Erik Goldman12.01.06
Acute Care vs. Preventive Medicine: A Tale of Two Cities
Action must be taken to preserve and advance the importance of holistic medicine before it’s too late.
ByErik Goldman
One of the most interesting aspects of my work as a medical journalist is the opportunity it affords me to view the healthcare landscape from many different angles, to get some sense of the “bigger” picture. What I see is very disturbing.
Several weeks ago, I attended the Transcatheter Cardiovascular Therapeutics (TCT) conference in Washington, D.C. TCT is a cutting-edge gathering where roughly 10,000 interventional cardiologists—the guys (this is one subspecialty that remains male dominated) who do angioplasty, vessel stenting and other heroic acute interventions—learn about emerging heart drugs, state-of-the-art imaging devices and hot new surgical gear. We’re talking the crème de la crème of high-tech, end-stage, acute care.
Money seems to be no object in the world of interventional cardiology. The exhibit hall at TCT looked like a cross between Disney World and NASA. The main educational sessions were projected on giant split-screen video systems with simultaneous audio/video feeds throughout the convention center. All attendees were given a handsome shoulder bag that contained, among other things, a library of 20 CDs of all of the significant cardiovascular studies over the last few years. “Satellite symposia”—industry parlance for drug or device company-sponsored educational sessions (usually with a nice lunch or dinner)—were plentiful. Research studies presented at a major medical conference like TCT typically involve tens of thousands of patients.
The “big news” trial at this year’s TCT was the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) study, which involved nearly 14,000 heart attack patients. It showed that a new (and expensive) clot-inhibiting drug called Bivalirudin could reduce the incidence of excessive bleeding epi-sodes—a complication in angioplasty procedures—compared with old-fashioned heparin (coumadin). Severe bleeding problems occur at a rate of roughly 10% in heparin-treated patients; bivalirudin seemed to reduce this to 3.5%—at least in the first 30 days following the procedure.
Two weeks after TCT, I went to Los Angeles, CA, for the CAM (Complementary & Alternative Medicine) Expo West, a conference and tradeshow aimed at naturopathic and holistic physicians, as well as mainstreamers interested in making the transition. The program was top-flight, with some of the leaders in natural therapeutics sharing science and clinical experience on applying nutritional, botanical and other non-pharma approaches to treat, or better yet, prevent the chronic diseases bankrupting our healthcare systems.
CAM Expo expected to draw around 1000 practitioners; it actually drew about 250, at best, and a roughly equal number of exhibit booths (making for some very grumpy exhibitors). In comparison to TCT, the exhibit hall at CAM Expo looked like a glorified high school bake sale. Though there were some excellent scientific sessions, particularly on the application of genomics in nutritional medicine, there was very little original data presented, and certainly nothing on the scale of the ACUITY trial. And attendees were on their own for lunch and dinner.
My point, you ask? It is simply this: all of the money in healthcare is at the wrong end of the continuum. The big dollars are in acute care of very ill people. Those committed to preventive holistic medicine, which could very well avert much of the need for acute care, are scrounging.
A study like ACUITY, which sets out to prove that an expensive new drug can fine-tune outcomes of costly operations in very sick heart patients, costs tens of millions of dollars, not to mention huge administrative effort. But the resources are there; pharma companies have an interest in getting this kind of data, so they manage to come up with that kind of scratch.
Try to find that level of funding for a 10,000-patient trial on, say, nutritional interventions to prevent progression of insulin resistance to type 2 diabetes, or omega 3 fatty acids and the prevention of myocardial infarctions, or comprehensive naturopathic care for the treatment of children with autism and ADHD. You’ll be grant writing for a really long time.
With the exception of a handful of massive but questionably designed NIH-funded trials, the nutritional and natural medicine world considers it major progress if someone can pony up the money to study 100 patients who aren’t of the small, furry, four-legged, long-tailed variety.
Yet just about everyone concerned with healthcare issues will acknowledge that the primary drivers of heart disease, diabetes, cancer and other common chronic diseases are dietary, environmental and lifestyle factors. We also know that those very diseases are crippling the corporations that pay for healthcare for a majority of Americans, as well as the federally-funded programs (Medicare and Medicaid) that cover our poor and elderly.
Despite massive public interest in holistic medicine, most practitioners in the holistic sphere, be they naturopathic doctors, holistic MDs and DOs, Oriental medicine practitioners, or massage therapists, are having a really hard time making a living.
At the 2006 annual meeting of the American Association of Naturopathic Physicians, I had a troubling discussion with Dr. Richard Thom, a professor at National College of Natural Medicine in Portland, OR, one of only four accredited U.S. naturopathic medical schools. One of Dr. Thom’s primary interests is in the economics of healthcare, and the preparation of young naturopathic grads for the hard realities of practice-building.
He told me that at best only 10-15% of all naturopathic grads are making what he termed a “real, full-time, adult living” practicing the medicine in which they’re so well trained. The overwhelming majority are being supported by a spouse or family member, taking on a second job to augment their income, or earning their way by writing, teaching, lecturing or doing something other than patient care.
