Social Iatrogenesis

“We’re 72^nd, We’re 72^nd!^”

by

JC Smith, MA, DC

Warner Robins, GA

Holding their index fingers up in the air, shouting “we’re number one!” is symbolic for victory by sport fans around the world. The same can be said about the medal count at the recent Olympic Games with the press, governments, and spectators from every nation keeping track of who’s winning the most medals, hoping they can proudly brag about being the best, too!

Being number one is important to most sports fans, but in regards to health care, it seems not so. When the World Health Organization announced at its June 21, 2000, press conference that America ranked 37^th out of the 191 countries in the United Nations in overall healthcare delivery systems, 72^nd in overall population health, while number one in overall costs, little was said by the US government officials, the various health associations officials, the media medical experts, or the public at large.

Indeed, being told, “We’re number 72^nd” in population health didn’t faze many people at all, or so it seems by the non-response. Perhaps they all were embarrassed at these deplorable statistics, but nothing much as been said or changed since this report was released. Incredibly, some medical spokesmen contend that American healthcare is still the best in the world despite these glaring facts—a good example of medical misinformation!

While these facts have left the medical establishment speechless, the “World Health Report 2000—Health Systems: Improving Performance”[1] struck a cord in me if no one else. I daresay if America were 72^nd in world defense, the proverbial sh** would have hit the fan. If we were 72^nd in education, parents would be in an uproar. If we were 72^nd in technology, the government would pour billions into research and development to catch up. And, God forbid, if we were 72^nd in the Olympics, many heads would roll.

But when we’re told America has the most expensive medical system while it ranks 72^nd in population health and 37^th in patient access to its healthcare delivery system, nothing is said by doctors, patients, politicians or insurance companies despite the fact that we lead the world in every category of chronic degenerative diseases, and the cost and trends are escalating daily. Moreover, America presently has over 42 million uninsured citizens who have no access to the medical system at all, almost 15% of our population.

So, what’s wrong with this picture of our American healthcare delivery system that no one seems concerned about? Let the WHO spokesman, Dr. Christopher Murray, explain:

“The World Health Organization has carried out the first ever analysis of the world’s health systems. Using five performance indicators to measure health systems in 191 member states, it finds that France provides the best overall health care followed among major countries by Italy, Spain, Oman, Austria and Japan.

“The US health systems spends a higher portion (14.3%) of its gross domestic products than any other country, but ranks 37 out of 191 countries according to its performance, the report finds. The United Kingdom, which spends six percent of GDP on health services, ranks 18^th.

            Dr. Murray, Director of WHO’s Global Program on Evidence for Health Policy says: “Although significant progress has been achieved in past decades, virtually all countries are under-utilizing the resources that are available to them. This leads to large numbers of preventable deaths and disabilities; unnecessary suffering, injustice, inequality and denial of an individual’s basic rights to health.” [2]

WHO’s assessment system was based on five indicators: overall level of
population health; health inequalities (or disparities) within the population; overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts); distribution of responsiveness within the population (how well people of varying economic status find that they are served by the health system); and the distribution of the health system’s financial burden within the population (who pays the costs).

Give CAM a Chance

In this light, the professional profiling of chiropractic care to the margins of the American healthcare system can be viewed as an example of the “under-utilizing the resources available” to treat the neuromusculoskeletal disorders, the leading on-the-job injury that plagues many workers and 80-90% of American adults sometime in their lifetime with acute low back pain. Imagine the positive impact the chiropractic profession could have to reduce the costs of workers’ compensation, improve the childhood outcomes of spinal problems like scoliosis, and to improve the overall quality of life for all Americans.

