferior within their specific domains of practice or areas of expertise. The motives of organized medicine in 1905 revolved around raising professional fees and elevating the professional status of medical doctors. Chokepoint medicine is 19th century thinking on 20th century steroids. This obviously was a political strategy and not a science-based one, but it was also a genuine reflection of the times—a twin birth of sorts, marking the nascent era of 'modern medicine' as well as the 1905 invention by the AMA of the political process we now know as ‘organized medicine.’
The Grand Debut of “Modern Medicine”
This era, and its organized politics, began with one of the most important scientific events in human history—irrefutable proof by Pasteur in 1881 that micro-organisms caused infection (sepsis). This gave birth to the new biological science of microbiology and bacteriology and the invention of hand washing and antiseptics to kill these germs. For the first time ever, hospitals had effective methods to prevent institutional epidemics and at least reduce contagious disease and cross-contamination between patients. This instantly made hospitals a much safer place and allowed them to become centers for the advancement of medical knowledge. Aseptic principles and sterile technique made surgery relatively safe for the first time and allowed it to be used to improve the quality of life and length of normal functioning. Prior to understanding the need for surgical sterility, 50% to 90% of surgical patients died of post-operative infections, so doctors only operated to quickly amputate a mangled limp or as a last-ditch effort to save someone who would likely die anyway.
Hospitals and invasive treatments were made relatively safe by the new science of microbiology. When combined with the curative potential of surgery, allopathic medicine was recognized as a potentially life-saving form of treatment for the 10% of patients who were gravely ill or injured. Educated people and the lay public alike easily assumed that medical doctors were equally knowledgeable and skilled in every other aspect of healthcare—the 90% of self-limiting conditions, routine and preventive care, health education, normal childbirth, breastfeeding guidance, nutritional information, advice on healthy lifestyle and sexual topics, etc. Everyone expected ‘modern medicine’ to eventually eliminate all human disease . Under these circumstances, it was just common sense to turn the ‘health’ care system over to MDs. Few questioned the elimination of traditional forms of non-allopathic care and people generally accepted whatever doctors substituted in its place.
The founding fathers of early 20th century medicine could not have imagined that by the first decade of the 21st century, student loans for medical school would, on average, create a $140,000 debt that took up to 20 years to pay off or that malpractice premiums would be $50,000 a year for the average GP and all this would have to be paid off by scheduling 10-minute appointments and seeing 60 patients a day, 5 days a week. On top of these protracted economic hardships, the control exerted by corporate medicine and restrictions imposed by health insurance companies would make the professional life of many physicians into a bureaucratic nightmare.
Back to the Heart of HealthCare_2.0 ~ High Quality Primary Care
Not matter how good the intentions of the founding fathers of Western medicine were, we know for sure that late 19th century ideas don't work in our early 21st century world. More of the same is not going to fix the problem. The upgrade to HealthCare_2.0 must be based on a systematic analysis of all models and methods of health and medical practices for comparative effectiveness. When combined with evidence-based medicine, it will create a rational process for the use of 'best practices' as the standard of care. Based on a solid scientific foundation of clinical effectiveness, the next logical step is to identify multi-disciplinary primary care as the hub for the health care wheel. Primary care is also the first line of defense against the overuse of prescription drugs and medical tests and procedures, each of which carries risk of harm to patients, even when they are used appropriately.
The best foundation for a high-quality system is a multi-disciplinary form of primary care that includes the independent practice of physicians as general practitioners, non-physician practitioners (nurse practitioners, midwives, PAs) and non-allopathic physicians (naturopaths, oriental medicine doctors, etc.). Each of these non-MD professionals is trained to provide primary care in areas of routine and preventive care of self-limiting conditions relevant to their own discipline. This generally includes non-urgent illnesses and psychological issues such as anxiety or mild depression, normal biology, routine physicals, life-style issues, supportive care and the management of stable chronic diseases and more.
Primary care is the foundation of cost-effective health care. As a cost-effective system, it must rely first on non-physician, primary care providers. The idea of the right practitioner for the right problem saves the health care system vast sums of money that can be redirected to improved health care coverage, effective prevention and to eliminate any need to ration medical care for the elderly, disabled or terminally ill. Instead of fighting against the tide of MD specialization (75% of new graduates choose to train in a specialty), we would be able to use the funds saved to pay for the kind of advanced care that only MD specialists can provide.