Holistically-minded MDs and DOs are in a slightly better position since they can still base their practices around conventional and reimbursable services. However, those who want to jump full-time into holistic practice must either stop taking insurance and hope enough patients will be willing to pay fee-for-service, or they join “concierge” practices, where patients pay an annual fee and obtain whatever services they need for this fixed amount.
TCT’s interventional cardiologists, however, are doing just fine. They’re riding a huge, well-oiled hospital-industrial machine that provides them endless streams of patients. Insurance plans and federal programs amply cover their services and they’ve got robust financial support from drug and device manufacturers. Given the current stats on diabetes, obesity and heart disease, they’ve got little to worry about in the future—they’ll have business for decades to come, so long as the system stays afloat and continues to reimburse them for what they do.
Though I’ve no way to prove it, my hunch is that CAM Expo West failed to draw more physicians because the very practitioners they’re trying to get are the least able to take three days out of the office and pay for an out-of-town excursion. TCT certainly has no problem drawing its minions.
Without substantial changes in state and federal healthcare policy, the evolution of natural medicine will remain in a sort of stasis. The existing system is simply not designed to fund preventive medicine and holistic healthcare, the very things we need to avert what all experts agree is a soon-coming healthcare train wreck. If holistic/preventive medicine practitioners cannot make a living, public access to their services will be limited, and the growth of the field as a whole will stall.
Mark Houston, MD, is the director of the Hypertension Institute at St. Thomas Medical Group, Nashville, TN. He specializes in early detection and nutrition-based treatment of metabolic syndrome, the “on-ramp” to type 2 diabetes. He told me that diagnostic testing methods now exist to detect the earliest metabolic changes leading to insulin resistance, hypertension, atherosclerosis, and all the end-stage complications of diabetes. In his experience, if these changes are caught before they become symptomatic, the vast majority of people can be effectively treated by dietary changes, exercise and targeted nutritional supplementation alone. A life of insulin injections, metformin and other pharmaceuticals, not to mention heart surgeries and amputations need not be a foregone conclusion.
Dr. Houston said he’s got patients flying in from all over the country to see him because they can’t find holistic physicians trained in functional medicine in their areas. “The insurance companies won’t cover this approach. They don’t cover the tests or the supplements, and they’re not good at paying doctors for nutritional counseling. It’s a really stupid system that we have, and that’s why the U.S. healthcare system is going to go belly-up.”
Clearly, something needs to change. I’m not arguing that we abandon the high-tech acute interventions that have saved so many lives. We need them and we will continue to need them for years to come. But we, as a nation, must also figure out how to develop healthcare financing that supports preventive healthcare and natural medicine.
I’m not convinced that the answer lies in trying to shoe-horn holistic health services into the existing insurance infrastructure. I think it is a bad fit that would ultimately hobble the evolution of natural healthcare and limit the personal choice and individual responsibility that are its cornerstones.
But I do wonder why supplements and holistic practitioner services are categorically excluded from “health savings account” strategies that are supposed to be all about freedom of choice and personal health accountability. I wonder why poor people cannot use their food stamps to purchase vitamins, herbs and other supplements. I wonder why there’s so little funding to study the practical real-world application of nutrition, nutraceuticals and natural medicine in the management of common chronic diseases.
I also wonder when the natural products industry is going to step up to the plate and start putting its weight, its wealth and the momentum of its public support into the larger endeavor of finding solutions to the impending healthcare disaster.
I wonder when the industry is going to start reaching out to its strongest un-tapped allies: executives of major corporations that are buckling under the financial strain of continued health benefits coverage for their employees. Corporate America is beholden to the existing pharmaceutical-based, insurance-driven healthcare model simply because its leaders don’t really know about other possibilities. And they don’t know because the natural products industry and holistic medicine communities have been far too meek—or far too self-absorbed to look at the larger picture.
It seems that our industry only goes to Washington to make noise when someone in Congress starts talking about undoing DSHEA or imposing regulations. We’re never at the table when broader health policy decisions are made. That’s not good enough.
I realize that the natural products industry will never be able to finance the level of research currently being conducted by the pharmaceutical industry. Absence of patent protection makes that all but impossible. I know that we’ll never be able to create the kind of feather beds for holistic practitioners that Big Pharma has created for conventional physicians, and I’m not sure that’s even needed. But I strongly believe that the industry must form stronger alliances with researchers and with the practitioner communities that have long been part of its support base.
I believe we’ve got strong potential allies in the corporate world who are anxious for relief from the paralytic costs of health benefits. Why are we not reaching out to them for research funding, political support and management intelligence?
Healthcare issues were not much of a factor in November’s mid-term elections; the Iraq war, the economy and energy issues seemed to eclipse them. But odds are good that healthcare will be back in the spotlight come the next Presidential election. It is time to start clarifying a vision and a practical policy agenda that supports preventive medicine and holistic healthcare. It is time to forge alliances between our industry, the broader corporate world and the practitioner communities. This industry needs to get up, stand up and speak out. There’s a lot at stake. NW