The WHO’s Ten Facts on Worldwide Patient Safety

September 29, 2007 at 1:13 am · Filed under Uncategorized, International Health

At a recent conference on patient safety, the World Health Organization(WHO) put out a call for more research in areas of health care-associated infections, adverse drug events, surgery and anesthesia, unsafe injection practices, unsafe blood products, and adverse medical device events. The WHO estimates that “tens of millions of patients worldwide endure disabling injuries or death each year, directly attributed to unsafe medical practices and care.”

The WHO also published its ten facts on patient safety which puts in a disturbing nutshell what health authorities are up against. While there are few surprises here, and the data is always a little suspect, you do get the picture.

1. Patient safety is a serious global public health issue. In recent years, countries have increasingly recognized the importance of improving patient safety. In 2002, WHO Member States agreed on a World Health Assembly resolution on patient safety.
2. Estimates show that in developed countries as many as one in 10 patients is harmed while receiving hospital care. The harm can be caused by a range of errors or adverse events.
3. In developing countries, the probability of patients being harmed in hospitals is higher than in industrialized nations. The risk of health care-associated infection in some developing countries is as much as 20 times higher than in developed countries.
4. At any given time, 1.4 million people worldwide suffer from infections acquired in hospitals. Hand hygiene is the most essential measure for reducing health care-associated infection and the development of antimicrobial resistance.
5. At least 50% of medical equipment in developing countries is unusable or only partly usable. Often the equipment is not used due to lack of skills or commodities. As a result, diagnostic procedures or treatments cannot be performed. This leads to substandard or hazardous diagnosis or treatment that can pose a threat to the safety of patients and may result in serious injury or death.
6. In some countries, the proportion of injections given with syringes or needles reused without sterilization is as high as 70%. This exposes millions of people to infections. Each year, unsafe injections cause 1.3 million deaths, primarily due to transmission of blood-borne pathogens such as hepatitis B virus, hepatitis C virus and HIV.
7. Surgery is one of the most complex health interventions to deliver. More than 100 million people require surgical treatment every year for different medical reasons. Problems associated with surgical safety in developed countries account for half of the avoidable adverse events that result in death or disability.
8. The economic benefits of improving patient safety are compelling. Studies show that additional hospitalization, litigation costs, infections acquired in hospitals, lost income, disability and medical expenses have cost some countries between US$ 6 billion and US$ 29 billion a year.
9. Industries with a perceived higher risk such as aviation and nuclear plants have a much better safety record than health care. There is a one in 1 000 000 chance of a traveller being harmed while in an aircraft. In comparison, there is a one in 300 chance of a patient being harmed during health care.
10. Patients’ experience and their health are at the heart of the patient safety movement. The World Alliance for Patient Safety is working with 40 champions – who have in the past suffered due to lack of patient safety measures – to help make health care safer worldwide.

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Interview with Steve Harden, President of LifeWings

September 28, 2007 at 10:31 pm · Filed under Podcasts + Videocasts, Hospital and Health System CEOs, Hospital Administration

Steve Harden started his career as a Navy pilot, with more than 300 aircraft carrier landings. Steve eventually co-founded Crew Training International, where he brought Crew Resource Management training (or CRM) to US and overseas air forces and commercial fleets.

More recently Steve founded LifeWings to bring CRM to health care. Steve spoke with me today about what hospitals can learn from guerrilla warfare tactics, how landing on an aircraft carrier compares with his current work, and the importance of bringing a wingman with you to the hospital

 Interview with LifeWing's president Steve Harden: Play Now | Play in Popup | Download (166)

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The Quality of Quality Hospital Data Questioned

September 27, 2007 at 11:52 pm · Filed under Uncategorized, Quality Measurement

BNA (paid subscription required) reported this week on a study done by researchers at UCLA’a medical school (published in Archives of Surgery) comparing hospital quality data on six publicly available websites. And the news was not good. According to the report for three of the private websites, “the searches demonstrated significant inconsistencies. For example, for colon removal, one hospital was ranked best by two sites, but worst by the other site, and the hospital ranked best on that site was ranked worst on another.”

