Report from the Hawaii Consortium Obama-Daschle Discussion: Role of Integrative Medicine in Healthcare Reform

Summary: Laura Crites, MA, MS, executive director of the Hawaii Consortium for Integrative Health Care, convened two Healthcare Community Discussions as recommended by the Obama-Daschle healthcare transition team. Their focus was specifically on the role of integrative medicine in healthcare reform. The document they submitted to Obama-Daschle is published here. It includes a half-dozen case histories, to ground the importance of the document. These are followed by specific recommendations in the areas of overall approach, research, education and practice. How will these recommendations line up with what comes out of the Bravewell-IOM Summit on February 25-27, 2009?

A unique, multi-stakleholder initiative

When former US Senator Tom Daschle, Obama's point person for healthcare reform, put out a call for grassroots input, Laura Crites, MA, MS was quick to respond. Crites, executive director of the

The Role of Integrative Medicine in Healthcare Reform

Healthcare Reform Community Discussion

Sunday, December 28, 2008
Saturday, December 27, 2008
Honolulu, HI

Hosted by:  Hawaii Consortium for Integrative Healthcare*
Contact:  Laura Crites  or (808) 941-8253

Group Submission

Embracing the words of one of Barack Obama's favorite presidents: "As our case is new, so we must think anew, and act anew," Abraham Lincoln declared in 1862. He added: "We must disenthrall ourselves, and then we shall save our country."

OVERALL SUMMARY  

Laura Crites, MA, MS, HCIH executive director

The group recommends that healthcare reform engage a major philosophical shift at the highest levels of public policy away from a primary emphasis on allopathic medicine to an integrative system of healthcare that treats the whole person, emphasizes the natural, least toxic and least intrusive approach to healthcare, educates the individual and engages him/her in making healthy lifestyle changes.  Integrative healthcare combines the best of complementary and allopathic/conventional medicine to meet the needs of the individual.

CONTEXT  

Although the advantages and disadvantages of the allopathic healthcare system are widely known and frequently discussed, the role of integrative medicine in reforming and transforming the healthcare system has been largely ignored.  Discussants in both of the community groups were guided to explore the role of integrative medicine in healthcare reform.   We did this in the context of a growing public commitment to a natural approach to healthcare, in particular complementary and alternative medicine.  We did this in the context of a growing understanding by allopathic physicians that they cannot, alone, serve the best interests of the patient. (A 2002 study published by the American Medical Association showed that 76% of physicians reported having patients using CAM, 59% had been asked about specific CAM treatments, 48% had recommended CAM to a patient; and 24% had personally used CAM.  (Arch Intern Med. 2002;162:1176-1181)

Finally, we did this knowing that true change cannot occur when we try to solve a problem with the same thinking that created the problem, to paraphrase Einstein.

General Questions

We hosted two community discussions, on Saturday, December 27 and Sunday, December 28.  A total of 42 people attended the community discussion.  Two people participated through a “virtual” discussion, returning the forms and reacting to the group input.

Personal Stories

• Pregnant patient experiencing severe nausea, in hospital, losing weight rapidly and fearful of losing the child.  Acupuncture treatment resolved the problem and she was able to leave the hospital  (Mian Long, TCM, contact info 808 225-1701  )

• Same type of problem as above but was treated by an integrative physician with ginger in several forms recommended and the problem went away.   (Tamar Hoffman, MD (808) 597-1999  )                  

• Had what seemed it to be a heart attack.  She called the ambulance and was taken to the emergency room where an EKG showed no heart problem.  An estimated $8000 worth of tests followed, over the objections of the patient and she was released 5 hours later with a prescription for an anxiety drug which she did not take and a bill for $8000 which she would have to pay out of her own pocket as she was unemployed.  She sought out an integrative physician, received instructions on breathing, de-stressing exercises and a recommendation for high quality supplements.  Cost: $350.  She has had no further problems.   (Betsy Crites   (252) 412-7111 ))

