Truth or Dare?
James C. Smith, MA, DC
1103 Russell Parkway
Warner Robins, GA 31088
Phone: (478) 922-4091
Reprint requests to above address
American Health Care:
Truth or Dare?
American health care is the most costly but among the least effective in terms of health care delivery and population health. Many investigations have revealed inherent problems with the present for-profit allopathic system. Regrettably, trying harder will not work to solve this costly dilemma.
Perverse economic motivations and a non-competitive market place highlight the current problems that any health care reform must address. Also, allopathic methods mainly treat the symptoms of disease and do not prevent the onset of health problems.
While health futurists and pollsters indicate the growing trend to alternative health care methods like chiropractic, the lack of a free market place in health care prohibits these “better mousetraps” from helping solve the health crisis.
“Trying harder will not work”
American Healthcare: Truth or Dare?
IF THE PROOF OF THE PUDDING IS IN THE TASTE, recent studies now confirm that the American healthcare system has gone sour. After a century of allopathic control of the American healthcare system, the facts are clear that the American model of health care just isn’t working well in comparison with other countries in the world. If the AMA were asked to play “Truth or Dare,” I daresay it would have a difficult time with the “truth” to admit that their model of drugs and surgery has been clinically or cost-effective.
The “truth” is much has been said of late about improving the worsening situation of the American health care delivery system as evidenced by the costly and failing health of the American public. The National Academy of Sciences, The Dartmouth Atlas of Health, and the World Health Organization have all come to the same conclusions in their studies—the American health care system is in dire straits. Their analyses are very similar, as well as their recommendations. But the “dare” in this situation is whether or not these recommendations will ever be implemented to create real change in the health care delivery system.
WHO: World Health Report 2000
On June 21, 2000 the World Health Organization issued its findings from the World Health Report 2000—“Health systems: Improving Performance.” The results of this extensive study stunned the US healthcare delivery system leaders because of its low rankings despite spending the most revenues per capita. In fact, in its assessment of the 191 nations in the United Nations, their final tally was surprising when they ranked the “overall health system performance” of the American health care delivery system 37th in the world and, even more shocking, they found the American population health is 72nd in their ranking. In terms of longevity, the US faired better at 24th in the WHO analysis at 70.0 years, although the US ranked number one in overall health care costs per capita.
To give a comparison with other industrialized countries in the world, France has the best overall stats, ranking 1st in overall health care delivery, 4th in population health, and 4th in overall expenditures. Italy is 2nd in health care delivery and 3rd in overall health while ranking 11th in expenditures per capita. Canada is 30th in health care delivery, 35th in population health while 10th in expenditures per capita. Needless to say, many other countries are doing a lot better with less money, proving that despite spending the most per capita—more than twice of the next country—our health statistics are sickening.
According the WHO Executive Summary press release:
“The US health systems spends a higher portion of its gross domestic products than any other country [13.5%] 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 18th. Several small countries—San Marino, Andorra, Malta and Singapore are rated close behind second-placed Italy.
“Dr Christopher Murray, Director of WHO’s Global Programme 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.’” 
Major Findings of the Dartmouth Atlas of Health Care
Other health policy investigators have also stated their concerns about the American health care system, such as The National Academy of Sciences (NAS) and the Dartmouth Atlas of Health Care. Here are a few of important conclusions that can be drawn from the 1999 Dartmouth Atlas series of publications:
• There is overwhelming evidence that the “system” of care in the United States is not a system at all, but a largely unplanned and irrational sprawl of resources.
• There is surprising under-use of preventive services that are known to reduce morbidity and mortality. Strangely, the use of these services is not related to the supply of resources, to measures of access to and continuity of care, or to overall spending levels.
• Geographic variations in surgery rates and outcomes are associated with three factors: (1) the poor quality of science to provide guidance to physicians making clinical decisions; (2) the sometimes poor quality of clinical decision making, and (3) the variations across hospitals and physicians in the skill with which the surgical care is delivered.