In addition to the three unnamed private websites, the researchers studied hospital ratings on CMS Hospital Compare, the Joint Commission’s Quality Check, and the Leapfrog Group’s Hospital Quality and Safety Survey Results. Timeliness, methods and incomplete data were said to account for some of the differences.

I think we should expect a lot more of this kind shake out of quality data over the next decade or so until professional consensus, market place pressure and better methodological governance takes better hold. But this kind of disparity in the numbers will lead to more patient confusion and feed a lack of trust in all quality data.

I don’t know about you, but I’d be a little nervous if I was the one facing colon surgery and looking at these findings.

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A Turning Point for Healthcare?

September 27, 2007 at 10:49 am · Filed under Benefit Design, Business of Health

Was GM’s announcement yesterday the tipping point for healthcare in America?

From the WSJ: “The labor agreement reached by General Motors Corp. is the most striking example of a bigger trend sweeping U.S. health-care: employers renouncing their decades-old role as chief health-care buyer.”

Everyone knows this is coming, the question is how fast? From the article, we see that now only 60% of firms offer health coverage (down from 69% in 2000). We also see that the average health premium for a family has doubled in 7 years. As more and more Fortune 500 companies unload and/or outsource their employees’ and retirees’ health care, more and more laypeople will be faced with a myriad of complex insurance decisions. Look for a new wave of companies to serve this segment (Steve Case is already after ‘em with Extend Health). Much of this trend is packaged as “consumer-driven healthcare” - i.e. consumers are given a set amount and are the ultimate decision-makers for how to spend it.

So how fast is this coming?

Interestingly enough, even the universal-coverage-minded Democrats aren’t proposing we get away from an employer-based model just yet. Even with Hillarycare 2.0 (which has received some positive reviews), Hillary was quoted with the following:

“We looked at every permutation of how you get to universal health care,” said the Democratic presidential candidate. “There’s great attachment to the employer-based system, even though it is eroding.”

While we’re on the topic, here are a few more opinions from previous posts:
- Ron Wyden (D-OR) believes the time is now to end employer-based healthcare.
- Dr. Richard Fogoros, author of Fixing American Healthcare, believes rationing is the solution (read this post from David Williams)

And check out this great article in the Economist that succinctly compares the Democrats’ health care plan proposals.

My guess is that the 80-20 rule applies to this - we’ll need around 80% of the population to be on individual plans before policies start to follow suit. And given the trends, this is still 10-15 years out.

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Promoting Participation in Employee Health Management

September 26, 2007 at 10:54 pm · Filed under Employer CEOs, Prevention and Health Promotion, Employee Health Management, Population health management, Health Management

Healthcare organizations (HCOs) , whether as employers seeking to enjoy the economic gains of employee health management (EHM), or as providers of EHM services to other employers, face the challenge of gaining enough participation among employees to make such services successful.  One wellness program provider, Gordian Health Solutions, has reported that the purely voluntary participation rate among employees tends to be around only five percent. [A. vanDusen “Slimming Down the Workforce” Forbes.com Sep 4, 2007]

Voluntary engagement in EHM programs may be low, but the participants who participate may be more motivated than non-participants to manage their own health, and to reduce whatever risks they have, manage their chronic conditions, and thereby deliver benefit to their employers, as well as to themselves.  But if only 5% of employees at risk participate, the potential gains will necessarily be low compared to the potential if high participation rates were achieved.

Gordian also reports that, with the right incentives, employers have achieved from 60-80% participation.  It suggested that an increase of $30 per month in health insurance premium costs to non-participants could promote higher participation, as well.  But while participation in EHM programs may be necessary to achieving the kinds of economic benefit employers seek, it is by no means sufficient.  It is the “success” or “efficacy” rate that delivers the benefits — of lower healthcare, disability, absenteeism, presenteeism, and turnover costs, as well as quality, customer satisfaction, and new business revenue.