• The patient was diagnosed with advanced spinal stenosis secondary to degenerative changes.  She suffered severe low back pain, pain and weakness in both legs, and had difficulty standing for more than 10 minutes.  Her symptoms were present even when she sat.  Her sleep was fitful, as she was frequently awakened by pain.  When she presented to the chiropractic office as a referral from her PCP, she was very skeptical.  Her main reason:  she was an anatomist and just retired from a teaching position at the University.  Her orientation to anatomy was medical so she highly suspected her doctor had sent her to the wrong place.  After 3 adjustments, she admitted her skepticism to the chiropractor and reported that she had not been pain-free in more than a year.  She wasn't sure what the chiropractor had done and, in fact, she didn't think he had done anything at all but thump her around, but she could sleep, she could rehearse for stage choral productions, and felt more robust than she had in a long time.  (Gary Saito, DC  (808) 593-9992  )

• After our discussion yesterday regarding training the doctors, I had an interesting interaction with a client today.  She has diabetes, but feels uneasy about the way her doctor is handling her case.  Knowing that diabetes can be hard on the liver, kidneys, and heart, my client was hesitant to take more medications than absolutely necessary.  Everything needs to be filtered through the liver and kidneys, so why take more than necessary, she thought.  Her doctor wanted her to take a statin drug for cholesterol.  Her total cholesterol number is ok, but specifically her LDL is just a few points higher than desired.  So the patient took matters into her own hands and decided to try a natural approach to lowering her cholesterol.  She is using red rice yeast extract.  (something that the pharmaceutical companies had successfully gotten banned for several years, to eliminate their competition.)  Her doctor was upset that she was doing that and told her not to take any supplements, as the supplements are not regulated.  The patient then told her doctor she was going to get acupuncture to help with her cholesterol and diabetes.  The doctor admonished her to not do this, but if she was going to do it, to make sure the needles were sterile. This doctor is a young, new doctor at Kaiser.  The patient just got the impression that the doctor was very young and was just spewing out what she had been taught to say at med school.  The patient was stunned that a doctor could appear so backwards and out of touch with what is happening in our medical culture now.  Very tragic that this is what the meds schools are graduating.  This doctor seems to not know much about alternative care and all its possible benefits. (Kari Webb, LAc  (808) 352-4005 )

• The patient was not considered a surgical candidate even though she suffered severe and chronic back pains because it was determined that her degenerative changes were too advanced and no amount of surgery would benefit her and could further incapacitate her.  She was given only a prescription drug regimen and told it was all they could do for her.  The drugs made her sick and significantly dulled her mental acuity.  After several years of painful tolerance of her condition, she was eventually referred to a physiatrist who offered the option of chiropractic care.  She took it, having no other choices.  She hobbled into the chiropractor's office, relying heavily on a cane for support.  Each visit at the chiropractor's office reduced her back pain.  At first severe and constant, her back pain lessened in intensity and became intermittent.  After a month of treatments, she could sit comfortably, sleep through the night, and she no longer begged her husband to massage her back for whatever relief she could get.  After 5 years of debilitating back pain, one month of chiropractic treatments resulted in mild and manageable pain and she was able to get out of the house whenever she wanted.  She was able to eliminate the most powerful pain pills, which led to clarity of thinking and more energy and vitality.  She firmly believes that chiropractic adjustments were the sole treatment that restored her health and function.  Her back is still severely degenerated, but she has put even the thought of surgery out of her mind.  (contact: Gary Saito, DC see above)

• The patient was scheduled for surgery to correct a spinal problem in the lumbar region.  She was young enough that the doctors felt there was a good chance the surgery would improve her status, so her surgery was scheduled a month out.  In desperation, she went to a chiropractor because she was very afraid of surgery and also afraid of what the outcome of surgery would be for her.  The chiropractor proceeded with conventional chiropractic adjustments and also counseled the patient on lifestyle, exercise, and nutritional recommendations.  She used to work in a jewelry store, standing for 8 hours a day until she could no longer tolerate the prolonged time on her feet.  By the time she presented to the chiropractor, she was no longer able to work.  Before the date of her surgery approached, she had significantly improved and called to cancel the surgery.  She improved gradually and was even able to go back to work at the jewelry counter.  She still requires periodic maintenance treatments, but after 20 years, she still hasn't had the need for surgical intervention.  She still sees her chiropractor about 4 times a year.  (contact: Gary Saito, DC (808) 593-9992 )

