Two Trends in Medicine: Control or Choice

Thanks to Greg Scandlen from Consumers for Healthcare Choices , I was invited to speak at their third annual members meeting and awards banquet in November of 2008  entitled "  Free-Market Healthcare: How Will it Fare with a New Congress and Administration?"     I was on a panel with a few people including Jim Pyles from the American Psychoanalytic Association, Joel C. White, David McKalip, M.D., Brian McManus and Dan Perrin. I   have included my speech below.

I have been asked to speak about trends in medicine as they relate to the recent elections.  There are two general trends in medicine.  One is about control, compliance and centralization within a sickness paradigm and the other is about choice, experimentation and decentralization within a wellness paradigm.  The former is what is being promoted for the most part by government, both political parties and a whole set of powerful economic interests.  The latter is part of the cultural milieu as well as foundational for a few relatively new and interesting movements in medicine. 

The control paradigm in medicine is quite obvious when you look at interests in nationalizing healthcare, the past creation of managed care, public/private partnerships, the promoting of Pay for Performance, Evidence Based medicine and HIT.  The control paradigm in not limited to physical medicine either but can be found in psychiatric medicine too.  Just think about the recent bill signed by Bush, which mandates parity for mental health treatment.  Add to that, the Federal Mental Health Action Agenda by SAMHA, which is a bi-partisan initiative by the Bush Administration. The FMHAA (Action Agenda) seeks to transform the mental health delivery system in America both public and private through various means including:

1. public/private partnerships,
2. developing prototype individualized plans of care, which must include evidence based medicine,
 3. launching the federal executives steering committee on mental health which will include; HUD, VA, DOE, DOJ, SSA and DOL,
 4. use of HIT.

Just consider for a moment of a few of the things I just mentioned.  The Federal government is going to assist in the creation of prototype-individualized plans of care, which will include evidence-based medicine.   In medicine, as it should be practiced, all plans of care are individualized.  They are less so  these days for the most part in much of our medical system because of the control paradigm.  The control paradigm promotes one size fits all programs and initiatives.  In fact and in practice, only doctors or other healthcare providers can actually create individualized plans for their patients.  Big business and big government cannot do so.

 Now let me comment on the requirement for evidence-based medicine.   The Action Agenda followed the New Freedom Commission on Mental Health, which was another Bush initiative.  There were two programs within the New Freedom Commission that were supposed to be included in the Action Agenda but due to a lot of push back from the grassroots, they were not.  If they are examples of what is meant by evidence based medicine, you can see why it is a concept that needs to do opposed. 

 The two were:  computer based mental health screening programs called Teen Screen and TMAP.   The latter produces a lot of false positives and gets students who do not suffer from a ‘mental disorder’ into the system for treatment.  Unfortunately, the ‘treatment’ used mostly these days are often dangerous drugs such as anti-psychotics, anti-depressants and anti-ADD type drugs.   Not to say that there are not a few individual cases were a specific drug might prove helpful but not to the extent to which they are being prescribed today for our youth.

 Now TMAP is an interesting case of the control paradigm. The Texas Medication Algorithm Project is a decision-tree medical algorithm, the design of which was based on the expert opinions of so-called mental health specialists. It provided a set of psychiatric management guidelines for doctors treating certain mental disorders within Texas' publicly funded mental health care system. 

Now, would it surprise you to learn that TMAP was not based on the good science but based on economic interests of specific pharmaceutical companies who wanted their drugs promoted over others?

Now, its important to keep in mind that the various ideas being promoted in control medicine such as evidence based medicine, pay for performance and HIT are part of a logical plan to control medicine by controlling doctors, patients, and medical resources.

 Imagine if we have all three:  PFP, EBM and HIT.     So, we would have national boards which would determine which procedures get paid for, the same boards deciding what constitutes evidence in medicine which will not include clinical practice insights, experience, experimentation and intuition, and then both doctors and their patients compliance can be tracked through HIT.  If doctors don’t comply, not only would they not get reimbursed but perhaps get a letter from their medical board questioning their license to practice medicine or a visit from some interested government agency. With HIPAA’s privacy rule which is really a disclosure rule and HIT, it would be really easy to keep track of all services provided by a specific doctor and the rates of compliance by a patient for a predetermined set of medical procedure for a particular disease or disorder.   We would have the worst of all worlds were innovation would be stifled, the doctors skills, knowledge, intuition and clinical experience would be second guessed by the so-called experts and bureaucrats and both doctors and patients compliance with the ‘system’ would be watched.  

Now, let me contrast that with the second set of trends in medicine I first mentioned which are based in choice, experimentation and decentralization within a wellness paradigm.

Since it is based on choice and experimentation, there is no one final model, program, initiative, movement or trend that can be referred to but a whole set of different efforts that have been unfolding over time that share a few common characteristics.

A few of the common characteristics that these trends seems to share are a recognition of bio-individuality i.e. each person is unique and cannot be treated in a cookie cutter fashion, that each person is a whole person i.e. biological and psychological entity within a specific environment, the patient is ultimately responsible for taking steps to improve their own health and well-being and
 that the actual relationship between the doctor or healthcare provider and the patient is important.  The latter is one reason many doctors are now getting out of all third party payment schemes.

These new trends are manifesting in many forms including in the growing interest in anti-aging medicine, the incredible explosion in the use of complementary and alternative medicine (In 2004, Americans spent $48 billion dollars in CAM including Ayurveda, acupuncture, massage therapy and herbal medicines.), the popularity of integrative medicine, in the fitness movement (, Americans spent  $14.1 billion in health club revenue in 2003), use of organic foods, (in 2007, Americans spent
$20 billion on organic food.) mind-body medicine, dietary modifications, use of nutritional supplements (Americans spent  $5.8 billion in 2007 on dietary supplements), etc

All of the things I just mentioned are no longer fringe ideas and movements, they are all now mainstream.  According to the NIH, in 2005, 27% of hospitals now offer some form of CAM including massage therapy, guided imagery, acupuncture and relaxation training.  

These relatively new and in many cases quite old movements are not only popular but also effective for the most part.  It is amazing to see the latest research that is coming out now on various health related topics as they relate to lifestyle.  Stress has now been connected to 60% of all diseases.  It is known to contribute to heart disease, cancer, high blood pressure, diabetes, and autoimmune disorders. The new field of psycho-neuro-immunology is seeking to understand the mind-body connection and how various techniques of mental and somatic management can in fact help reduce the stress response and thus the negative effects of stress.   Similarly, diet is also connected to a very high percentage of diseases and disorders such as cancer, heart disease, diabetes, ADD, OCD and stroke.  Dietary modification, the reduction in the use of additives, preservatives, coloring agents and other excitotoxins as well as the use of dietary supplements can help to improve health outcomes and even improve education and behavioral outcomes.

One question to be asked is who will win in the battle for the hearts and minds of the American people.  Will it be the control or choice movement?  For the most part, big business and government at all levels are promoting the former while more and more Americans are choosing the latter.  I think what we need to do is not only to survive the control movement but thrive in the choice movement by doing two basic things.  The first is to work against all efforts at all levels of government that seek to put one’s health choices in the hands of bureaucrats whether in the government or in the private sector.   To do so, it will be necessary to work in transpartisan coalitions were conservatives; libertarians, progressives and liberals can come together to project health freedom.  There will obviously be areas of disagreement but you might be surprised how much common ground there actually is when it comes to health freedom.  The second thing to do is to learn more about these new movements in health and wellness promotion.  We can’t just fight the old control system but we must work to build the new ones, which will replace it.

Michael D. Ostrolenk, Director of Government Affairs, Association of American Physicians and Surgeons.