As debate about health care reform has flopped around without any real progress for the last two years, and as we’ve read all we can endure of white papers and shoot-from-the-lip editorials on this crisis, some of us keep recalling the old quip about rearranging the deck chairs on the Titanic. Sure it’s a tired metaphor, but will anybody deny it fits?
This nation’s health care system has collided with the cold, hard reality of our population’s deteriorating health. The ship is sinking, and the lives of all on board are at stake. Can it be kept afloat just by shifting the burden of payment or extending insurance coverage to more passengers or—and this statement may shock some of my chiropractic colleagues—getting everybody under chiropractic care? Not likely. At the very least, the quality of this country’s health care will keep declining and its cost will surely rise. For all intents and purposes, this ship is dead in the water .
It’s time to build a new ship.
But what would it look like? Who would steer it? What kind of health care would it deliver? Who would get that care? Who would pay for it?
First, unlike the designers and captain of the Titanic, we need to consider more seriously the reality of the iceberg.
James L. Chestnut, D.C., currently one of the most articulate advocates of prevention and wellness, observes that an estimated 80 percent of our industrial adult population has chronic illness and will die from it. The sheer financial cost of chronic illness—which drugs and surgery only address symptomatically—he says, “is unsustainable at all levels from individual to corporation to government to society.” Chestnut—who, I am delighted to say, is now affiliated with Life University—also pinpoints the cause of chronic illness:
“Chronic illness is a lifestyle illness. Chronic illness rates have risen exponentially since 1900, as have prescription drug use and surgery. Our genes have not undergone any significant change during this period of time. It can’t be genes. During this period of exponential increase in chronic illness, our genes have remained virtually unchanged, but our lifestyle has changed significantly. The changes in our lifestyle, away from what we genetically require as a species, mirror the increases in chronic illness and the damage it can do.”
The ice-hard reality is that society doesn’t understand that chronic sickness is not genetically pre-determined; blaming the genes is an erroneous idea that medical practice assumes and propagates. People have yet to realize, partly because of Big Pharma’s $57-billion-plus in annual marketing, that they can improve health across the board, not by taking drugs, but by changing habits. At this point, the everyman is unwilling to take responsibility for his health because he doesn’t believe it would do much good anyway. He believes he’s predestined to be sick, and sooner or later he’ll have to pop a pill. Make that pills, plural, by the boatload.
Lewis Thomas, who served as dean of Yale Medical School and later president of Memorial Sloan-Kettering Institute, wrote: “As a people, we have become obsessed with health. There is something fundamentally, radically unhealthy about all this. We do not seem to be seeking more exuberance in living as much as staving off failure, putting off dying. We have lost all confidence in the human body.”
Actually, society is obsessed with disease, not health, but his basic point is right on. Our aim ought to be “seeking more exuberance in living” and developing more “confidence in the human body.” Thus, the first component—indeed, the central driver and coordinator—of any new health care system must be health education, and its goal must be to change the culture from one that sees sickness as inevitable to one that sees health as sustainable. The focus must shift from looking for diseases to treat to looking for better ways to live. Most obviously, people need education about the enormous benefits of good nutrition and regular exercise. It’s encouraging to see more medical voices starting to advocate those things, as chiropractors have been doing for more than 100 years. Yet, as with an iceberg, the biggest chunk of the problem lies beneath the surface.
The elements of health and disease involve the totality of how people live. Health isn’t an exclusively physical phenomenon. It’s a life systems phenomenon. Here at Life University, we’ve identified health as having physical, emotional, social, intellectual, spiritual and environmental elements, and we recognize that they all comprise a unique living system in each individual. We already have incorporated these interrelated aspects into a program to improve the health of our faculty and staff. We call this program the Wellness Portfolio, and we’re developing it as a possible piece of a new concept in health care practice.
When we look at those inextricably interconnected components of health, three things become evident. For one, achieving health must be approached holistically rather than through medicine’s traditional reductionism. For another, it’s clear that no single doctor, such as the classic family practitioner, is qualified to analyze, let alone care for, everything with everybody. And finally, this approach isn’t limited to isolated symptomatic events, but requires a patient-provider relationship over extended time.
Commenting on a recent study by the New England Journal of Medicine on the depressing increase in hospital mistakes despite a decade of effort to improve hospital safety, popular Internet presence Joseph Mercola blogged:
“The United States also now ranks 49th for male and female life expectancy worldwide… Among the most likely suspects for Americans’ declining health were not obesity, traffic accidents, murder or other ‘big killers’ you might suspect. Rather, researchers pointed to unnecessary medical procedures and an uncoordinated system with fragmented care, where patients rely on numerous providers to treat various bits and pieces of a problem, rather than seeking out one provider who will treat them as a whole.”