• I saw my son-in-law to be go through the conventional cancer treatments 15 years ago. The chemotherapy left him wasted and sickly. I know that chemotherapy does help at least 5 different cancers...but his wasn't one of them. Unfortunately, he died just 3 weeks after his oncologist told him he was on the mend!! So when I found a cancerous breast tumor (aggressive) 8 years ago, I had the tumor removed, and then decided not to do the conventional treatment, instead searching online for alternatives....and found Ralph Moss, Phd. He was a bright light for going alternative. I found a Homeopathic MD in Honolulu who tested me, and then detoxified me for 12 months. From there I went to a highly recommended naturopath who tested me for many things...(.ie: my blood levels of copper, which were high, and which feeds tumors!)  He also told me my vegetarian diet was totally wrong for my metabolic and blood type! So now, 8 years later with no recurrence I have the energy of a teenager....(I'm 60).. I did spend much of my retirement money for these treatments, as my medical insurance didn't cover any of it. But I am now healthier than I would have been if I'd done the chemo and radiation! I have talked to so many women who still, after 10 years since their conventional treatments, do not feel right!!! (Cheryl Lathan  (808) 261-8303, .

• I got into the field of acupuncture because I had nerve damage after two separate, unrelated surgeries.  Anytime you cut into the body, this type of scenario could present itself.  It happens and I'm not here to criticize the surgeons.  But I'm here to say that if this happened to me, I KNOW it has happened to others.  Acupuncture healed the nerve damage and I am doing well.  I want other people to know that they do not need to suffer from nerve damage, regardless of the cause.  When I told the surgeons I had nerve damage, they had no answer for me other than to "wait a year, maybe it will heal itself."  I found this answer unacceptable and sought out other avenues.  I paid for the treatments with my own cash. (Kari Webb, LAc (808) 352-4005 )

• From infancy, I suffered from allergy induced severe bronchial asthma. I spent most of my first 2 years in and out of the hospital, much of that time in oxygen tents. Early in my childhood I experienced the conventional approach to treatment of asthma, which included multiple medications, including inhalers and synthesized adrenaline to open my bronchial tubes. By elementary school, this regiment included a mimeographed handout given to my teachers specifying in which weather conditions and what areas of the playground I was allowed to participate in outdoor recess. By middle school, I was being treated by a more progressive allergist who promoted less medication, more participation in physical activities and breathing exercises. This progress inspired me in my high school years to begin a self study program on how nutrition and exercise affects allergy based asthma.  By the time I was ready to begin my freshman year in College, I had left all of my allergy and asthma medications behind and have since not needed the assistance of pharmaceuticals or allopathic medicine to stay asthma free. (Chrisopher Nygard  (808) 639-6411  )

• In the area of healthcare and meeting medical needs my experience has amounted to stumbling in the dark and an inability to extract myself from reliance on conventional medical doctors and remedies. My efforts to sort out and get clarity about the alphabet soup of natural healing practitioners and traditions haven't been productive or edifying. Before moving to Hawaii ten years ago, I had heard and read about the natural healing wisdom of indigenous Hawaiian culture and when we first arrived in Hawaii I tried to find a natural healing practitioner that could serve as a family physician, but the results of those efforts were not positive or helpful. (I suspect there are many people who depend on conventional doctors and hospitals are like me and need help in understanding the contrast between preventive healthcare and treating symptoms and in evaluating the claims and abilities of natural healing practitioners).

• Coming from this background of uncertainty and confusion about natural healing and natural healing practitioners, the concept of complementary and integrative healthcare is like a ray of light in the darkness. (Dayle Bethel  (808) 523-2906  )

Summary of Responses from Discussion Questions    

Because we perceived the questions as inadequate in getting to a true place of substance on healthcare policy we focused our discussion on creating an ideal healthcare system.  This system would be a true integration of conventional medicine and complementary/alternative medicine.  Following is our summary of “true change we can believe in”.  We present the following problems and recommended solutions.