While participation may be increased dramatically through negative incentives, they may reduce the net benefits thereof.  Employees who are punished for not participating, or rewarded for participating, may “participate” in whatever ways are used to measure such participation, in order to avoid personal financial costs or achieve financial rewards.  But will they be truly “engaged”, and make the behavior and lifestyle changes that are necessary and sufficient to improve their health, and thereby benefit their employer?

Moreover, employees who feel “coerced” into participation by threatened punishments may become sullen and uncooperative at work, as well as in their participation.  They may not improve their productivity or performance, due to a decline in their motivation, even if their health improves. [W. Lynch & H. Gardner “A Hierarchy of Aligned Incentives” Health as Human Capital Foundation 2006 (www.hhcf.org)]

And if that were not sufficient reason to be careful, positive incentives add to the costs of EHM programs, dollar per dollar.  Moreover, their effective cost, relative to the benefits desired, is usually increased significantly because of limited efficacy or success rates among participants.  In fact, participation incentives’ costs are multiplied directly compared to the benefits gained, based on these rates.

For example, participation in weight management programs may yield true “success” in as few as 5-10% of participants, in terms of losing weight and keeping it off for an extended period.  Smoking cessation programs may only yield a 20% “quit rate”.  If so, then incentives paid for participation will automatically be multiplied.  To predict this effect, the participation costs per participant are divided by the efficacy rate.

For example, if participation incentives for weight management are $100 per participant, and only 10% lose weight, the effective costs per success are $100 divided by 10% equals $1000.  In other words, it takes paying ten people $100 or $1000 in total, to get one to quit, or $1000 per quitter.  With smoking, a $100 incentive with a 20% quit rate would mean a $100 divided by 20% equals $500 per success.

And these are not the only costs per participant, since the EHM program, itself, will cost something.  If program costs per participant are as little as $100 each, these costs are also multiplied in the same way, depending on the efficacy rate of the program.  This would mean the costs per success for the weight management program would be doubled to $2000 per success, and costs for smoking cessation to $1000 per success.

This would put a major burden on the EHM sponsor and provider alike, since both depend on achieving a positive, and ideally admirable return on investment (ROI) ratio, as well as net economic benefit.  For them to simply break even, the overall economic benefit from weight management would have to be at least $2000 per success, or $1000 for smoking cessation.  This may well be the case, but to achieve even a $2.00:1 ROI ratio, the overall economic benefit would have to be $4000 for weight management, and $2000 for smoking cessation.

This multiplier effect would be significantly less if the efficacy rate for EHM programs were higher.  If the efficacy rate for a stress management program, for example, were 50%, the participation incentive of $100 per participant would only add $100 divided by 50% = $200 per success, as would the $100 in program costs, making total costs only $400.  The benefit per success would only have to be $400 to break even, and $800 to achieve a $2.00:1 ROI ratio.

Moreover, offering an incentive for success, instead of for participation, may significantly increase the efficacy rate of the EHM program.  It should even reduce the proportion of participants who participate just to avoid penalties of non-participation, or gain rewards for participation, and add to the success rate increase.  In the case of weight management, or smoking cessation, for example, the employer could afford to offer a $1000 per success incentive for weight loss, and $500 for quitting smoking, rather than a $100 participation incentive, and still gain the same net economic benefit per success.

Since the costs of a success incentive are subject to no multiplication, they can be significantly more generous than the participation incentive, particularly when the efficacy rate for the EHM program involved is low or only modest.  A large incentive offered for success may be enough to overcome the lack of an incentive for participation, by being significantly larger, and offering a reward that can be gained through behavior the participant can control, even enlist family and friends or co-workers to help the participant succeed.

Another approach that seems to have worked in EHM generally is to appeal to the competitive spirit of employees.  As the vanDusen article reported, the Blue Cross/Blue Shield Association has found that team competitions in EHM help increase participation in its “Engaging Consumers @ Work” program.  A team approach, where participants are grouped in teams with prospects of winning a success incentive based on the success rate within the team, could promote peer pressure and enlist peer support to each member, and raise success rates even more than individual success incentives do, while costing no more.

