Health Care Transformation: Still a Work in Progress
Where does “health care transformation” exist? Google finds us 70,600,000 hits on the subject. Good luck with that. Is it out there in parts? On the horizon: in accountable care organizations; patient-centered medical homes? In gene therapy and epigenetics? In HIPPA-compliant health information networks? In our National Prevention Strategy? In diet therapies approved by the Centers for Medicare & Medicaid Services for cardiovascular disease? In the pages of recent books like Daniel Agus’s “The End of Illness,” or Martin Seligman’s “Flourish” or Clayton Christensen’s “Innovator’s Prescription?” (by all means, add your own titles.) In the high-priced social sharing of TEDMED?
Five years ago I slid serendipitously onto the outer edges of health care, landing in the highlands of integrative medicine. As a product of the exemplar of disruption, the Internet, I recognized in integrative medicine its elements (those pesky therapies and products referred to as “alternative” medicine, or CAM), its practitioners and their fervor, commitment, diligence and belief that characterized the tenacity of entrepreneurs, agents provocateur and sheer believers who took up the controls of the Internet in the 2000s. I also noticed the massive consumer use of its many modalities.
Health and the Internet, as it happens, share a common disruptive attribute, both evolved over the last 30 years: gradual assertion of control by the “user.” Along the Web it is all user-generated-content, where blogs, social media sharing sites proliferate, and where “conventional” publishing revenue models recede in the wake of multi-million-member social businesses.
In health the concept user-generated-health care usually applies to the use of social applications and biometric apps whose data can flow to care providers or across patient communities. But long before the Web appeared user-generated-health was called “lifestyle” for those into gyms, fitness centers, organic foods or supplements. Those long-standing personal activities, however, did not affect health care in the same way that digital social networks upended media industries. That disruption began the 1980s when consumers started making use of herbal therapies, acupuncture, homeopathy and other approaches, both to address health problems that conventional medicine could not resolve, or—half the time—just to enhance their own wellbeing.
Just as the new generation of bloggers was formed out of former readers and media consumers, many practitioners of holistic disciplines had been patients themselves, and, having experienced their own pronounced relief, turned themselves and their careers to the practice of these disciplines. Or if they were sufficiently well off they might have also joined the generation of philanthropists who have funded significant research and clinical application of CAM therapies.
I was initially interested to find that these practices did not exist solely in exurban strip malls or storefronts and second story clinics in commercial districts, which many did. the National Institutes of Health had invested $2 billion to investigate CAM approaches; in the 2000s, medical schools inaugurated academic centers of integrative medicine; professional medical societies such as the American Academy of Pediatrics established sections organized around “complementary and integrative medicine.” This was a substantial national intellectual and clinical infrastructure.
The question was: What were the 30+ million adults who use CAM each year expecting? Why are they bothering? At such numbers, this was plainly far more than stretching for personal transcendence or recovering from the 60s. When Harvard’s David Eisenburg, M.D. published his landmark study on the vast public use of alternative therapies in 1993, a long process commenced, supported by the Institute of Medicine, that was intended, and still is, to establish a proper place for CAM in U.S. medicine.
It became obvious to me that whatever the state of the evidence-base for the reported benefits or the motivation of the clients, the formation of such a national infrastructure around non-conventional health practices was the result of individuals (“consumers” before they became “users”) spending $30 billion-plus for them in the marketplace, out of pocket. If there were a transformation for health, it would come from the disruptive potential of such large numbers, choosing therapies regarded caustically by the establishment (as in: “Nobody will ever trust a blog!” So said the former editors of many publications), and paying for them to boot.
The longer I explored the field, three factors stood out:
1) The continuous adoption of integrative practice and thinking within the conventional care system, even in unlikely places. (Did the U.S. Army really allow a psych doc to circulate among forward units in the battle terrain in Afghanistan to administer acupuncture for pain? It did, and to measurable benefit. It is one aspect of the military’s aggressive focus on emotional and psychological resilience training now embodied in its Total Force Fitness program);
2) The increasingly discouraging health status of the nation’s citizens and inability of the conventional care system to resolve the trends, to say nothing of their costs; and
3) The obvious potential for integrative approaches in wellness and prevention.
The key of course is in the broad appeal, i.e., consumer demand that still drives that adoption.
At times I think of integrative medicine as a kind of plug-in for conventional medicine. It is a handy metaphor, but really not apt for what is really a parallel, complementary conception of health, healthiness, healing potentials and wellbeing. It is a related but fundamentally different paradigm whose primary precepts include:
- A whole-person orientation that animates almost everything else:
i. The physician who is committed to being highly attuned to his or her patient in the fullest measure, as a means of delivering the best healing possible
ii. The mind, body and spiritual dimensions of anybody’s state of health
iii. Collaborations among team members, the center of which is the patient
- Treating the underlying cause of illness and disease
- The integration of the all therapies, procedures, technologies and skills available that have proven value, whether that value is derived from RCTs or from psych docs treating wound pain on the battlefield with acupuncture
- Self-care, including for health providers
- The individual’s innate powers of healing
Among the tenets that accompany these precepts is the belief that in the West we have succeeded in setting aside perfectly good knowledge about sustaining health, about healing and about healing relationships that are often better suited to benefit our biology than are manufactured variations, if only we would apply it. This of course refers largely to what grows and flows from the land and to community healing practices long since left to history or to other cultures.
In practice, there is movement toward these precepts, though of course mostly far from full engagement with them. Health insurance companies support pilot programs applying integrative therapies in conjunction with usual care. The U.S. military has funded research showing that yoga provides relief to Post-Traumatic Stress Syndrome patients (among many other subject of integrative focus). Progressive employers such as Dow and the software firm SAS have expanded their employee wellness programs to include a few CAM modalities. And the language of the whole-person often appears alongside patient-centric service descriptions.
Last fall The Atlantic Monthly profiled the progressive health care company CareMore, now part of WellPoint, that organizes itself to serve elderly patients, and in ways as close-to-the-patient as is physically possible. There, the article reports, “Doctors coordinate multiple kinds of care for individual patients. The underlying philosophy is simple: a patient is one unified human being, not a collection of disconnected symptoms.”
As I recently contemplated what kind of contribution such a whole-person, mind-body paradigm would make to our nearly mythic health care transformation, a realization set in: In the academic clinics at Duke Integrative, at the Osher Center, Scripps Institute, Thomas Jefferson University Hospital, the University of Maryland Medical School, at Yale, at the University of Arizona, the University of Wisconsin, in military and VA health clinics and at a steadily increasing number of hospital enterprises like the Mayo Clinic (which recently added integrative therapies to its clinic at the Mall of America in Minneapolis) and among thousands of independent clinics around the country, large and small, some led by M.D.s, most not: a transformed health paradigm is already in place.
Because the leaders of those institutions have deliberately worked over the years to maintain and sustain links with their conventional brethren and increasingly with specific CAM disciplines that represent hundreds of thousands of practitioners across the country, their models and their outcomes offer a patient- and practice-centric path to a transformed understanding of health and wellness potentials that have nothing to do with information networks, electronic records (or funding physician practices to invest in same), or operational and clinical processes streamlined to the max.
And most of them are open for business.