Modern medicine has a problem. It can fix a damaged heart, battle cancer into remission, and operate on the deepest recesses of the human brain. Yet it continues to struggle with the everyday anguish of an aching back.
Americans now spend billions of their own dollars seeking relief from such chronic conditions in alternative schools of health, such as acupuncture or chiropractic. RAND researchers have started to examine what it would take—and what it would mean—to more fully integrate such practices into the medical mainstream.
The obstacles are forbidding; the insurance questions alone might require an actual act of Congress to solve. But the benefits could transform health care as we know it, expanding its scope from sickness and trauma to whole-body wellness.
Unconventional medicine, once dismissed as quackery by the medical establishment, might be the missing piece of modern health care.
“How do we take two parallel systems and bring them together?” asks Ian Coulter, a senior health policy researcher who holds the RAND/Samueli Institute Chair in Policy for Integrative Medicine. “That,” he added, “is the future.”
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A Different Model
Arnie Hagler came to integrated medicine by way of the floor at Chicago's O'Hare International Airport. He was in between flights when the pain in his lower back finally laid him out.
Prescription drugs couldn't touch it. And so Hagler, now 74, a biophysicist who spent his career working with the pharmaceutical industry, took a chance on a chiropractor. “Saved me from surgery,” he says now. He's come to see integrated medicine as a way to “stack the deck” for his own health and well-being. After all: “You can't solve a problem with the 15 minutes that you get in a standard medical service these days.”
That's a common refrain from the millions of Americans who now balance their care between medical science and the healing arts. Practices such as acupuncture, naturopathy, and therapeutic massage were once considered New Age; now, they're more often called complementary and alternative medicine, or CAM.
What they share is a focus on holistic wellness, on helping the body heal itself—on making the patient as much a partner in health as the practitioner.
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Americans spent nearly $34 billion out-of-pocket on CAM treatments and products in 2007, the most recent year for which reliable data are available. Most of that went toward treating quality-of-life conditions such as chronic pain, and lifestyle conditions such as obesity or high cholesterol—the soft spots of clinical medicine. Complementary approaches to back pain alone accounted for nearly $9 billion of that spending, one study found.
“There's something going on. People appreciate these kinds of visits,” said study coauthor Patricia M. Herman, a senior behavioral scientist at RAND and a licensed naturopathic doctor.
“The health care system is built for trauma,” she added. “The big things that are killing us now and affecting quality of life are those chronic conditions and lifestyle diseases, and those require a different model.”
To get a sense of why those different models of medicine remain a step outside the mainstream, start with a mild October day in 1893, when medical students lined the streets of Philadelphia to jeer at a parade of homeopaths. “Sugar pill, sugar pill,” they chanted, “never cured, and never will.”
The U.S. Veterans Health Administration now makes such routine use of chiropractors that it no longer considers them alternative.
The medical establishment spent decades deriding most other practitioners as dangerous charlatans—“unconscionable quacks,” according to a pivotal paper in 1910 that set the tone for generations of doctors. The American Medical Association tried to run chiropractors out of business until 1980, dismissing their practice as an “unscientific cult”; a federal judge later ruled its boycott amounted to an illegal conspiracy.
“We've come a long way,” said John Scaringe, a professional chiropractor and the president of Southern California University of Health Sciences. Its students of Eastern medicine and chiropractic will soon share their classrooms with future physician assistants, a pioneering attempt to integrate even the training of health care professionals.
“We're not looking at it as holistic versus traditional health care, but contemporary health care,” Scaringe said. “We're hoping that in the future, we don't have those distinctions.”
Mainstream medicine has started to reassess the potential of some CAM treatments to relieve health problems ranging from headaches to depression and PTSD to the chronic pain of fibromyalgia and cancer. The U.S. Veterans Health Administration, for example, now makes such routine use of chiropractors that it no longer considers them alternative. Georgetown University offers its medical students a course in mind-body techniques—to help them cope with the high stress of medical school.
Yet the road from here to fully integrated health care, uniting the best of modern medicine and its alternatives, remains a long one, full of barriers, RAND researchers have found.
Some states, for example, still forbid medical doctors from partnering with complementary health providers; naturopathy is entirely outlawed in South Carolina and Tennessee. Many states license CAM practitioners but limit the scope of their practice and don't treat them as primary health care providers.
Then there's the tangle of insurance regulations. No insurance codes even exist for some CAM specialties. Government-sponsored health plans, including Medicare, also don't include most CAM providers, a situation that in some cases only Congress can change.
One section of the Affordable Care Act seemed to open the door to greater coverage of CAM practices and providers; but another section allowed insurers to quietly nudge it closed again.
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Toward an Integrated Vision of Care
The result has been what one RAND paper called “siloed chaos,” with mainstream and complementary medicine practicing independently of—and sometimes wholly unaware of—each other. It also has built a double standard into America's health care system, with the full suite of treatment options available only to those who can afford to pay out of pocket for them.
“We have evolved into a dangerous situation,” said Dr. Mimi Guarneri, a cardiologist who once placed hundreds of coronary stents a year but now helps run a fully integrated health clinic in La Jolla, Calif. Its exam rooms and blood lab are just down the hall from a massage room, a yoga studio, and soft easy chairs for vitamin infusions.
“We're trained to treat every ill with a pill,” Guarneri said. “We translate the science of disease into practice. But what about the science of health? If you have a sick tree with bad fruit, do you just cut off the branches? Eventually, you look at the soil. It's the same thing with health.”
“We know that patients appreciate CAM. We should start paying attention to this.”
RAND researchers have started to champion a new way of thinking about medicine in all its forms, one not necessarily based on the double-blind clinical trials that have become the gold standard of modern health care. The question should not always be whether a treatment can outperform a placebo under the strict controls of a clinical trial, they argue, but whether real patients get real relief from it.
What those patients want to know, RAND's Coulter says, is not so much how a specific spinal realignment performed in a clinical trial, but whether it's safe to go to a chiropractor in the first place—and whether the visit will help that aching back.
“We know that patients appreciate CAM, we know they give it very good satisfaction scores, we know they're willing to pay for it,” he says. “We should start paying attention to this. This is worthy of attention.”
RAND has some history here. It helped pioneer modern health insurance with a groundbreaking experiment in the 1970s and '80s that enrolled thousands of people in test coverage plans. At a time when the medical establishment still disavowed most outside treatments, those early RAND plans offered participants a rare benefit: full coverage for chiropractic care.
— Doug Irving