Stephen Bolles: 4 Questions on Integrative Practice and Health Reform and One Answer ("It's the relationship, stupid")

Summary: The healthcare career of Stephen Bolles, DC includes a director position with the consumer division of United Healthcare, a vice presidency with one of the emerging universities of natural health sciences and a leadership role in establishing the integrative clinics at the renown Woodwinds Health Campus in Minnesota. Here Bolles takes a look at the emerging healthcare reform debate and asks 4 good questions, including the ultimate economic challenge: "Who is not going to be doing something that they are doing now?" He suggests one place where we would be served to remain buoyed: relationships. But, Bolles askes, can this system support the relationships that are critical to real change?

Stephen Bolles, DC

  Regarding Integration, Ox-Goring, Relationships & Measurements

Key questions on healthcare reform

Stephen Bolles, DC
OpenHealthMedica.com

As I listen to and watch everything that's going on these days about health care reform, the Second Coming (Obama's Inauguration), and the pent-up hunger for an update on liberté, égalité, et fraternité, I have a few questions.

First and foremost, what is integration? It's a word that still polarizes people (as your blog has recorded), because it's hard to define it without one's self-interest as a kind of hidden gravitational force. So when different stakeholders gather around a table, the first issue that I think needs to be confronted is one of taxonomy. And because it's hard not to see integration as an environment where your profession's interests are more fully represented, my next question isn't one of addition, it's more about subtraction.

	Four Good Questions on Healthcare Reform - Stephen Bolles, DC What is integration? Who's not going to do something they're doing now? What force, metric, consideration or value will drive the priorities? Will the container for all of this be our current system?

And that is: who's not going to do something they're doing now? It's easy to see how some services viewed earlier with disdain by the mainstream system have become mainstream; they added something that was needed and unavailable in mainstream form. But the crushing economics of health care drive out duplication, so at some point someone with an economic interest is going to find that they either aren't preferred or aren't wanted any more. The prospect of 'less medicine, more health' is a compelling vision, but there are some very powerful interests out there who are deeply entrenched.

That mud wrestling will be entertaining to watch in some respects (ever see the movie The Magic Christian?); as I've said before, what may be more painful to watch is the struggle between non-medical interests who have overlapping areas of therapeutic expertise. Who's going to become the favored resource for headache care? Massage therapists, chiropractors, tui na practitioners, naturopaths, or.....? Who's going to become the favored resource for nutrition? Enlightened RD's, naturopaths, chiropractors, or....? Will there be one paradigm of health and healing, or more than one? Will the Western or Eastern models predominate, or can there be a blending that preserves the integrity of both cosmologies? Or will there be a new center of the argument, a totally different driver than pluralism (a minor factor like economics, or consumer marketplace preferences)? Our present health care system, in all its dysfunctional glory, does not easily tolerate duplication. The model of 'vertical integration' in our delivery systems has scrubbed the medical side of a number of redundant (read: excess costs) processes, providers and middle-men. Will integrative health care be subject to the same scrutiny? And if so, what happens to those who are pushed aside and marginalized in a new way--with more potent and long-term results because the system is now successfully 'horizontally' integrated? Who's going to cry, "Foul!"?

Embedded in that consideration is my third question: what force, metric, consideration, or value will drive the priorities? It's hard, honestly, to see past the economics. The need to gather more data and evidence is never-ending, but we're playing catch-up with a target that is getting farther and farther away as the need for information outstrips the availability of information. The consumer-facing, retail health care marketplace hangs a lot of window-dressing on the drivers and dynamics of it, but at the end of the day, it's most often about dollars.

And my last question is what the 'container' for all this is going to be: will it be our current system? The emerging Greek Chorus of voices of those who occupy powerful seats at the table who are openly observing that the system is imploding on itself and collapsing under its own weight is starting to gain in numbers, and make a compelling case that trying to fix the existing faults simply cannot be justified from any perspective. If that is true, why are we trying so hard to run up the gangway to get on a sinking ship? If it's not the current system, should integrative providers/professions stop seeking integration and focus, instead, on a kind of Cosmology Smack-Down?

The current form of our health care system does not support the kind of relationships that really produce change. -- Bolles

My personal sense is that the basic issue is not the paradigm of health vs. disease care--which we can quickly agree is so fundamentally misguided and so inverted that the system cannot endure. It is more that fundamentally, the faulty paradigm has more to do with process than outcomes. The current form of our health care system does not support the kind of relationships that really produce change. If, as the evidence I'm aware of suggests, the single strongest predictor of my health and wellness are the practices of whom I surround myself with (as a source of modeling and social network support), will any other locus of relationship dynamic and control matter at all? I would suggest that lessons drawn from the failure of disease management programs, the ineptitude of health plans in their efforts to develop member loyalty and buy-in, the degree to which our culture has become inured to pervasive messages of healthy lifestyle practices, and the potency exhibited by social network aggregation (see America's 44th Presidential election) all point to the conclusion that "it's the relationship, stupid."

To me, therein lies the power of what integrative health care providers have created with patient/consumers: in many cases what we do doesn't matter a whole lot compared to how we do it. I fear that, if we forget that, we will have squandered this opportunity. I hope that we remember that as we stumble out into the light, blinking--hoping that it is, indeed, a new day.

Stephen Bolles
Open Health Media
Cell phone: 612.910.4814
openhealthmedia.com