How integrative medicine can make health care simpler, more effective and more affordable.
Marco Visscher, Ursula Sautter and Carmel Wroth | November 2009 issue
Suffering from headaches and depression? Don’t let your doctor put you on Prozac; instead, look for the underlying causes.
Maybe there are problems at work or at home that you can solve.
High cholesterol? Try the Mediterranean diet, with a glass of red wine a day. And if you really need to take statins, drink green tea to counteract the harmful side effects.
The best way to win the “war on cancer”? Eat healthy, exercise and develop an active social life.
An increasing number of physicians are realizing that this type of approach—geared to prevention and a conservative use of medications and technology—not only increases patients’ vitality but saves lots of money. In the debate over health care reform, one group of doctors and researchers would like to change more than just how health care costs are covered. They believe—in the words of Dean Ornish, founder and chairman of the Preventive Medicine Research Institute in Sausalito, California—that it is time to “change not only who is covered but also what is covered.” With that insight as a starting point, they hope to inspire President Obama to take a different approach to health care.
Ornish and other critics of the current system claim that a great deal of Western medicine is too often ineffective and sometimes even harmful. There is an overemphasis, they say, on treating symptoms and on the idea that caring for your health is primarily the responsibility of medical experts rather than of individuals themselves. Zhaoming Chen, chairman of the American Association of Integrative Medicine (AAIM), describes the way things currently work as sick: “We only treat the disease after it occurs.” The figures bear him out: 95 cents out of every dollar spent on health care is spent on treating illness. “The best way to reduce the costs is prevention,” he says.
The emphasis on prevention is a crucial element in “integrative medicine,” a practice that combines the best of Western health care with alternative or complementary healing methods employed when conventional therapies are ineffective. Integrative medicine puts the patient, not the doctor or the insurance company, at the center of attention, and it puts the focus on the sources of illness not the symptoms. As it becomes more likely that health care reform will not result in any drastic changes, integrative health offers simple, effective and cost-effective solutions for much of what ails both patients and the delivery of medical care.
The litany of health care problems is by now pretty familiar. Costs are escalating, along with the instances of conditions like cancer, diabetes and heart disease. The U.S. ranks 37th in the quality of its health care system, according to a 2000 World Health Organization report, despite spending twice as much per person as any other developed country. Some 48 million Americans, 16 percent of the population, don’t have insurance; a lot of those who have it discover, when they become ill, that they don’t have enough. Earlier this year, the American Journal of Medicine published a study showing that illness and medical bills contribute to more than half of all personal bankruptcies—a portion that’s increasing fast. Of the cases studied, three-quarters involved individuals with health insurance, most of whom were well-educated, owned their own homes and had decent jobs.
Daniel Dunphy, a doctor with the San Francisco Preventive Medical Group, an integrative clinic where both conventional and alternative therapies are prescribed, shakes his head at the statistics. He believes that whatever reform is eventually passed, it will not bring about the necessary fundamental changes. “What we now have is not a health care system; it’s a medical delivery system,” Dunphy says, referring to the tendency of doctors to prescribe pills or refer patients to specialists whether they need it or not. “And we’re even bad at that. We give medical care to people who don’t need it. And when people do need medical care, we don’t give it to them. But if we do, we do everything we can to avoid reimbursing them.”
The exclusion of “pre-existing conditions” from coverage has long been a point of contention between insurers and consumers. Less well publicized is the fact that tests, interventions and procedures for which there is no sound medical basis account for around 30 percent of all medical expenditures, according to a statement from last year’s Health Reform Summit convened by the U.S. Senate Committee on Finance.
In a recent article on the New England Journal of Medicine website, Robert A. Levine, clinical professor of laboratory medicine at Yale University, blames unnecessary care on “perverse incentives” that reward doctors for every procedure: a prescription for medicine, a referral for a test, or an operation. “Even if all physicians were highly ethical and ordered only tests and treatments they deemed truly important,” Levine wrote, “it would take saints not to have their judgment skewed in favor of decisions that will provide them with financial rewards.”
Health care costs are continually rising but people are not getting any healthier. Any reform that does not address this fact will fail. So here is Ode’s five-point prescription for the future of health care, a prescription that applies the tenets of integrative medicine to make health care simpler, more effective and more affordable.
1. Prevention is better than cure
Dunphy draws an iceberg in the air with his index fingers. “What we see in Western medicine is only the tip of the iceberg,” he explains, referring to the symptoms that are treated with pills and technology. “What we don’t see is all that’s underneath the surface, which is what is leading us to disease and away from it. This is where chronic illnesses occur.” And it is these illnesses—cancer, diabetes, heart disease—that account for a large chunk of health care spending. If we can prevent these illnesses, Dunphy argues, we can avoid a great deal of suffering—and save a great deal of money.
