Not many years ago acupuncture was viewed with suspicion by most Americans; if, that is, they’d even heard of this traditional Chinese medical technique. Not until President Nixon’s famous trip to China in the early 1970s, when a reporter accompanying the President became ill and was successfully treated by Chinese doctors, did the American public get its first introduction to this form of "alternative" care.
Today, things are different. Acupuncture, chiropractic, orthomolecular medicine, homeopathy, herbal medicine, and therapeutic massage are among alternative or complementary health care practices that have become increasingly popular in recent years. Indeed, the Journal of the American Medical Association last year ranked alternative medicine as one of the top three issues of importance to physicians, devoting an entire recent issue to the subject. Such attention from the medical establishment is hardly surprising. Alternative medicine now represents an $18 billion industry, with more than 40 percent of Americans reported using some type of alternative health care in the last year.
Significantly, alternative medicine is also finding its tentative way into mainstream health-care delivery. On the West Coast, especially, but all across the country, large integrated-healthcare networks are beginning to show interest in various alternative therapies. At Cedars-Sinai Medical Center in Los Angeles, for example, patients now enjoy the services of the center’s new Integrative Medicine Program, which offers mind-body behavioral therapies, acupuncture, and chiropractic care.
This newfound openness to more holistic-type care is obviously a response to consumer demand. One California-based managed care provider reports that nearly three-quarters of its members use some form of alternative treatment in conjunction with their conventional medical care. Nearly half also say they are willing to pay more each month to have access to alternative care.
Will Jump Through Hoops for Coverage
Unfortunately, paying more is exactly what many people are doing, at least in out-of- pocket expenses, for it is often still a battle to convince insurers to cover alternative health care. "Overall, the coverage for alternative health care remains mediocre," says Dr. Paul Rubin, a chiropractic physician at American WholeHealth in Chicago. "We’re in a constant battle with the insurance companies about what is‘necessary’ or‘unnecessary’ treatment. The industry seems to be lagging behind not only what the public wants, but increasingly, what physicians and others are prescribing.
"It’s not unusual for an insurer to verify over the phone that they’ll cover a particular treatment, only to have the claim denied when it is submitted in writing. The industry strategy seems often to be to just wear down the provider and the consumer, to make everybody jump through hoops in the hope that they will just get tired enough to not press on for reimbursement. Unfortunately, many times that is the end result. For patients with complex or chronic conditions, it can thus become doubly difficult to design treatment programs with any certainty that the insurance will be there."
Equally frustrating, what is covered or not covered and how well it is covered can vary widely from insurer to insurer. Most insurers, for example, will cover chiropractic care for back pain or other neuro-muscular-skeletal problems. But many chiropractors also treat such conditions as chronic fatigue syndrome, fibromyalgia, or other immune-related disorders. What often happens in the real world is that practitioners must submit claims that focus not on treatment for the disease itself, but for related sub-conditions associated with the disease, such as, in the case of fibromyalgia, the muscle aches or trigger point complaints associated with the condition.
In Illinois, although some managed-care providers do pay for a percentage of acupuncture and chiropractic care, it remains a sometimes vexing process to actually get a claim paid. Illinois also requires by law that acupuncture be prescribed by a physician, which, of course, becomes a prerequisite for insurance coverage (although non-M.D. acupuncturists with a written prescription from a physician can now, unlike a few years ago, legally treat patients). But it remains rare for individuals in pre-paid health plans in Illinois to have access to acupuncture or other alternative care options (see sidebar).
Attempting to discern the financial reasoning behind what is covered or not by insurers is also a perplexing journey. "Many insurers will pay for brain surgery but then deny claims for inexpensive treatments that help a person reduce their stress or improve their nutrition," notes Charles Lo, M.D., of the Acupuncture Clinic in Chicago and Oak Park. "They often will say they can’t cover many alternative therapies because they’re unproven, but in actuality most of the things done in Western medicine are unproven. Studies concerning the efficacy of coronary bypass surgery, for example, show very little proven benefit in terms of improved longevity. Yet the use of bypass has become very common. Insurers don’t hesitate to pay for it."
Of course, this apparently inefficient approach actually does make sense — if you consider the philosophy of the medical profession as a whole. Conventional medicine is largely a disease-treating machine; the orientation has traditionally not been to promote wellness. Yet treating disease can be many times more expensive than taking measures to prevent it.
There is also something of a paradox at work in today’s health-care economy. The trend in insurance reimbursement in recent years has been toward restricting patient choice, with many HMOs operating more as gatekeepers of investor’s profits than as providers of their members’ health needs. Yet, if the choice between alternative or conventional medicine is often portrayed as a debate between a more holistic, creating- health model of care versus a more science-based, attacking-disease model, what it really represents is something more profound. It is that growing numbers of individuals want to take responsibility for their health, to become co-partners with their physicians, and to make informed and independent choices about the type of care they receive.