• It is hard to find evidence that more resources are required to improve the quality of care in fee-for-service Medicare. We believe the problem lies not so much with too little Medicare expenditures, but instead the misallocation of the money being spent. To improve overall quality, it will be necessary to improve the quality of clinical science, the quality of clinical decision-making, and the quality of medical resource allocation. 
Crossing the Chasm or Jumping into the Abyss?
The NAS Executive Summary, in their evaluation of the American health care delivery, “Crossing the Chasm: A New Health System for the 21st Century,” concur that the system is just as bad, if not worse, than either the Dartmouth or WHO analyses would admit.
“The American health care delivery system is in need of fundamental change. Many patients, doctors, nurses, and health care leaders are concerned that the care delivered is not, essentially, the care we should receive. The frustration levels of both patients and clinicians have probably never been higher. Yet the problems remain. Health care today harms too frequently and routinely fails to deliver its potential benefits.
“Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case…Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm.”
Despite this outcry from the foremost healthcare researchers, little has changed since the Managed Care Organizations (MCOs) with their Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) were implemented. In fact, many believe that this new arrangement has contributed to the demise of the American health care system. According the NAS Executive Summary:
“Yet all this organizational turmoil has resulted in little changes in the way health care is delivered. Some of the new arrangements have failed following disappointing results.
The committee is confident that Americans can have a health care system of the quality they need, want and deserve. But we are also confident that this higher level of quality cannot be achieved by further stressing current systems of care. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”
The NAS committee created an agenda for crossing the chasm, and two points in particular should be of interest to the chiropractic profession.
“That purchasers, regulators, health professions, educational institutional, and the Department of Health and Human Services create an environment that fosters and rewards improvement by (1) creating an infrastructure to support evidence-based practice, (2) facilitating the use of information technology, (3) aligning payment incentives, and (4) preparing the workforce to better serve patients in the world of expanding knowledge and rapid change.”
While everyone should applaud the opinion of the NAS to change the systems of care by supporting evidence-based practices and aligning the payment incentives to avoid over-use (fee-for-service) and under-use (capitation), oftentimes they fail to recognize the economic motivations that currently control the American health care delivery system—the profit motive of the insurance carriers as well as the greed and bias of many within the medical profession—that act to prohibit either evidence-based methods to emerge or re-aligning payment incentives to reward “best practices” or alternative methods.
The Death of Free Enterprise in Healthcare
It was stunning to find no criticism whatsoever in the NAS report regarding these financial factors in our health care system—no acknowledgment of the high costs, waste, abuse, fraud and greed of health care in America compared to other countries—other than to state that Americans invest annually $1.1 trillion, or 13.5% of the GDP, which they predict will grow to $2 trillion by 2007.
The NAS report also fails to mention the lack of a free enterprise system of competition among health care providers and professions to lower the costs by virtue of the “better mousetrap” concept. They also fail to mention the huge, $26 billion-dollar, government subsidies of the medical and pharmaceutical industry, nor did they mention the medical bias of health care bureaucrats that permeate every level of governmental health care administration. Indeed, it appears we now have a one-party system in healthcare.
The NAS Executive Committee also fails to mention the lack of freedom of choice for patients to select physicians of any type, nor did they mention the trend to alternative health care in America. This omission is particularly glaring in light of Dr. David Eisenberg’s surveys that showed Americans made almost twice as many office visits to non-MDs than to MDs—a trend that should indicate a growing disenchantment with the present allopathic system. It seems this committee believes the American medical system can reform itself by following their suggestions. In effect, I believe, the NAS wants the foxes to do a makeover of the henhouse by rearranging the perches.
It’s All About Money
P. Joseph Lisa, in The Assault on Medical Freedom, declares, “Regrettably, restraint of trade, unfair trade practices, anti-competitive activity, and conspiracy to eliminate the competition have been hallmarks of American medicine. It has been this way from its conception and blatantly continues to this day.”