Headache pain is another NMS condition that is pandemic in our society. According to the International Headache Society, 17.8% of adults suffer from frequent “cervicogenic headache” more than five times each month. While tension-type headaches aren’t the killers like stroke or cancer, they do adversely affect the daily activities of many people. 89% of tension-type headache sufferers reported their headaches affected their relationships with friends, colleagues and family. 38% of tension headache sufferers indicated their regular activities were limited, and 4% said headaches affected their work.[3]

            This study by the Duke University Evidence-based Practice Center with funding provided solely by the FCER through a restricted grant from the NCMIC Insurance Company found “manipulation is effective in patients with cervicogenic headache…pharmacological treatments are not suitable for all patients, nor are they universally effective. Drug treatments may also produce undesired side effects.”[4]

Obviously a case can easily be made that shows manipulative therapy as a proven method for the epidemic of NMS disorders that affect millions of Americans daily. As well, by denying the recommended non-invasive “proven method” for low back pain, spinal manipulation to treat these neuromusculoskeletal disorders, according to the US federal guideline on acute low back pain,[5] patients are thus victims of the “unnecessary suffering, injustice, inequality and denial of an individual’s basic rights to health” when they are forced into drugs and spinal surgeries. At this point social iatrogenesis is more the cause for illness than germs or clinical iatrogenesis. Indeed, the healthcare system itself is to blame for making people sick.

            Unfortunately, the American medical model of healthcare has resisted the widespread implementation of non-allopathic, alternative, or CAM interventions as a first-avenue of treatment. Whether it’s chiropractic’s fight with back surgeons or natural remedies vs. allopathic drugs, the fact is a for-profit health care system is inherently at odds with the expensive, non-medical solutions. Indeed, the better mousetrap theory is absent in the medical industry due to monopolistic control of the healthcare delivery system by the medical society itself.

Healthcare Reforms

It’s not as if there haven’t been attempts to improve the dire situation of healthcare in America in the past. Clinton’s Health Care Reform Act in 1994 and, more recently, the Patients’ Bill of Rights, both of which failed to pass Congress. Every administration since Harry Truman’s has attempted to reform the American healthcare delivery system, all to no avail. Apparently the AMA, hospitals, the insurance industry, and drug companies like the system just the way it is now, and have resisted any substantial change in the healthcare delivery despite the evidence and critics.

 Even the prestigious New England Journal of Medicine has expressed concerned over America’s failing and expensive healthcare system. Marcia Angell, MD and past editor of The New England Journal of Medicine, wrote a commentary, “Patients’ Rights Bills and Other Futile Gestures,”[6] which revealed her underlying disbelief that present legislation will improve the dire straights of managed health care.

She states that “…most important politically—middle-class voters are getting fed up with the abuses of managed care. They are frustrated by shorter hospital stays, restricted choices of doctors, arbitrary denials or limits of coverage, increasing deductibles and co-payments, and all the other methods by which the industry resists actually providing services to sick people.”

While these barriers and hurdles may be new to the sanctimonious world of medicine, we chiropractors have had to deal with these problems forever, such as restricted access for patients by medical gatekeepers, arbitrary denials or limited coverage by biased insurance policies, and economic barriers like high deductibles and co-pays designed to discourage the use of insurance altogether. I guess slummin’ with the chiropractors has finally made Dr. Angell mad as hell, and she’s not taking it anymore!

“What we should instead conclude is that the private managed-care market has been a miserable failure at delivering health care. It has creamed off ever larger percentages of health care premiums in bloated administrative and marketing costs and profits, it has rewarded health plans that cherry-pick the health and avoid the sick, and it has resisted at every turn providing adequate services to those unfortunate enough to need them.”

Well, Dr. Angell is certainly right about that, but she left off a few concerns of mine, such as patients often have no choice of practitioners in PPOs, or given informed consent to their options/alternatives to medical care, second opinions are generally limited to another medical opinion, little emphasis on the preventive treatments, no free market competition to lower health care costs by offering better services at lower costs, hospital and insurance boycott of complementary and alternative healthcare like chiropractic care that drives up costs and unnecessary surgical failures, just to name a few problems she failed to mention.

While she overlooks the downside of her own medical industry, Dr. Angell doesn’t stop with her gripes: “What needs to change is the system itself. Contrary to conventional wisdom, incremental changes, such as patients’ rights legislation, will not work.”