Since all costs that are incurred per participant “cascade” in a multiplied fashion to costs per success, while success incentives do not, HCOs might at least test the idea to see what improvements in their success rates and net economic benefit results.

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Speaking of CAM and Science – A New Example

September 26, 2007 at 10:50 pm · Filed under Hospital and Health System CEOs, Sickness care, Treatments and Therapies, Research, Alternative Medicine

It has often struck me as a writer, that once I initiate research into a given subject, complementary and alternative medicine (CAM) most recently (see my posting of Sep 24), I almost always run into a new story on that subject, often in a matter of days.  This time it was: C. Johnson “Study: Acupuncture Works for Back Pain”, Washington Post Sep 24, 2007.

The article is an example of both scientific and economic reasons to consider at least the specific CAM treatment involved, namely acupuncture.  Analysis by German researchers indicated that acupuncture works significantly better than conventional medications and other traditional Western treatments.  Over 1100 patients were randomly assigned to 1) acupuncture; 2) sham acupuncture, or 3) conventional therapy.  In the acupuncture group, 47% of patients improved, compared to only 27% in the conventional group.

One of the particularly interesting findings from this study was that sham acupuncture, i.e. where the treatment is “faked” by not inserting the needles as deeply as acupuncture requires, achieved almost as good results as the real thing, with 44% of patients getting the sham version improved.  While Dr. James  Young of Rush University Medical Center, who was involved in the research, says that we don’t know precisely why acupuncture works, and often treats his own patients that way, it is clear that it does work.

When dealing with pain, the patient often wills improvement, by believing there will be an effect, or where the sham treatment creates such a belief.  This “placebo effect” is particularly strong in pain management, and if it occurs with sham treatment, it makes sense to use it as well.  Apparently, in this research, at least, the conventional medical treatment did not produce nearly as great a placebo effect, or else its objective medical effect was so low that even with its placebo effect, improvement was still significantly less than for either sham or true acupuncture.

Dr. Heinz Endres of Ruhr University Bochum, in Bochum, Germany, reported in an e-mail that “patients experiences not only reduced pain intensity, but also reported improvements in the disability that often results from back pain, and therefore in their quality of life.”  He noted that these findings are in line with a theory that pain signals to the brain can be blocked by competing stimuli, such as the needles used in both forms of acupuncture.

It could be, as Dr. Brian Berman at the University of Maryland’s center for complementary medicine suggested, that acupuncture changes the way the brain processes pain signals, or by releasing natural painkillers in the body.  If this is the case, then there is a logical physiological, as well as psychological reason for the reported success.

The “conventional” treatment includes traditional prescription painkillers, injections, physical therapy, massage, heat therapy, or other treatments, with all patients in the study receiving about ten sessions lasting a half-hour each.  Many include both massage and heat therapy in the CAM category, so even when these were included, the acupuncture as a specific therapy appears to work better, though no results specific to these therapies alone were reported.

Because CAM is such a “loose” category of solutions, and because there are so many different specific therapies and therapists that may offer and deliver treatments, this finding cannot be seen as proof that CAM, in general, works – either this treatment for all problems and all patients, or even for all patients with this problem.  As has been demonstrated many times already, people’s genetic differences often create vastly different levels and types of response to traditional medications and treatments, so it should not be a surprise if the same is true for CAM in general, and for acupuncture treatment of back pain in particular.

Of course, to employers or insurers who are looking for the best and least expensive way to manage workers’ or covered members’ back pain, these findings may provide both a scientific and an economic reason to not only accept acupuncture for back pain, but even to recommend it over conventional treatment.  In the spirit of competition, we should look forward to seeing conventional medicine fight back, perhaps by identifying one particular treatment that does better than acupuncture did in this case.  The more we have rigorous science applied to questions of what works, as contrasted to the sophistry of both politics and the market, the better we will all be in the long run.