Indeed, did the Wilk v. AMA antitrust case liberate hospitals from the medical society’s boycott of chiropractors? Did the RAND investigation of low back pain (LBP) and its acknowledgement of spinal manipulative therapy (SMT) as an appropriate method change the nature of LBP management in the medical field? Has the AHCPR guideline on LBP emancipated insurance programs to allow payment for SMT as a “proven method”? Have Dr. Pran Manga’s reports urging chiropractic gatekeepers for all LBP cases been implemented anywhere? The answer to all these questions is a resounding “no.”
Obviously evidence-based criteria sounds good in principle, but in practice it’s another story. Indeed, it’s all about money and monopolistic control, not evidence-based “best practices” or using the best technology to solve health problems.
“New technologies are bursting onto the marketplace according to the free-market principles of Adam Smith. But they are not being paid for according to free market principles. Instead, they are reimbursed by compensation regulations set by doctors and insurance companies to maximize their profits and to keep out cheaper, more effective alternative therapies. They are set without regard to public health and healthcare policy concerns,” according to Dr. James Carter, in his book, Racketeering in Medicine.
What’s the answer to these huge problems of the medical cartel? Interjecting free market enterprise to allow pluralistic competition to prevail, thus offering better services at lower prices. Realistically, only when actually mandated by legislative enactment will we see an open marketplace in healthcare, which is unlikely considering the enormous political and monetary influence of the AMA.
On the other hand, is a single-payer system the solution like those in Canada and the Scandinavian countries? Since the US is the only major country that still has a for-profit healthcare system, converting to a single-payer system will be like pulling teeth without Novocain. The Clinton Health Care Reform Act in 1994, while flawed, was scuttled by the medical/drug cartel and insurance companies that like things just the way they are. This cartel has too much money and too much influence among people in high places for reforms to take place quickly. And the last thing the AMA wants is a pluralistic marketplace with open competition for health care dollars. Indeed, a closed market under their sole control suits their interests best, as it would with any monopoly.
This for-profit, cost-plus incentive is the leading economic reason why the better mousetrap concept is being ignored in health care. Research futurists, such as Dr. Clem Bezold of the Institute for Alternative Futures, deem this incentive as a “perverse motivation.” This cost-plus motivation is one reason why private health insurance and workers’ compensation insurance are so expensive—there is no real incentive on the insurers’ parts to decrease costs, as in a self-insured situation. Simply put: higher gross cash flow = higher percentage take. Indeed, the better mousetrap of chiropractic and other alternative care would lower their gross revenues, something any good capitalist has no interest in achieving!
Considering back procedures are the third-leading reason for hospital admissions and the average “surgical back” costs $13,990 compared to $800 for an average chiropractic case, and that the annual costs of back problems in the US alone range up to $75 billion, this is a huge money-maker that the medical cartel has no interest in having it decline with spinal manipulative therapy (SMT) or any other alternative method.
Distributive Injustice for Chiropractors
Research repeatedly has shown the poor results from back surgery, including a study by Dr. E. Berger published in Surgical Neurology that showed the high rates of permanent disability from spinal fusions. The results were stunning, to say the least. 71% of the single-operation group had not returned to work more than 4 years after the operation, and 95% of the multiple-operations had not returned to work. In none of these cases was there a neurological deficit that precluded gainful employment—the failure to return to work being blamed on chronic postoperative pain. In fact, back surgeries don’t work well, are costly, and leave a wake of disability behind them.
In this light, the present boycott of chiropractic care for back pain in lieu of medical care is woefully outdated clinically, perpetuates inadequate standards of care, it’s an obvious waste of tax money, increases the cost of health insurance premiums for consumers, and it denies patients access to the best care possible. This has led to increased costs for employers and increasingly unsuccessful outcomes for patients. It also has denied doctors of chiropractic the right to compete on a level playing field, a concept Pran Manga, PhD, medical economist, refers to as “distributive justice.”
