With all of the rhetoric about health care reform, most discussion has focused on health insurance reform and not true reform of the health care system.
Clashing Paradigms
The current polarization within health care stems largely from a clash between two different health care paradigms that go as far back as ancient Greece. The Coans, led by Hippocrates, adhered to a holistic world view in which the patient was viewed as a whole and promotion of health included diet, exercise and a balanced lifestyle. In contrast, the Cnidian School focused on diseases of parts located in organs or organ systems.2 The Coan School held that disease had a natural basis that was the result of an imbalance within the person. The Cnidian tradition saw diseases as real entities with an existence distinct from the person.2 The current biomedical model dominated by specialists is a legacy of the Cnidian School.3 Health care research and treatment practices today are directed by the prevailing reductionistic paradigm, thereby lacking focus on health promotion and wellness.
Health Promotion and Wellness, Not Just Disease Prevention
The dominant reductionistic medical world view at best limits health promotion to disease prevention. In addition to disease prevention, health promotion and wellness efforts can significantly assist those at risk or currently experiencing health problems. Specifically, attention should be directed to the following:
- Increasing access to appropriate alternative health services in conjunction with appropriate health care decision-making and procedures to promote adherence and healthy outcomes, in addition to integrative care whereby decisions are based on a holistic patient-centered paradigm,4 not just which drug will prevent or treat a disease.
- Supporting health education and communication initiatives based on research that pays proportionately greater attention to factors that impact health and wellness, not just disease.
- Supporting initiatives to increase public awareness of problems impacting health and wellness. This includes not only all health care providers, but also health educators in schools, colleges and universities.
- Supporting initiatives that reduce behaviors associated with disease, injury and disability, including tobacco use, poor nutrition, and physical inactivity. Policy changes like calorie labeling on restaurant menus is not enough when a complete reform of the food industry is needed to eliminate empty calories and highly processed foods. Prescribing drugs to prevent heart disease begs for a revolution that does not promote a drug solution, but instead focuses on reducing stress, diet and inactivity.
- Supporting initiatives to disseminate evidence-based health promotion and wellness strategies in addition to the drug-related research on which most research monies are currently spent.
- Ensuring access to appropriate health, referral and early intervention services in a variety of settings including alternative health care.
- Promoting healthy environments that are major determinants of health and well-being. Clean air, water and soil are all critical components to good health. For example, clean air standards can help lower asthma rates. Environmental and policy changes have resulted in reductions in tobacco use, increases in seat belt use, and improved sanitation levels. Emphasis should be on different ways that the environment affects health, including the connection between sustainable agriculture and public health, and improving community and school environments to encourage healthy eating and more physical activity. Increasing evidence demonstrates that the characteristics of the physical environment from the presence of parks to the availability of healthy foods in neighborhood stores are directly linked to eating and activity behavior.5
Costs Related to Health Care
The U.S. health care system is in critical condition, ranking below most developed nations. Reforming its deep problems requires attacking causes, not symptoms. The United States pays more and gets less. Overall U.S. health care costs approach $2.5 trillion per year, yet evidence shows that quality of care is lower. In fact, the United States has the highest death rates from conditions that could be prevented or successfully treated.6 Surely there is a case for reform, if not revolutionary changes. Even with the passage of the health reform law, politicians are divided on health care reform and are reluctant to pay for it. The status quo is unsustainable and health care reform is inevitable and urgently needed, not solved by insurance reform alone.
Major U.S. Health Care Problems
Costs and Quality: Regional variation in health care costs and quality are dramatic based on region. For example, Medicare costs can be two or three times higher to treat patients with the same illness, but without better outcomes.7
Medical Errors: Medical errors occur regularly, compromising patient safety. The Institute of Medicine reported in 1999 that preventable medical errors kill 44,000 to 98,000 Americans each year, costing about $29 billion. This problem persists and tort reform, while reducing the cost of malpractice insurance, will not reduce the number of lives lost. Again insurance reform will not address the need for health care reform. According to the 2005 National Vital Statistics Reports, medical errors cause more deaths than breast cancer or automobile accidents. The Robert Wood Johnson Foundation, after comparing developed countries, reported in 2009 that U.S. patients are at greater risk from medical errors. And in January 2009, The New England Journal of Medicine stated that using a simple checklist would reduce errors and cut the surgery death rate in half, saving U. S. hospitals about $15 billion per year.8
System Fragmentation: The health care system is fragmented, uncoordinated, and therefore inefficient, wasting valuable resources.9 Most medical errors result from poor communication among health care workers. Too often, clinicians work in specialized silos, aren't trained to work in teams, and don't share information with each other. It can be argued that the culture of medicine perpetuates this obsolete structure by exalting doctors as infallible, invulnerable and in charge.8 Now here is a major case for a revolutionary change. Health information technology with electronic records can enable system-wide recording and sharing of essential information, improving coordination and reducing errors, duplication and waste.10 This is not a panacea, however, and will only improve the system if the records are read. Too often, corners are cut and records containing essential information are scanned while red flags are missed.