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A National Private Health Care Market Place: Feeding Reform to the Big Dogs

September 26, 2007 at 3:16 am · Filed under Uncategorized, Insurance, Health Plan/Payer CEOs, Policy Makers, Business of Health

The Wall Street Journal, and at least one major republican presidential contender want to create a national private health insurance market place as part of any reform. In an editorial last year on market-based health care reform proposals offered up by AHIP, the WSJ argued in favored of creating a private national insurance option. They complained that “the current system is a special interest anachronism in this age of Internet and global commerce,” and that we should “let the markets work” presumably at a national level rather than through 50 sets of state regulations.

Rudy Giuliani proposes that people be allowed to purchase health insurance across state lines if state mandates prevent affordable coverage. Giuliani writes in a Boston Globe opinion piece,

“One of the advantages of our federalist system is that different states can try different approaches to solving problems and learn from each other. States should be empowered to meet benchmarks regarding the affordability of insurance options and the availability of preventive care. The result will be a health care system focused on wellness, not just sickness. And if a state insists on expensive mandates that keep health care options unaffordable, we will open the state insurance market up to interstate commerce so their citizens can shop for insurance options in other states.”

Other than the single payer option, this notion is one of the most radical out there and would turn the health insurance industry on its head. Although the idea doesn’t seem to be gaining much traction, we should give it some serious attention.

My contention is that a national private health care market imposed on the states will take us to the same uncomfortable place that we would end up if we followed the single payer route: zero local control over health care planning, decision making and responsibility. Maybe being from Hawaii, I’m overly sensitive over the vast distance between Washington, D.C. and Honolulu. But I think there’s more to worry about here than just geography.

For that last twenty years or so, local control over health care has steadily diminished. Certainly the federal government has been the prime perpetrator with the federal HIPAA law emblematic of this trend. Its implementation pushed millions of dollars in unnecessary costs onto the states and local health care delivery providers while bringing very little of comparable value to the table. And for all of this, local authorities have little or no control over the administration and enforcement of the law which rests primarily with the federal government.

Unfunded mandates managed by federal agencies and the immense cost shifts to states and private payers from Medicare and Medicaid have covertly, and significantly, inflated local health care costs. In addition, the increasing regionalization of these government health programs often cut out local agencies and providers from participation.

On the private market side, we see the rapid consolidation of both health insurers and providers into fewer, and much, much larger corporations. Many are for-profit with wall street priorities. Many have global aspirations; health care is getting flatter after all. But along with Washington, these are very big dogs in a yard getting smaller everyday.

Both single payer and the opening up of a national private health care market place beyond state and local authority, are reform strategies that feed these big dogs. Combined with, say the national licensing of physicians and other providers, a national private health care market place could explode in organizational bureaucracy, complexity and alienation from local concerns.

And when these big dogs fight, as they are wont to do, the collateral damage can be considerable.

To be fair, national private market competition may reduce costs, or so the argument goes. But that’s not a given. Hawaii, for example, is one of the lowest costing states when it comes to health care premiums. So go figure.

It would be easy to dismiss these concerns as the whining of parochial special interests or the entrenched status quo. And well there’s not much one can say to deflect that kind of critique. One could ask, of course, what area of political and economic life is absent “special interests” but that would be begging the question.

For me it comes down to the inherent dangers I see in these two health reform strategies for local communities to become even more marginalized from important decisions that impact their daily lives than they already are. It may be a a fool’s errand to try a keep health care local, but it’s like this: I still need to walk the dog rather than the dog walk me no matter what its size.

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Book recommendation: Fixing American Healthcare

September 24, 2007 at 9:23 pm · Filed under Policy Makers

On my way to Singapore this summer I reviewed a pre-publication copy of Dr. Richard N. Fogoros’s book, Fixing American Healthcare; Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare. There’s a blurb from me on the opening pages of the finished product:

Dr. Fogoros has hit the nail on the head with a bold, insightful critique of the U.S. health care system and a plan for radical reform that just might work. Fixing American Healthcare is a much-needed antidote to the fruitless incrementalism that dominates contemporary debate.