“We would argue that the principle of distributive justice, and a parallel principle of equality of opportunity, require that the government implement all cost-effective substitutions; failure to do so results in unfairness to the taxpayers and unfairness to certain health care professionals…The monopolization of the health care services turf is also inequitable from yet another perspective. It denies some professions equal opportunity to earn income commensurate with their ability, effectiveness and effort…Inefficient use of health human resources is not just economically wasteful, it is also inequitable and generates higher levels of taxation…Equity is likely to become more important as the struggle over the health care turf becomes fiercer, and as taxpayers demand even greater value for the taxes they pay.”
“Chiropractic care is a cost-effective alternative to the management of neuromusculoskeletal conditions by other professions. It is also safer and increasingly accepted by the public, as reflected in the growing use and high patient retention rates. There is much and repeated evidence that patients prefer chiropractic care over other forms of care for the more common musculoskeletal conditions… The integration of chiropractic care into the health care system should serve to reduce health care costs, improve accessibility to needed care, and improve health outcomes.”
Regrettably, the for-profit health and workers’ compensation insurance carriers would prefer boycotting chiropractic care because it’s inexpensive compared to surgery. In fact, they more they pay out, the more they can charge employers with higher premiums, so being cost-effective is not an asset in this model. Indeed, employers are punished financially and workers are punished physically by this perverse motivation of the insurance companies wishing to keep costs high for their own profit. And WHO wonders why the US ranks first in overall expenditures but only 37th in health care delivery and 72nd in overall health? Again, it’s all about money.
While the NAS report failed to mention the political bias by the AMA toward its competition, they did admit that applying the evidence-based research to health care delivery is another huge gap that must be crossed.
“In the current health care system, scientific knowledge about best care is not applied systematically or expeditiously to clinical practice. An average of about 17 years is required for new knowledge generated by randomized controlled trials to be incorporated into practice, and even then application is highly uneven…and that there are insufficient tools and incentives to promote rapid adoption of best practices.”
While the NAS report suggests improving the implementation of evidence-based “best practices” into the infrastructure, the resistance to change remains a huge hurdle that cannot be overcome by their lofty recommendations. Just as Congress had to pass a federal law to mandate that HMOs allow birthing mothers to stay one day longer in hospitals, I predict Congress will have to do the same in order to have the adoption of best practices into the mainstream.
What’s the Dare?
While NAS, WHO and the Dartmouth Atlas researchers all admit the dire straits—the “Truth”—of the present American health care delivery system, none are willing to admit that the quasi-monopolistic medical cartel has fundamental flaws that will prohibit any meaningful change—the “Dare.” Since the fox is still guarding the henhouse, the likelihood of significant change is remote until the farmer carrying a shotgun arrives to rid the problem.
To illustrate the resistance, and duplicity, of medical critics to real change, an editorial by the former editors of The New England Journal of Medicine, Drs. Marcia Angell and Jerome P. Kassirer revealed their bias. “It is time for the scientific community to stop giving alternative medicine a free ride… Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted.”
No one remotely familiar with the medical-chiropractic warfare would believe chiropractic has ever gotten a “free ride.” Moreover, with the recommendations for SMT over back surgery by numerous investigations (RAND, Manga, AHCPR), chiropractic care is still not fully integrated into the mainstream healthcare delivery systems, despite the assertion of these editors, “If it is found to be reasonably safe and effective, it will be accepted.” Their bias to these recommendations remains another obstacle to overcome.
Again, it’s all about money, not evidence-based science as they contend. Although these NEJM editors’ faint appraisal of the acceptance of alternative health care is hopeful, it will still face the same barriers to implementation—the perverse motivation for more expensive medical procedures rather than the less expensive alternative methods and the inherent medical bias within every healthcare system. Since money drives this medical engine, and not evidence-based research or clinical practice guidelines, all alternative methods will share the same fight of inclusion in this turf warfare with organized medicine.
In summary, it’s obvious the American healthcare delivery system has many “truths” that need significant change. The experts from the WHO, NAS and the Dartmouth Atlas agree that the “dare” of implementing this healthcare reform will be dependent upon many factors, plus a few they failed to address that I mentioned—the lack of pluralistic competition and free enterprise. I contend that eventually the chiropractic profession can help in many ways to improve patient outcomes, lower costs and provide much needed conservative care—both therapeutic and non-therapeutic—to many Americans, if given the opportunity.
