Health Care Reform
by Siegfried Othmer | August 14th, 2009
At a town hall gathering, the elderly gentleman pleads: “I like Medicare. Don’t let the government take it over.” Where, then, does one start the conversation about health care? President Jefferson said that it would take an educated populace to secure democracy. That’s grounds to worry. There’s probably nothing one can say to the ranters that would bring them back into the conversation. We do have something to say, however, to the insurance companies that are stealthily fomenting this nonsense while they publicly give lip service to the insurance reform effort.
Let’s start the conversation where we are presently. Insurance companies are currently entitled to exclude anyone from coverage. What happens, then, to the person who cannot obtain insurance coverage? The Constitution stipulates that the role of government is to “provide for the general welfare.” There must be a public option to which the person may repair, because leaving a person without insurance against large risks should not be ok in a civilized society. Surely insurance companies could not object to the existence of a public plan that insures those whom they will not insure. But yet they do object. Their well-being is threatened by a public insurance option, and the well-being of the uninsured is simply irrelevant in that context.
The highest priority at the moment is to find a way to include the uninsured within the system. We don’t even allow people to drive without insurance, and this is a much bigger issue for all concerned—for the individual and for the society that ends up either paying or bearing the loss. The cost isn’t even that high–$2000 per year per uninsured (versus $8300 average per year for Medicare recipients). Much of this just surfaces costs that are currently hidden within the system.
Unfortunately, this modest reform of the system will end up further consolidating a health care delivery model that is in need of much more fundamental revision. Every new group of beneficiaries that is recruited to the existing system may in future act as a pressure group to hinder the change that needs to occur. It is clear to everyone except possibly the grandpa at the beginning of the story that lifestyle changes need to be encouraged. One way to do this is to allow insurance premiums to reflect actual risk, for example with respect to smoking and obesity. Here the instincts of a government agency to level the playing field would tend to run the other way. We need all the good incentives we can get to oppose the bad ones we are exposed to in our consumer culture.
More generally, it is difficult to see how a procedure-based reimbursement system can readily fold in the prevention strategies and the ongoing health status monitoring that would be ideal. Likewise it is difficult to envision how a diagnosis-based system can support the emergence of integrated health care. What ultimately has to happen is an alignment of interests between the person and the caregiver, which can only happen under conditions of a long-term relationship, and it can only happen if the hub in that health care network has an integrative perspective.
We find ourselves at a time when only two percent of graduating medical students plan to go into primary care. The American College of Physicians warns that the nation’s primary care system is “at grave risk of collapse.” The existing incentives are clearly not moving us in the direction that we need to go. Further, the newly graduating MD bee-lining to develop a specialty practice is not prepared in any event to provide the integrative perspective that is needed.
Indeed, where is such an integrative perspective to be found? As a matter of fact, it is emerging among neurofeedback practitioners. Whereas some are still beguiled into particularized thinking by the QEEG, to most of us it is apparent that we are interacting with a highly-integrated physiology. So many different kinds of problems simply melt away with our procedures that most MDs would be incredulous if they only knew. William Mize, MD, agrees, saying that his colleagues would simply dismiss most of our reports as impossible and hence not worthy of their attentions. At the same time we know that we cannot act alone. We depend upon the integration of our work with pharmacology, with nutrition, with standard medical care, with psychotherapy, with developmental optometry, with chiropractic, and with a variety of other disciplines.
We therefore have no choice but to function with an integrative mindset, nor do we have the choice of just going it alone professionally. We also have the advantage of being largely outside of the reimbursement system, so that we are not being entrained to its flaws. What seems to be taking shape over the years is the development of an “applied psychotherapy practice” that covers much of the health care terrain and yet functions largely outside of the realm of diagnosis and even of disease and disorder. The biofeedback/neurofeedback practitioner is therefore in an ideal position to serve as the “hub” of an informal network of alternative and mainstream practitioners that collectively promote health and high functionality in their clients.
We therefore have the possibility of incubating a healthier health care model on a small scale, one that will multiply if it is successful. What stands in the way of this is the fact that we remain part of the conventional way of doing business in one key respect: we also operate on a fee for service model that represents such a barrier to entry for many people. Potential clients coming to us are confronted immediately with a several thousand dollar decision. So we have gravitated toward the end of the spectrum where conventional therapies have failed rather than to the end where they are not yet needed. We have to develop an “ongoing care” model that is affordable to people.
The above sounds like yet another self-serving declaration by a neurofeedback advocate, but the reader should ask the following question. Looking at the health and functionality problems that people face on a daily basis across the land, whose offices should be busier to deal with it? The vast majority of problems that interfere with functionality and put people of the path to serious dysfunction down the line can be handled with a self-regulation strategy. On the other hand, much of the problem with standard medicine is traceable to the fact that practitioners are not aware of the implications that they are interacting with a self-regulating system.
The inappropriate resort to medical remedies allows the real problem not only to persist but to get worse. The most obvious category among the disorders of disregulation is the sleep disorders. Clearly Heath Ledger and Michael Jackson would both have been better off with neurofeedback. No medical remedy existed for their sleep problems. The inappropriate resort to medical remedies progressively made things worse. Both conditions would likely have yielded readily to a neurofeedback regimen anywhere along the line.
Alan Gaby, MD, has given an excellent example of a disregulation cascade: He called attention to the recent finding that Avandia, which is used to treat diabetes, is associated with a “two-to-three-fold increase in the risk of suffering an osteoporotic hip fracture. So, patients taking Avandia may eventually need to take Fosamax to keep their bones strong. Unfortunately, new research shows that the use of Fosamax is associated with a doubling of the risk of developing atrial fibrillation. So, the patient goes into atrial fibrillation, which is treated with amiodarone, which leads to severe pulmonary and hepatic toxicity, and now the patient is in real trouble and on the hook for serious medical bills.”
The alternative, according to Gaby: “Brown rice, beans, chromium, and exercise would have been a lot cheaper and a lot safer treatment for diabetes than Avandia.” He might have thrown in neurofeedback also. And there’s more that should be done nutritionally. Much of diabetes is manageable entirely with a comprehensive self-regulation strategy, and even insulin-dependent diabetics should rely principally on such a strategy.
Any health care reform with hope of actualization has to work with ideas that are on the table already, that are known to the policy makers. Real health care reform needs to come from a very different place, from the bottom up. It certainly cannot come from the system that is ongoingly sustained in a state of dysfunction. We are living with the answer to the health care conundrum on a daily basis. That is to say, we know what needs to be done because we are doing it. But we don’t have the right service delivery model to make our work relevant to the population that needs us most. In order for value to be attached to what we do by the public at large, there has to be a broad understanding of the issue of self-regulation. It is up to us to bring that about.
Al Burstein, then the head of clinical psych at Tennessee, once mused that he didn’t expect the truly significant advances in treatment to come from the established institutions; rather, he anticipated they would be developed by those practitioners battling daily on the front lines. Your observations, Seigfried, would seem to bear him out.
This should be no surprise, of course, since the whole clinical enterprise is at any one time wrestling with a broad range of clinical issues, and many clinicians do approach their work with the intellectual rigor of a scientist. Moreover, the initial insights that lead to breakthroughs in therapy tend to happen in a kind of right-brain synthetic experience that is much less likely to occur in the model-driven perspective of a laboratory scientist planning his next research project. Clinical work tends to negate all the models one may have brought to the task sooner or later, forcing one to think new thoughts.
Open dialog is necessary when dealing with all forms of illness.I am hoping to see more money going into research and governments doing their part. All my respect goes to those suffering, be it you personally or a loved one. My hope is for a major development in the near future to help all those in need.