Broken System of Care  

The biggest problem is a healthcare system that focuses on symptom management, treating the disease rather than the patient and a practice of defensive medicine.

Recommendations

Shift in Philosophy 

We recommend a major shift in public policy and healthcare philosophy at all levels toward an integrative healthcare system that incorporates the best of conventional and complementary medicine.  This system would treat the whole person, be cost effective, engage the individual in making lifestyle changes, reduce the use of drugs and their side effects, reduce the use of expensive diagnostic tests, reduce the frequency and length of hospitalization, reduce liability insurance costs, and it would reflect the reality that the population is increasingly seeking out natural, whole person treatments that are often found in complementary and alternative medicine.

Focus on Least Toxic, Least Intrusive Interventions  

We also recommend that the least intrusive, least toxic, most natural approach tohealthcare be the preferred first point of contact. This would typically be the complementary/alternative medicine (CAM) health care providers such as Traditional Chinese Medicine (TCM), acupuncture, chiropractic medicine, naturopathic medicine, massage therapy, lifestyle medicine and holistic physicians.  These providers not only offer gentle, natural healthcare intervention which is cost effective but they also take the time to educate the patient and work with him/her in making necessary lifestyle changes.

Remove Emphasis on Drugs  

We recommend that healthcare reform reduce the emphasis on drugs as the preferred first response to health challenges.  This approach is a major contributor to cost increases in several ways----thru the cost of drugs themselves, through the cost of side effects from drugs which leads to more drugs and often hospitalization, and through the cost of lawsuits related to the same.  While some drugs can be life saving, the current emphasis on using drugs as the intervention of choice, to silence all symptoms is a major contributor to the healthcare crisis.

Continue Research   

A major obstacle to implementing integrative medicine has been the charge that complementary  and alternative medicine is not research based.  We call for a review of this rationale for the following reasons.

First, we do so based on awareness that the scientific basis for conventional medicine is overstated. An estimated 80% of what MD’s do on a daily basis is not based on research.

Second, research on individual drugs currently being prescribed becomes meaningless when a patient is taking more than one drug as the interaction of these drugs has not been researched.

Third, in spite of the research on allopathic medicine, the high level of negative outcome is what drives the high level of liability insurance.  

Fourth, it is important to recognize that major research  has been done around the world on complementary medicine and what we call complementary treatments have withstood the test of time.  For example, the healthcare philosophy that underlies Traditional Chinese Medicine has been supported by over 3000 years of successful practice.

Finally,  it should be recognized that research is an ongoing process for BOTH allopathic medicine and complementary/alternative medicine. We recommend that research be continued on both types of healthcare but that “lack of research” not be used as a means to impede the promotion of integrative medicine.

Cost of Healthcare   

The second major problem with the system is the cost of healthcare and how that cost is covered.  We recommend the following:

Recommendations

Adopt universal, government-run healthcare. 

We need only look at all the other industrialized nations to see how their approach to universal healthcare provides what we are seeking.  While these systems are not perfect, people in these countries praise them, and the health outcomes of the population strongly suggest they are on the right track. Healthcare coverage is not related to employment   All Americans should have access to guaranteed healthcare regardless of age, social status, or employment.

Free choice in pursuing health and healthcare

There is currently a bias against getting healthcare treatments if you are healthy.  Individuals should be rewarded and encouraged to pursue healthcare in whatever ways they decide such as participation in yoga, exercise, nutrition classes, etc.  For example, in Germany, as a preventive measure, individuals are given spa vacations as a way of maintaining health. In China, a physician is considered successful if her/her patient does not become sick.  A physician is considered inferior if patients do become sick.

Tort Reform 

The cost of liability insurance for allopathic physicians in Hawaii  In contrast, the chiropractor pays about $1500 a year in liability insurance in Hawaii and the specialist in Germany pays approximately $2000.  Clearly, something needs to be done with this vastly expensive aspect of providing healthcare in the US. Further, we propose that if people had the freedom to go to any practitioner of their own choosing, there would be far fewer lawsuits. range from $25,000, yearly, for family practice to $100,000 a year if the physician adds a specialty such as breast care and offers diagnosis through high tech machines.