Indeed, perhaps the largest “dare” in this scenario will be when the medical monopolists who have fought the alternative health care professions tooth and nail for decades realize these methods do work—the “truth.” Obviously the results of Dr. Eisenberg’s two polls have shown the overall popularity of alternative and complementary health care. As he concluded, “Perhaps ‘alternative’ isn’t so alternative anymore.” If more Americans were to have unfettered access to complementary and alternative approaches by inclusion in their health insurance policies, and if alternative providers were given full parity and access to the health care facilities and all programs in the public and military sectors, the likelihood of lower costs and improved patient outcomes would increase dramatically.
I do not mean to imply that allopathic medicine should not be an integral part of the health care delivery system. However, close observation will reveal that it functions best in crisis care, trauma, and other emergency room procedures such as neo-natal cases. But in terms of the prevention and management of chronic degenerative disorders, and back pain in particular, the medical methods have not proven clinically or cost-effective. Indeed, as the NAS report states, “Trying harder will not work. Changing systems of care will.”
 WHO: The World Health Report 2000—Health systems: Improving performance. June 21, 2000.
 1999 Dartmouth Atlas of Health Care. Center for the Evaluative Clinical Sciences at Dartmouth Medical School
 Crossing the Quality Chasm: A New Health System for the 21st Century, The National Academy of Sciences, 2001.
 NAS report, ibid. page 4.
 NAS report, ibid. page 11.
 Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States — prevalence, costs, and patterns of use. N Engl J Med 1993;328:246-252.
 Lisa, PJ, The Assault on Medical Freedom, Hampton Roads Pub. Co, pp. 31, 1994.
 Wilk et al v AMA et al. US District Court Northern District of Illinois, No. 76 C 3777, Getzendanner J, Judgment dated August 27, 1987.
 Shekelle PG, et al (1991) The Appropriateness of Spinal Manipulation for Low Back Pain: Indications and Ratings by a Multidisciplinary Expert Panel, RAND, Santa Monica, Calif. Monograph No. R-4025/2-CCR/FCER.
 Bigos S et al. (1994) Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14, AHCAPR Publ. No., 95-0642, Rockville MD; Agency for Health Care Policy and Research, Public Health Service, US Dept. of Health and Human Services.
 Manga, P and Angus, D. “Enhanced chiropractic coverage under OHIP as a means of reducing health care costs, attaining better health outcomes and achieving equitable access to select health services.” Working paper, University of Ottawa, 98-02
 Carter, JP, Racketeering in Medicine, The Suppression of Alternatives, Hampton Roads Pub., pp. 218, 1992.
 Bezold, C. “The Future of Chiropractic: Optimizing Health Gains” Institute for Alternative Futures. July 1998.
 Mushinski M. Average hospital charges for medical and surgical treatment of back problems: United States, 1993. Statistical Bulletin. Metropolitan Life Insurance Co., Health and Safety Division, Medical Dept., April-June 1995.
 Bigos S et al. (1994) Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14, AHCAPR Publ. No., 95-0642, Rockville MD; Agency for Health Care Policy and Research, Public Health Service, US Dept. of Health and Human Services.
 Berger E. Later postoperative results in 1000 work related lumbar spine conditions. Surg. Neurol 2000 Aug:54 (2)101-6.
 Manga, P and Angus, D. “Enhanced chiropractic coverage under OHIP as a means of reducing health care costs, attaining better health outcomes and achieving equitable access to select health services.” Working paper, University of Ottawa, 98-02.
 Manga P. Economic case for the integration of chiropractic services into the health care system. J Manipulative Physiol Ther 2000 Feb;23(2):118-22.
 NAS report, ibid. page 13-14.
 Angell, M., Kassirer, J. P. (1998). Alternative Medicine — The Risks of Untested and Unregulated Remedies. N Engl J Med 339: 839-841