Around half of all American adults have a chronic illness, according to The Partnership, a John Hopkins University-led initiative to improve care for Americans with chronic health conditions. Preventive Medicine Research’s Ornish claims that three-quarters of the more than $2 trillion spent last year on health care went to cover these conditions, among which he also includes obesity. “All of these can be not only prevented but even reversed through diet and lifestyle intervention,” he says. “It just seems so obvious to me that this is where we should be putting our focus.”
AAIM’s Chen agrees: “If we do not reduce the incidence of chronic diseases and change our lifestyles, we are not going to reduce the costs.” He points to a recent Archives of Internal Medicine study of over 20,000 Germans, which found that non-smokers who maintain a healthy weight, healthy diet and exercise 30 minutes a day lower their risk of developing diabetes by 93 percent, heart attack by 81 percent, stroke by 50 percent and cancer by 36 percent, compared to people who haven’t integrated any of these factors into their lives. According to Chen, doctors should explicitly discuss lifestyle choices with their patients, including everything from learning to better handle stress to exercising more and enhancing social contacts.
There is, however, a long way to go before prevention is on the agenda. While prevention is indeed better than cure, we tend to reward those who find solutions for existing problems rather than those who ensure that those problems don’t occur. The system is even designed to reward insurance and pharmaceutical companies when they treat a disease instead of preventing it. Plus, by definition, the benefits of prevention won’t show up for decades, or even generations. “It’s hard for Congress to engage in a comprehensive integrative health approach because the savings will only be visible many years later,” says William Novelli, a professor at Georgetown University’s McDonough School of Business and the former CEO of AARP, the consumer group for older people. “That’s an artificial barrier we need to cross.”
But, according to Ornish, there’s an even greater challenge: Prevention just ain’t sexy. “Prevention is boring,” he says. “We need to focus on living better. [If you have a healthy lifestyle,] you’re likely to look better, feel better, lose weight and gain health, as well as to smell better, taste better and love better.” What’s not to like?
2. Promote healthy food
Roberta Lee, a primary care physician at the Beth Israel Medical Center’s Department of Integrative Medicine in New York City, believes the first prescription any doctor should write should be about diet and lifestyle. “You can never lose by maximizing lifestyle management,” says Lee, pointing out that many conditions not easily diagnosed or cured in a conventional framework can be improved by dietary and lifestyle changes. “There are specific diets that promote wellness,” she says. “They reduce inflammation, increase fiber and increase vitamins and minerals that come in the form of a lot of fruits and vegetables and whole grains.”
One the first graduates of Andrew Weil’s integrative medicine fellowship at the University of Arizona Center for Integrative Medicine, Lee is pioneer of integrative health care. She teaches other doctors at Beth Israel through the school’s own fellowship program and practices at the Beth Israel Continuum Center for Health and Healing in New York, where patients can be treated by doctors who’ve studied integrative techniques. She complains that nutrition doesn’t get the attention it deserves: “The typical doctor has an average of two hours of nutrition lectures in medical school.”
When a 24-year-old woman came to Lee with a bad case of chronic fatigue syndrome, the first thing she did was talk to her about her dietary and lifestyle history. The patient had low energy levels even after sleeping well; she tired easily when she exercised. She became depressed and was taking antidepressants. Lee learned that the woman had trained as a competitive tennis player throughout her childhood and adolescence. With such high levels of activity, it was easy for her to burn up calories, so she had never watched what she ate. The result: She drank a lot of sports drinks and often ate junk food. “What she had was calories, but not nutrition,” says Lee. “She had eroded her nutritional reserve.”
Lee got her on a new diet, based on whole foods and plenty of fresh vegetables and fruits. She also prescribed supplements, including a probiotic to help with her digestion, and sent her to see an acupuncturist. In six months, the woman’s symptoms were gone. She went off antidepressants and started vigorous exercise again. “Just the idea that patients have responsibility and power over their own health is the most important thing,” Lee says.
People with type 2 diabetes have that power, too. By simply following the guidelines of the American Heart Association—a low-fat diet rich in whole grains, with low intake of fats, sweets and high-fat snacks—they can bring down their chances of needing drug therapy by 30 percent. A study in the Archives of Internal Medicine suggests that a Mediterranean diet—rich in whole grains, fruit, vegetables and nuts—is nearly twice as effective at reducing the need for drugs.
Even with the best of intentions and high doses of will power, it can be tough to stick to a proper diet, something the Preventive Medical Group’s Dunphy is reminded of when he drives half a day north from San Francisco. In Eureka, a city of 26,000, he sees fast food chains and obese people wherever he looks. The city’s main attraction, he says sarcastically, is its jail: “That’s what we spend our tax dollars on.” But drive north for another half-hour and you enter Arcata, which has put a cap on fast-food eateries; nine is enough. The Plaza in the heart of the city sports a farmers’ market that sells local produce, some of it organic, to a healthy-looking clientele.