Well, we at Life University would agree with Mercola about the deadly damage of unnecessary medical procedures and fragmented care, but disagree that any one provider can “treat [patients] as a whole.” Not only does no one kind of doctor, including the chiropractor, have such comprehensive expertise, but the real flaw here lies in that little word “treat.” It presumes that, if disease symptoms are successfully addressed, then health is attained. But health, as Dorland’s Medical Dictionary famously defines it, is not really about treatment at all: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” In short, it’s impossible to treat people into health; at best, you can sometimes treat them out of disease. To put it another way, if we achieve health, we automatically eliminate disease; but eliminating disease does not automatically achieve total well-being.
It’s this understanding that has helped chiropractors for decades recognize there’s more to well-being than the right chemical reactions. Our philosophy, called vitalism, is defined as “a doctrine that the processes of life are not explicable by the laws of physics and chemistry alone and that life is in some part self-determining.” What’s more, chiropractors understand the implications of this philosophy as applied to health care. They know there are, in effect, three kinds of care that can benefit this self-healing, self-determining organism.
The first kind, which, incidentally, will usually mark people’s initial entry into any health care system, is what we at Life refer to as “condition-based care.” The person comes in with a pain, symptom or disease, and the doctor’s responsibility is to address that condition. This may include referral, co-management, or, in a large majority of cases, just chiropractic care. The second aspect of care is what most patients think of as prevention, or what we chiropractors term “corrective care.” In that case, the doctor’s goal is to reduce the subluxation and maximize spinal-neurological function. Most patients see this care as important so their problem doesn’t reoccur. The third kind of care is what we call “wellness/development care.” In this phase, we’re helping the complete person become all he or she can be.
It’s in this third phase of care, especially, that we face the challenge of providing a truly holistic approach and doing so through a long-term relationship. However, this challenge is neither insurmountable nor necessarily costly. To begin with, in these days when so much data is easily accessible, it is possible to chart societal norms for where the average person is with regard to each of the components of wellness in the context of age and other factors.
An average male’s physical strength, range-of-motion, stamina, etc.—let’s say for this example—peak at age 35. On the other hand, his social and intellectual health components may peak in his 70s or later, and so forth with the other components of health. Thus, it’s possible to look at the major factors of a person’s life at age 40, determine where he stacks up against the norms, and provide direction appropriately. The exercise regimen, for instance, recommended for that 40-year-old is likely quite different from the one for the 70-year-old. Yes, we realize each patient is an individual with a unique history and varied circumstances, and seeing an individual’s condition relative to an average is only a starting point. But that starting point may provide a direction for focused wellness and development care.
How could that be provided, given the complexities of everyone’s life?
Imagine a clinic with several health care providers and an educator or educational program at the center. Perhaps this imaginary clinic has an M.D., a chiropractor, a nutritionist, a positive psychologist, a health coach, an exercise therapist and other on-site specialists, or a network of health experts nationwide. Again, though, it is not just that you have various providers together. The key is that they are coordinated through on-going patient education during a long-term relationship. The education, targeted toward each individual patient, drives the care and determines changes in direction as time goes by. This personalized educational program is directed by the health coach, such as those now graduating from Life University in our undergraduate program.
So, you come into this holistic clinic with what you believe is tennis elbow, and you’re seen by a chiropractor or a sports health specialist. You’re given whatever palliative care is appropriate; in other words, you have a condition, and yes, it’s “treated” by ice or hot packs or a chiropractic extremity adjustment or perhaps you even have to be referred out for surgery. But in this case, let’s suppose you’re referred to an exercise therapist, who gives you some tailored exercises to strengthen the soft tissue; in other words, you’re in rehab with a view not only of repairing the damage, but also strengthening your arm, shoulder, elbow and wrist so the problem doesn’t flare up again. That’s the second phase of care, and in it, if not before, you begin or continue with regular chiropractic spinal adjustments so your nervous system can help your body heal itself and stay healthy.
Now imagine that along the way you have conversations and even extensive analysis about your overall health, and you see that you’re below the norm in certain aspects. You realize that your tennis elbow is a reminder that you’re inconsistent with your pushups, you started eating chocolate sundaes again, and you’ve been staying up until 2 a.m. watching “Law & Order” reruns. “Gee, Doc, I’ve had so much going on in my life lately, I just haven’t had time to exercise. My wife and I may be getting a divorce. Our company was bought by a Chinese conglomerate, and I’ll probably lose my job. Did I mention that I found pot in my son’s dresser drawer last week? Fluffy has been with us 11 years, and we had to put her down yesterday.”
Through your real engagement with one or more clinical professionals, who not only are skilled at their specialty, but also committed to education for total health, you work with the health coach to draw up your own health profile and a personalized health plan. Because you helped draw them up, you’re more likely to carry them out. Your plan may include small, easy steps at first to improve your exercise and diet. It may involve additional referrals, such as to a psychologist or marriage counselor, who can help you learn stress reduction techniques and provide guidance on addressing your challenges at home and at work. You begin to see yourself in a paradigm of marching toward total well-being rather than one of dodging pain, masking symptoms and slipping down a dismal path of aging and death.