I meant what I wrote. Unlike others who dance around the topic or try to have it both ways, Fogoros doesn’t shy away from embracing bold, unpopular ideas as cornerstones of his solution. Here’s a taste from early on in the book:

[R]ationing of healthcare is a central theme in this book… I am not talking about something bland or benign… There is nothing pretty about rationing healthcare. Rationing is bad, and if we’re going to do it we should at least be willing to acknowledge exactly what we are doing. So here’s the definition I like: To ration healthcare is to withhold medical services from individuals who would probably benefit from them because we have decided not to buy those services for everybody who needs them.

I like this definition because it’s straightforward. Also, it puts the onus on us… instead of those nasty “scarce resources” themselves. That makes it harder for us to dance around the real issue, which is: if we’re going to ration healthcare then we ought to do it in the least harmful way possible.

Fogoros makes a compelling case that the problem with our current health care system is covert rationing, which has profound corrosive effects. Once the problem is laid out, Fogoros proposes a solution that encompasses open rationing and is characterized by six key principles. Among other things he wants to see competition between health care and other services provided by society, and rationing decisions left to individual patients to the extent possible.

Fogoros also insists on universal health care coverage as a key principle. Presidential candidates who advocate the same thing should study Fogoros’s book to see how it might actually be done.

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It truly is all a matter of ideology?

September 24, 2007 at 10:45 am · Filed under Insurance, Hospital and Health System CEOs, Policy Makers, Universal Coverage

Let me preface this essay by saying that, I am writing this as a health care provider, a hospital CEO, and a concerned citizen.  In the past we have talked almost incessantly about the 47 million uninsured in our nation, and the lack of funding for domestic issues ranging from education to infrastructure.  (And in the spirit of full disclosure, I consider myself a moderate and don’t believe that this venue is appropriate for a political rant, but . . .)

An article in the New York Times today by Sarah Kershaw opened with this sobering piece of information, “The federal government has told New York State health officials that chemotherapy, which had been covered for illegal immigrants under a government-financed program for emergency medical care, does not qualify for coverage. The decision sets the stage for a battle between the state and federal governments over how medical emergencies are defined.”

I’m not sure what to say about this.  At our hospital the decision to treat or not to treat will remain the same. We will treat.

The Washington Post’s Christopher Lee wrote recently that, “If anything looked like a sure thing in the new Congress, it was that lawmakers would renew, and probably expand, the popular, decade-old State Children’s Health Insurance Program before it expires this year.”

This surely seems like a dream come true for any politician, something that creates a health care safety net for children who, otherwise would not have the coverage or financial wherewithal to pay for this care.  What politician would even consider vetoing an already established program that offers health insurance for kids?

Interestingly, President Bush has indicated that he will veto it.  It’s important to note that his veto will not be because he is concerned that this program doesn’t work, he has acknowledged that S-CHIP works very well.  He has also indicated that he will not veto it because it is fiscally irresponsible?  In fact, this plan is, overall, a very reasonable expenditure. Yes, he objects to any expansion of the plan, but, it appears that this will not be the only reason for his veto.

It seems that Mr. Bush’s decision to take this stand is ideological.

The program is diametrically opposed to his philosophy of government.  If you take care of kids, and that plan works, then you can take care of adults, too.  Expansion of government is not something that this president embraces.  But the administration clearly continues to embrace the Iraq war, and that costs money, lots of money.

From the New York Times, January 17, 2007 by David Leonhardt:

“…For starters, $1.2 trillion would pay for an unprecedented public health campaign” a doubling of cancer research funding, treatment for every American whose diabetes or heart disease is now going unmanaged and a global immunization campaign to save millions of children’s lives.

Combined, the cost of running those programs for a decade wouldn’t use up even half our money pot. So we could then turn to poverty and education, starting with universal preschool for every 3- and 4-year-old child across the country. The city of New Orleans could also receive a huge increase in reconstruction funds…”

Is it truly is all a matter of ideology?

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A Future for CAM in Health Management?