For now, Dr. Lo, a strong advocate of patient choice in health care, thinks the best advice for younger individuals with few health problems is to buy a catastrophic health plan with a high deductible. And prepare to pay out of pocket for routine health needs. And seek out the doctors or other practitioners you feel most confident and comfortable working with.
It’s also a good idea, if you have a health plan, to read the fine print about what exactly is covered in terms of alternative care. As Dr. Rubin cautions, "Even many of the companies that promote themselves as‘alternative health-care insurers’ are in our experience as providers often selling more of a marketing strategy than a genuine alternative in health-care options. Some say they cover acupuncture, but it might be limited to six or ten visits a year. If you’ve got a chronic health condition, you could go through that in three or four weeks."
Health Care — or "Winning Product Lines?"
To some extent, the grassroots demands of consumers for more holistic choices in health care represents a kind of quiet revolt against another, more troublesome kind of culture change — the corporatization of health care. And with it the public perception that the health care system has become too impersonal, too bureaucratic.
It’s worth remembering that it is only since the 1960s that corporate medicine began to assert itself as a major player in the health sector, as Paul Starr, author of The Social Transformation of American Medicine, reminds us. And it is only since the mid-1980s that large-scale managed care has risen in prominence. Previously, the system was based largely on thousands of individual practitioners, free-standing, non-profit hospitals run by religious charities, public hospitals, and urban teaching hospitals.
In today’s health-care economy, health- care planning has become health-care marketing, patients are "customers," and administrators speak a language of consumer demographics and "winning product lines." And, the long-standing fears of doctors that a European-style national health system would lead to an intrusive, government-controlled bureaucracy has led, instead, to an intrusive, privately-controlled bureaucracy of insurance administrators and investor groups.
Yet the rise of alternative health care also shows the power of consumers to influence the system. Go back to the early 1980s and few, if any, insurance companies covered alternative therapies, with the sometime exception of chiropractic care. It is a sign of the times that Mutual of Omaha recently became the first major insurer to cover Dr. Dean Ornish’s heart-disease prevention program. The Ornish program, which focuses on diet, lifestyle changes, stress management, meditation, and group therapy, costs about $6,000 per patient, significantly less than the roughly $40,000 cost of bypass surgery (with overall costs for surgical patients often exceeding $100,000).
Obviously, alternative health care is no longer being ignored by mainstream medicine. The National Institutes of Health, through its new Office of Alternative Medicine, currently spends about $14.5 million annually on clinical trials and research. Earlier studies have established acupuncture’s effectiveness, for example, in treating the nausea associated with pregnancy and chemotherapy, and the pain following dental surgery, and in providing relief for asthma and back pain. Several new acupuncture pilot studies are now in the works (e.g., osteoarthritis, alcoholism), as well as new trials to study, for example, the efficacy of herbal treatments for Parkinson’s Disease, dementia, and traumatic brain injury. It is thus likely that insurers and health care systems will continue to integrate new areas of alternative treatment into what is covered and what is provided, based on the results of these and other future trials.
Managing Care, Managing Health
Of course, it is unrealistic to separate the issue of alternative care and how it is paid for from the larger issue of how money moves throughout the health-care economy. The American system of health care remains what the New England Journal of Medicine once described as a "paradox of excess and deprivation." The truth is, we spend more and deliver less (about 40 percent more per capita) than the country ranked second worldwide in per-capita expenditures, Canada.
Under the present managed-care system, says Arnold Relman, M.D., editor-in-chief emeritus of the New England Journal of Medicine, insurers are pitted against patients and health-care practitioners are hampered from doing what they know to be best. Left out of the current health-care equation is any overarching health-care policy based on providing the greatest good for the greatest number. Instead, the system, Dr. Relman concludes, is driven by "competing groups that take no responsibility for the whole."
If the current system is in need of an overhaul, the trend toward greater personal health awareness at least signifies a more positive kind of culture change in the works. Marc Micozzi, M.D., Ph.D., executive director of the College of Physicians, sees in the emergence of alternative medicine a glimpse of where the entire health-care system is headed. In his view, the health-care system of the future will blend both today’s alternatives and today’s conventions, forging a new model of care defined by themes of self-care and self-cure. He is right.
This new model of care will be founded on the idea that no doctor, pill, or surgery intrinsically has the power to grant or dispense health. Health care will be about nurturing self-healing. Tapping into this self-healing potential will increasingly become the guiding directive of a health-care system that embraces the challenges of scientific medicine as it discards labels of allopathic versus holistic medicine, conventional versus alternative care.
But, of course, if health itself cannot be bought, health care certainly can. And the crisis in health care will remain for now as much an issue of how we pay — or don’t pay — for care, as in the choices we make and in the nature of the care we provide.