After a year, let’s say, you’re at the gym three times a week, you’ve stopped taking drugs, you’ve discovered you actually like vegetables—who knew?—you’ve stopped throwing your stapler across the room, you’ve actually solved some of your family problems (though you still miss Fluffy a lot), you’ve started asking questions about issues like vaccinations and your life is back under control. You’re happier and more confident than ever. Oh, by the way, last Thursday you beat the local tennis club pro six-love, and it’s the fifth time you’ve won in eight weeks. And, for the first time in your life, you understand what health is because you’re living in it and loving it. Since health is not once achieved and forever retained, your relationship with the clinic continues. You set new goals and receive the guidance and care you need as you get older and your circumstances change.
How would this be paid for? Well, there are a lot of potential business models, but consider this. One of the underlying reasons for soaring health care costs—again, that block of ice beneath the surface—is that there are few financial incentives for anybody to be well. We expect that the Wellness Portfolio taking shape at Life University will demonstrate improved health outcomes with cost-saving implications. Stephen Bolles, D.C., on staff at Life, writes this about the Wellness Portfolio he’s helping devise and implement:
“Recently initiated, this effort seeks to ask its group of 50 members to set goals across six domains of health: physical, emotional, social, intellectual, spiritual and environmental. The goals they set—and how they achieve them—will be traced individually and collectively. The outcomes will be compared to a variety of metrics in order to evaluate the potential value of the program as a way of lowering insurance coverage costs. As they master their goals, they’ll be challenged to raise the bar—figuratively or literally.”
Setting goals for health! Wow! Isn’t that a radical concept in the current disease-treating environment? The everyman could take responsibility for his health, saving himself, his employer and society serious money in the process. Do you see how different that is from fearing things out of our control? How genes, germs, viruses and sinister forces yet to be identified and forever beyond our ken have doomed us to choose between suffering and medical bills equal to the GNP of a small country?
Several years ago, a cadre of us across various disciplines met together in what we came to call the San Diego Project. We spent several days designing a theoretical health care system, projecting clinics all over the country like the one described above. We had a financial expert in the group, and we ran some numbers. Suppose you had 300 families at each clinic paying $3,000 a year for a total of $900,000 per clinic. Then add economies of scale possible through communication technology and multiply that by, say, 10,000 similar clinics across America. A small portion of those nine or 10 billion bucks would fund a catastrophic health insurance policy, and the rest of the bundle would support salaries and overhead. Pay-for-services would be part of the package. There would still be hospitals and individual practitioners, but eventually, thanks to information technology, they could all be linked together around the hub of education to improve public health.
Isn’t this at least a concept worth exploring? Some of you may be thinking, “Well, that sounds like a fine idea, Dr. Riekeman, but is it realistic?”
A decade ago, when we worked on the San Diego Project, I shared your skepticism. Today, after listening to two years of the reform debate, I’m more skeptical than I was then that big government, big insurance companies, Big Pharma and the big medical profession will ever figure this out. Even if they did figure it out, there are too many deeply entrenched big special interests and too much big money to be spread around to protect them. There are undeniably too many politics, and those politics are like the ice the Titanic encountered. Historians believe that, because of its rapid melting, the iceberg on that tragic night in 1912 was transparent, invisible, that is, like black ice on an asphalt highway. The old politics are just too slippery and treacherous for initiating a new paradigm.
But if a new health care system can’t be generated from the top down, what about from the bottom up? Communication technology has changed the entire seascape. For instance, there are blogs all over the Internet exposing the marketing games played by pharmaceutical companies. Gone is the veil of secrecy over how the current allopathic system works. Gone is the notion that you can take medication without sometimes getting horrific side effects. Gone is the confidence that you can go into a hospital and not get sicker than when you went in. Gone is the expectation that insurance company profits are reasonable and justifiable. Now, given the fact that knowledge is power and the truth will emerge—gone should be the fear that this mess can’t be cleaned up.
Beyond the sheer increase in knowledge about the gaping holes in the ship of care, social networking has opened the door to actually doing something about the crisis. These days, individuals are working together in what marketing guru Seth Godin calls “tribes,” people who share goals and join forces in the virtual world outside traditional institutions to make their goals a reality. In this era, when entire governments are being toppled by grassroots communication efforts through YouTube and Twitter, it’s no longer foolish or idealistic to think savvy entrepreneurs can create health enterprises that both can generate excellent revenue for doctors and save cash for patients, simultaneously.
Instead of thinking big, it’s time to think small; instead of placing hope in big institutions, it’s time to look to the power of individual people. Build it, and they will come. Develop the right model, and it will be replicated, and those entities can be networked into a viable system. We want to lead the way at Life University, and we’re eager to partner with others who think in the same paradigm.