Apparently she wants to throw the baby out with the bath water without suggesting the bath givers may have perverse motivations themselves. While she may want systemic changes to end the causes of social iatrogenesis, she hasn’t addressed the economic factors of providers or the downside of such changes, such as a possible drop in gross incomes of medical providers.

She continues by suggesting three changes:

1)     “First, employers should get out of the health care business altogether…they have a clear conflict of interest since they have a strong incentive to keep premiums as low as possible.

2)     “Second, just as employers are not good proxies for their workers, so investor-owned managed-care companies are not good proxies for doctors. They, too, have a conflict of interest. They have obligations to their investors as well as to their enrollees. That the former often take precedence is evident from all the ways in which the industry limits medical services even while maintaining high profits and executive salaries. In my view, there is no place for these businesses in a good health care system.

3)     “Finally, health care insurance should not be optional, as it is in our employment-based system. Just as everyone over the age of 65 is covered by Medicare, so should everyone under that age be covered…. In 1993…I called for a universal, single-payer system and suggested that we could attain that goal by extending Medicare to all Americans….Those who worry that such a reform would increase taxes should remember that we all pay for health care anyway—through our paychecks, deductibles and co-payments, and the prices of goods and services—and that Medicare is far more efficient than the market-based part of our health care system.”

Wow, what a radical idea—Medicare for everyone, aka, socialized medicine! Bypass the indulgences of the fat cats in the insurance world altogether, unburden employers with this responsibility, and have the government administer health care. I can only imagine the rancor that will bring from the insurance lobbyists and legislators who make plenty of money from their contributions. I don’t think we’ll find an answer coming from legislators as long as the insurance/medical/pharmaceutical PACs are so wealthy and influential.

Return to Free Enterprise in Healthcare

While it’s one thing for liberal experts to suggest a government-based health care system like the rest of the entire world has had to do, but when the former editor of the NEJM suggests it, something’s amiss. So, what’s the answer? To maintain the present expensive private healthcare system with no free marketplace and no freedom of choice in the selection of doctors or the type of care offered, or to change to a quasi-socialist system where government bureaucrats run the show instead? Neither sounds optimal to me.

Let me suggest a very radical idea: A return to free enterprise! This concept seems to be a forgotten notion in the healthcare industry where managed care has restricted consumer choice with their own brand of socialism, and where medical societies dominate the healthcare scene with their virtual one-party system. It seems experts no longer suggest this option to solve this medical mess by having fair competition on a level playing field.

While free enterprise drives the American industrial engine, it’s off-track for healthcare, or so it seems. Forgive me for being naïve, but I thought free enterprise was the basis of our society’s economics, but apparently not when it comes to healthcare. Even Dr. Angell omitted this option in her suggestions for change, illustrating how deeply rooted healthcare is in its monopolistic, one-party nature.

So, it appears America’s overall population health status as 72^nd will prevail for sometime until matters get worse with more “mangled care” and the system finally goes broke. Perhaps then we resort to total Medicare like the rest of the world already has. And the strangest thing about this whole situation is that nobody seems to care as health stats worsen and cost increase to the eventual bust. I’ve not heard one peep from the AMA, ACA, ICA, the White House, CNN, or any news agency about this fact that we’re 72^nd in the world, 37^th in healthcare systems, or 1^st in total cost.

Strange, indeed, don’t you think? Rome burns and everybody fiddles around, ignoring the obvious need to re-invent our healthcare system. Maybe there’s something amiss with our drinking water that causes avoidance and denial of the obvious problems that WHO and Dr. Angell have mentioned. Or, as Clinton discovered, maybe you can’t beat the medical monopoly politically or financially. Indeed, until the golden goose of health insurance monies is dead, we will continue to see the gradual decline of healthcare in America.

In the meantime, I guess we’ll all have to settle being 72^nd in the world in population health. Give a try and shout it out, “We’re 72^nd, we’re 72^nd.” How does it sound? Rather disappointing, no doubt. But, sadly, it’s the truth.