MDs in general practice would become the invaluable hub the primary care system. A large core of physician GPs will always be needed to provide care to patients who need MD diagnosis or treatment and those who simply prefer to see a medical doctor. GPs are a critical aspect of the practice of non-physician practitioners, as NPs rely on MDs to provide a consulting service and receive referrals whenever a patient’s condition requires a higher-order of medical services. NP and non-allopathic physicians would be needed in numbers equal to the population seeking routine and other forms of non-urgent care. Regardless of the category of caregiver, quality primary care always preserves and protects individual choice.
Fortunately, most areas of the US have timely access to medical doctors, hospitals, and surgery to be used in event of a serious or urgent medical situation. The US has created a good system of emergency, “at-the-scene” care, stabilization and transport, via our first responders—EMTs, paramedics, ambulances and transport by helicopter and plane. This demonstrates that the health care profession in the US already knows how to create a cooperative and collaborative model of health care for everyone, which is so necessary in creating a system that focuses its resource on prevention.
A Vision for the 21st Century—HealthCare_2.0
The good news is that we have the money, talent, technology and other resources to develop and maintain a system that is fair and affordable, preserves individual choice and reliably delivers care that is as safe and cost-effective as any other industrialized country. This can be done without taxing the middle class, rationing medical services for the elderly, limiting the advance of medical science or turning the healthcare system over to government bureaucrats. Two trillion dollars a year ($X,000 per person) is twice as much as any other country spends per person. That’s more than enough money treat everyone and meet every genuine medical need by creating an articulated model of multidisciplinary healthcare that works at every level.
HealthCare_2.0 includes the allopathic tradition of crisis or ‘rescue’ medicine, but is not exclusively organized around it, choosing instead to develop a broad-based system of health care that includes the traditional concept of the ‘healing arts.’ This provides the US with a multi-disciplinary system staffed by professionals who can devote their time, talent and industry to a prevention-based model of care, while providing humane and non-discriminatory treatment to everyone, regardless of health status or medical needs.
HC_2.0 collaborates with all stakeholders—patients, the lay public, professionals, scientists, politicians, government regulators and members of the business community. It integrates this input, takes the best of all the available options, acknowledges future contributions from science and technology, and coordinates all these elements into an effective and efficient system that all Americans can be proud of.
The Action Plan Wrap-up for HealthCare_2.0 starts with:
1. Recognizing the limitations of a medical care system organized around after-the-fact interventions and acknowledging the social, medical and economic advantages of a health-focused system.
2. Systematically using the analysis of comparative effectiveness and evidenced-based medicine to create a standard of care based on "best practices" to be used by all categories of health care professional and in all setting.
3. Identifying and economically supporting a multi-disciplinary form of high-quality primary care as the hub of the health care wheel.
4. Welcoming the miniaturization of contemporary medical equipment for testing, monitoring and treating 'in the field.' Innovations like the "information station" can make cost-saving, high-quality care available in community and home-based setting while substantially reducing healthcare costs. Full use of miniaturized medical diagnostics and therapeutic equipment will expand the ability of the US to provide high-quality medical services in remote locations and third world countries, leading the way for American ingenuity to improve the health and wealth of populations worldwide.
5. Looking forward to a brighter future made possible by scientific and technological innovations, especially in the area of genomic, DNA diagnosis and treatments and prevention of disease through the use epigenetics (the ability to turn genes off and on for prevention or treatment of disease).
Links to pertinent references and original sources on the history of organized medicine and the ‘new’ obstetrics as a surgical specialty:
History of AMA's relationship in 1908 w/ the Carnegie Foundation & Flexner Report
Material taken from Dr. H. Smith William’s lengthy interviews of Dr. J. Whitridge Williams, who was formerly a gynecological surgeon (1890s) and at that time was Chief of Ob-Gyn at Johns Hopkins; book also includes extensive quotes from papers Dr J. W. Williams published in JAMA.
Excerpts from all 8 chapters (total 50 pages out of original130 pages)
Part 1: Intro & selective quotes from entire book
Part 2: Lengthy excerpts from Chapter 6, 7, and 8,
Part 3: Chapters 1 thru 5Part 4: Addendum of quotes from the American Society for the Study and Prevention of Infant Mortality (1910-1914) on midwives and obstetrical education by Drs. DeLee, Williams & other obstetricians of the era