Health Insurance Costs: For too many Americans, private health insurance is becoming unaffordable. To offset costs, insurers have shifted more payment responsibility to enrollees, usually across the board. This leads to at-risk consumers abandoning essential care or dropping their health insurance altogether. Without a public option that provides competition, this policy will continue. Health insurance reform in its current state surely requires a revolutionary approach to change.
Medical Fraud and Abuse: It has been reported that Medicare fraud siphons $60 to $90 billion annually from the system.11 Although evidence shows that every dollar invested to combat fraud saves $1.5,12 the 2008 budget ($456 billion) allocated less than two-tenths of a percent for that purpose. In addition, we can't afford longevity if it is characterized by unnecessary hospital admissions and physician visits, excessive testing and "defensive medicine." A paradigm shift away from passive treatment toward health promotion and wellness strategies that actively engage the patient can improve the quality of life of seniors and save money in the end.
Medical Malpractice/Tort Reform: For many doctors, escalating malpractice premiums and lawsuits have made the practice of medicine unprofitable. To avoid malpractice claims, practicing "defensive medicine" by ordering duplicative or unnecessary tests or procedures can be hazardous to the patient in addition to inflating health care costs. For example, the American College of Radiology reported in 2004 that Medicare and private health insurers pay nearly $16 billion a year for unnecessary imaging tests.8
"Defensive medicine" has other negative consequences. In the current environment, doctors who make mistakes fear not just lawsuits, but also professional punishment including loss of hospital privileges. Doctors are therefore reluctant to report errors that hinder the gathering of information needed to create system-wide methods for preventing future errors. The proposal to alleviate malpractice-related problems by limiting awards doesn't confront the root causes of medical mistakes or the cultural impediments to reducing them.8
What We Need: A True Revolution
It appears obvious that revolutionary changes in the health care system are needed; a paradigm shift to break free of the Cnidian fragmentation of care that reduces patients to body parts or systems is needed. Too many specialist and too few primary care doctors perpetuates this fragmentation. While lip service is paid to Hippocrates (in the form of the Hippocratic Oath), following this philosophy is not the norm. Coan emphasis on the whole person while striving to promote health and wellness provides a framework or way of looking at the results of empirical inquiry. A paradigm provides a lens for viewing the world of health care based on habits of mind and webs of belief. The prevailing conventional care that relies on pharmaceutical medicine cannot assimilate CAM therapies that are based on a different paradigm.
A total shift in health care is essential if we are to move toward recognition of the value of continuity of care, health promotion and wellness. At present, physicians are not reimbursed for providing health promotion and wellness care. Screening for disease prevention treated by drugs is only a small part of what constitutes the care necessary to promote health.
References
- Kuhn TS. The Structure of Scientific Revolutions, 2nd Edition. Chicago: University of Chicago Press, 1970.
- Phillips TJ. Disciplines, specialties and paradigms. J Family Practice, 1988;27:139-41.
- Jamison JR. Chiropractic philosophy versus a philosophy of chiropractic. The sociological implications of differing perspectives. Chiro J Aust;21:153-9.
- Gatterman MI. A patient-centered paradigm: a model for chiropractic education and research. J Alternative and Complementary Medicine, 1995;1:371-86.
- "Nutrition and Physical Activity." The Prevention Institute. www.eatbettermovemore.org/nutrition.html
- "How Does the Quality of U.S. Health Care Compare Internationally?" The Robert Wood Johnson Foundation/Urban Institute, August 2009.
- Associated Press, Sept. 7, 2009.
- Levi G. "Healthcare Reform - Politicians Miss the Point." March 7, 2010.
- Enthoven AC. Integrated delivery systems: the cure for fragmentation. Am J Managed Care, 2009;15:S285-90.
- Fendrick AM, Chernew M, Levi GW. Value based insurance design; embracing value over cost alone. Am J Managed Care, 2009;15:S2775-83.
- CBS News, Oct. 25,2009.
- U.S. Department of Health and Human Services, 2009.
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