Baber Ghauri, MD, MBA, FHM, FACP, ABIHM
An undeniable fact of moving towards a standardized healthcare system is flattening of the distribution curve of physician performance. The hope is that most of the flattening occurs through advances in efficiency through things like health information technology and training, but the fact is that those who underperform will be cut, and unfortunately for our society, those best performers that very often have other options will also drop out voluntarily. With healthcare composing a large chunk of our gross national product, a career in healthcare is no longer synonymous with direct patient care, and we are already seeing some of our communities best physicians reduce their clinical hours or even leave their beloved past-time altogether for other roles and opportunities.
As more and more of our best clinicians and diagnosticians transition their careers, those that remain will not be equipped to manage some of the more uncommon conditions, and Integrative Medicine may be the only answer for patients who are labeled for one reason or another as exigent. Some such reasons include diagnostic complexity, social factors, and simply not enough time in the day among others. Take for example, the following case of diagnostic complexity:
The “Business Case”
Jane Pashond is a 45-year-old caucasian female smoker that suffers from inflammatory bowel disease (IBD), eczema, depression, and obesity who presents with increasing fatigue, chronic pain, and digestive issues for many years. She has seen many doctors, and her exam is within normal limits as are her labs, including her liver function tests. Her regular office visits with her excellent care team, which includes her primary care doctor and GI specialist are typically 12 minutes and 18 minutes, respectively. She is on multiple medications, some of which require routine monitoring. Her single visit copayment is $20 for her PMD and $35 for her GI specialist. In one year, she is likely to spend almost $500 in copayments and over $1000 for medications, her total out-of-pocket cost of care is approximately $3500 which does not include her $3900 annual insurance premium. Most importantly, this cost is considered the cost of maintenance care and does not account for exacerbations of any of her conditions, which would easily double or triple her out-of-pocket costs for this care.
By now, Jane has spent over $7000 on her health care, all the while without any guarantee on her health forecast for tomorrow, living every day hoping that an exacerbation is not forthcoming. Now that she has a high deductible insurance policy (she could not afford any other), which is almost $4000 more than her previous insurance plan. An integrative approach to her care would uncover several root cause issues that are very uncommonly addressed by traditional allopathic care, the same type of care that earned me much acclaim for providing to my patients prior to my Integrative Medicine training, despite its often mediocre value.
Coupled with an Integrative approach, her depression, obesity, and eczema can be REVERSED and her IBD can be treated with simple diet and lifestyle changes that will also eliminate her fatigue, pain, and digestive issues. Part of her dietary treatment will include a full nutritional assessment with a customized nutraceutical plan designed to be mimic or be subsidiary to traditional pharmaceuticals with almost none of the side effects. The initial assessment will uncover heavy metal toxicity that is at the root cause of her eczema, causing subclinical liver disease, not showing up on her liver function tests. Through careful, time-intensive interviewing, her 20-year-old water heater is found to have lead pipes, which is eventually attributed to her recently worsening and progressive symptoms. She will also learn about sleep hygiene and stress reduction. This will significantly impact her IBD, which, by-the-way is actually IMPROVED by her cigarette use (this is evidence-based). But since her IBD will be controlled better by a plant-based diet with low genetically modified organisms (GMO) and gluten, she will save an additional $2100 a year from smoking cessation. If this sounds too good to be true, then you’ve been around the block enough to know that benefits from this philosophy of care have ENGAGEMENT by patients and providers as a prerequisite. So why would Jane now, after all this time, all of a sudden be engaged?
“Patient Engagement, yeah whatever…”
Given the scenario, it is doubtful, but let’s assume Jane is somewhat indifferent about her care. In the past, there was little to no incentive for alignment of patients and providers because the out-of-pocket cost to patients was constant – essentially just an insurance premium along with a much lower, if any copayment for fee-for-service physician visits. But in 2015, the potential $6100 savings is a tremendous incentive for most patients to at least consider an Integrative approach (when offered), especially when their primary care doctor can share some of the savings with the patients’ payer. With only minutes per visit, even the best trained primary care doctor or specialist can only meet this goal by engaging the Integrative specialist, who has at least 50 minutes per visit- more than enough time to have the conversations that are necessary to share the evidence and develop the trust for that all-important prerequisite, patient engagement. More importantly, Jane cannot even get an appointment with these high-demand providers in today’s increasingly competitive market for great care.
The problem is that Providers in the traditional payment system are not being given the time, training, or resources to offer patients low-cost alternatives to traditional care. These largely unknown interventions form the basis of the entire discipline of Integrative Medicine, which now requires fellowship training before eligibility for certification. With the rising cost of care delivery, this virtually guarantees that existing providers will not have the opportunity to pursue this training. Serving as both a care delivery partner and an educational outlet, Integrative Medicine practices provide the time, training, and resources to our patients and providers alike to employ evidence-based integrative practice into their care management.
There are many Jane Pashond’s in our communities, and the exciting part of our new healthcare marketplace is that our entire population of consumers is finally being incentivized to live healthier lifestyles. Some would consider McDonald’s 30% drop in net income this year as partial evidence of this, the first time in their history. Others might find the increasing use of wearable health technology as proof. Still, others may just be trying to save the extra money by not getting sick in the first place and may enjoy the feeling of being stronger, faster, and having more energy and agility to play with their loved ones. Whatever the reason, there’s no denying that Integrative Medicine has penetrated the healthcare marketplace. The challenge lies in using evidence to educate our consumers into being able to make intelligent and informed healthcare purchase decisions.
Finally, I must say as a technologist that is usually looking for answers that are coming tomorrow, and I am amazed at my increasing level of hope and belief on a set of 5000-year-old disciplines as a significant part of the solution to our healthcare delivery problems. Considering Google defines Technology as “the application of scientific knowledge for practical purposes, especially in industry,” maybe I should be more inclusive of what I consider to be technology.