Reduce Costs With Integrative Medicine 

The exorbitant cost of healthcare in the US can be dramatically reduced with integrative medicine.  This would be achieved by: promoting healthy lifestyles, emphasizing more natural, healthy, whole person approaches over invasive, potentially dangerous treatment, reducing liability costs, less expensive hourly rates for healthcare providers, reduced hospitalization and surgery, reduced costs of drugs and the costs of drug side effects.  With the addition of a whole person approach to mental health education we would also see a vast improvement in our population's emotional conditions.  

THE CHANGE PROCESS

Implementing Integrative Medicine and Shifting Public Policy  

It is important to recognize that the use of complementary and alternative medicine is nearing a tipping point so that the recommended public policy changes would not be dramatic but the outcome of the changes would be!  People are paying up to $30 billion a year for CAM treatments, engaging in up to 600 million visits a year.  Many physicians are referring patients to CAM providers and a substantial number of medical schools have set up CAM departments.  It should be noted, however, that these departments are often struggling and few have successfully accomplished integrative medicine training for medical students.

Education  

While the internet provides a major source of education for those who choose to pursue it, we recommend the following actions in order to implement a shift in philosophy on a public policy basis:

Require integrative medicine education in medical schools and graduate schools of psychology.

While the professional schools for CAM providers require courses on allopathic medicine to include information on when to refer a patient, this information is not required in allopathic schools, even if the school has a Department of Complementary and Alternative Medicine.  To implement integrative medicine, medical students should be required to study the philosophy of traditional Chinese medicine, naturopathy, chiropractic medicine, the medical uses of massage therapy, and psychology students should be encouraged to study wellness models that support mental and emotional health rather than simply treating symptoms of mental and emotional disintegration.
 
Expand funding for CAM Schools
  
The government should recognize the value of schools that qualify CAM providers and subsidize them or otherwise support their expansion.

Education in the public and private schools  

Healthcare reform should also engage  school students in taking required classes on nutrition, and other aspects of healthcare and healthy living to include physical fitness.  We propose that existing providers would make themselves available to educate children and adults in public forums.

CAM Providers as Educators  

It should be recognized that one of the fundamental roles of the CAM provider is educating the patient about their body, how to support its natural tendency toward health, and making healthy lifestyle changes. Thus, a policy shift in support of integrative medicine will go far in educating the consumer. CAM providers and holistic physicians should be encouraged to provide public education regarding a natural approach to health and healing.

Healthcare Coverage   

CAM treatments should be fully covered by the universal healthcare plan. Patients could be given a set amount to spend on wellness that they could use at practitioners of their choosing.  We believe that incentives could be used to entice people to become more proactive in their own health care.

Creating Integrating Physician Practice   The algorithms or paradigms that are currently used by the medical profession to identify what treatments and/or tests should be used in what sequence, should be amended to include complementary/alternative medicine or natural, whole person treatments near or at the top of the pyramid of treatment as well as throughout the sequence.  This pyramid of treatment can be easily designed by experts in the various healthcare philosophies.

Recognizing The Larger Picture, Think Holistically   

It is important that true healthcare reform recognize that all things are interconnected.  For example:

• Farm subsidies for major agricultural industries end up reinforcing and promoting cheap food that is unhealthy,
• Environmental policies have an impact on our ability to live lives as free of toxic substances as possible,
• Educational policies need to assure that school children are taught how to live a healthy lifestyle.  Food and drug policies as developed by the Food and Drug Administration need to be monitored to assure that they do not favor profit over healthy, toxic-free, safe products
• A culture of consumption, promoted, in large part, by the focus on GDP as the way of measuring economic health, increases stress, increases debt, reduces the commitment to the environment, negatively impacts relationships, encourages a quick-fix approach to healthcare and reinforces the role of costly and dangerous drugs in achieving health.       

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