September 24, 2007 at 9:06 am · Filed under Insurance, Employer CEOs, Health Plan/Payer CEOs, Hospital and Health System CEOs, Prevention and Health Promotion, Population health management, Health Management

The idea of using the altogether too loosely defined set of CAM solutions in treating the sick has been a contentious one for as long as I have been involved in health care.  Our family was an osteopath when I was growing up, when even that was a kind of “alternative” approach to medicine, though it has been largely incorporated in traditional medicine today.  I have on occasion tried acupuncture and chiropractic, without becoming a convert to CAM as “the” alternative.

With the growth of interest and investment in proactive health management (PHM) applied to individuals and populations, in private practice, worksites, retail clinics, employee and insured populations, is opening up a significant new opportunity for “complementary and alternative medicine”, however it is defined.  Included among what some define as CAM are the use of “nutriceuticals” whose use has been scientifically supported, such as folic acid for pregnancy, along with stress management coaching, for example for general risk reduction.

The determination of whether and which CAM solutions will be covered by insurance, incorporated into traditional medical practice or “integrative medicine” programs, etc. has largely been a function of four different avenues: political, scientific, popular, and economic.  As CAM penetrates the PHM market, it is likely that the economic and market avenues will dominate, though the political and scientific will continue to play a role.

The political route has been used by a number of CAM practitioners and their supporters, with noisy protests, effective lobbying, etc. leading to mandates for coverage in state legislatures, and by Medicare or Medicaid at the federal level as well.  In a country where freedom of choice is such a mantra, it is difficult to argue against people having the right to choose CAM therapies and individual practitioners whose efficacy and safety may not yet have been proven.  And when they cost less than traditional medicine, it becomes that much harder.

The scientific route is increasingly being used in recent years, as studies are finally being done in keeping with traditional standards of rigor, though many CAM therapies are difficult to compare to a meaningful “placebo”.  What is the “inert” alternative to chiropractic, for example, or even acupuncture that would compare to the sugar pill that can be used in pharmaceutical trials?  And Chinese medicine, for example, leans toward total customization for the individual patient, so there is no clear single alternative that can even be compared to a single placebo.

Moreover, there is the question as to whether the placebo effect should be discounted in CAM studies.  Since this same affect often plays a significant part in pharmaceutical and medical care success, the overall effect should arguably be recognized, rather than just the demonstrable difference that the therapy makes alone.  If this effect is stronger in CAM, as it seems to be in many cases, particularly in treating chronic pain, then why discount or ignore it?

The market has long been a major factor in promoting acceptance of CAM, particularly when few scientific studies were being performed.  When more than 30 or 40% of consumers use CAM practitioners or treatments of some kind at least some of the time, the voice and wealth of consumers can support such solutions even if insurers and traditional medicine refuses to.  And if physicians wish their patients to inform them about CAM solutions they are using, as part of coordinating care and avoiding contra-indicated mixing of the two, they must at least be willing to discuss the idea with patients.

As consumers have an increasing share of the healthcare burden imposed upon them, they may more frequently seek care from CAM providers whose prices tend to be significantly lower than those of physicians.  The very transparency that is being espoused so reluctantly by traditional providers about their prices will tend to make it easier for consumers and payors alike to identify which are the most cost-effective providers of sickness care, and consumers may have different notions about which effects they think most important than do traditional providers.

The potential that CAM solutions and practitioners can protect and improve the health of consumers with as much success as do traditional providers seems very real.  For one thing, most CAM providers do not command the same income as do physicians, so their services need not cost as much.  For another, having been forced most of the time to live without any, or with limited insurance coverage, CAM practitioners often operate with nowhere near as high an overhead practice costs as do physicians.

And if employers, insurers, and government payors are persuaded that CAM strategies for protecting and improving the health of consumers can achieve the desired cost savings they not only wish for but feel are essential for survival, there should be a far more open mind about CAM in health management than there has been in sickness care.  While arguments over the safety of some CAM therapies will no doubt continue, if they do no harm, and end up saving payors more money than traditional providers do, it seems likely that they will be even more widely accepted, by payors as well as consumers.

I expect to see some major disruptions in the health management market, as the four avenues are used simultaneously in the health as well as the sickness domain.  It should be very interesting.

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