“This country needs better food,” Dunphy concludes, “and better means organic and fresh fruits and vegetables. That should be taught as well at medical schools and in kindergarten.”
3. Promote positive lifestyle changes
It’s true that you are what you eat. But it’s equally true that you are what you do. The vast majority of health problems and risk factors for illness stem from the choices we make: how much time we spend working, exercising and relaxing, how much time we spend with friends and outdoors, whether we take the stairs or the elevator. Beth Israel’s Continuum Center, like a small number of other hospitals and clinics, is designed around the idea of promoting healthy lifestyles.
The Continuum Center itself is a refuge of peace and harmony. Every day at 12:30 p.m., patients can come in from the hubbub of Manhattan’s Fifth Avenue for a meditation class. While waiting to see a doctor or health practitioner, patients sit in a spa-like waiting room, decorated with plants, leather chairs and a sea-blue designer rug. Even the examination rooms have natural wood cabinets, cork floors and soothing sage and ochre wall colors. All materials are eco-friendly. “People feel different in an environment like this,” says the Center’s Lee, adding that Continuum physicians try to enhance patients’ awareness of the emotional and lifestyle components of disease. “At the heart of it, people don’t even understand that stress affects health. It’s not about illness just being in your head; it’s recognizing the consequences of things like chronic stress,”she says.
Another integrative health center, the Sanoviv Medical Institute in Rosarito, Mexico, takes the concept of a healing environment a step further. The Institute—a fully equipped in-patient hospital and surgical center—is located on a beautiful stretch of Pacific coast, an hour south of San Diego. The recommended stay for most patients is two weeks. And while they are there, patients learn and experience a lifestyle based around stress reduction, emotional well-being, healthy eating and exercise. Many patients come with serious illnesses such as cancer and multiple sclerosis; others come just to detox and clear out the accumulated effects of stress.
Isaac Meza has practiced medicine at Sanoviv for four years. He and his colleagues seek to understand the patients’ lifestyle and genetic vulnerabilities before treatment. Meza recently treated a 65-year-old man suffering from severe migraines, fatigue, muscle pain, memory loss and disorientation. The symptoms began after he had an aortic valve replacement to treat high blood pressure. The surgery triggered another symptom as well, cardiac arrythmia, so he had a surgery to implant a pacemaker. After that, his doctors prescribed a cocktail of drugs, including blood thinners, pain killers and cholesterol-lowering, blood pressure and sleep medicines. “This patient came to us so toxic he couldn’t live his normal life,” says Meza. “We put him on a program to lower his medications.”
The program included dietary changes, supplements, daily exercise and a stress management plan that included psychological counseling and daily meditation. After two weeks, the man regained his energy and alertness and his migraines disappeared. And he went home—as all Sanoviv patients do—with a detailed plan of action to keep up these lifestyle changes.
Meza says the underlying problem was that he didn’t have enough energy to deal with the stress of surgery and detoxing from all the medications. Without the lifestyle change, Meza says the man would have been at risk of a recurrence of the high blood pressure that started the whole problem. “The biggest part of their treatment happens when they go home,” says Elise Dubois, director of Sanoviv’s chiropractic and fitness departments. “This is not a one-shot deal. We give them the tools to take responsibility for their health and to make changes.”
Lifestyle interventions can be effective for a range of conditions. According to a 2007 study in the British Medical Journal, by shifting to a healthier lifestyle participants with impaired glucose tolerance—the biggest risk factor for developing type 2 diabetes—cut their chances of developing the disease in half. A 2004 study in The Lancet showed that lifestyle changes—quitting smoking, healthier eating habits, moderate alcohol consumption and regular exercise—can prevent 90 percent of cases of heart disease, which currently accounts for more premature deaths and higher costs than any other illness, according to Ornish.
Ornish, who was President Clinton’s consulting nutrition and lifestyle advisor while he was in the White House, is convinced lifestyle interventions are not only more effective but less expensive, too. “Randomized controlled trials show that angioplasties and stents [to open blocked arteries] do not prolong life and do not prevent heart attacks” unless they are performed within hours of an attack, he says, refering to a 2006 study in The New England Journal of Medicine. Nevertheless, in 2006, around a million angioplasties were performed, many days or weeks after an attack, and manufacturers sold $6 billion in stents. Ornish adds that, except for a small subgroup of patients, bypass surgery does not prolong life; some 400,000 bypasses were performed in 2006.
Yet simple lifestyle changes could make much of this expenditure unnecessary. In 1997, health insurer Highmark Blue Cross Blue Shield started a program designed by Ornish to help patients with heart disease and those at high risk of heart disease or diabetes, take preventive action. The daily regimen involved eating low-fat, whole foods, exercising moderately, managing stress and joining a social support group. Seventy-eight percent of participants avoided bypass surgery or angioplasty, and they recorded significant reductions in blood pressure, cholosterol levels and weight relative to the control group. In 2003, a cost analysis showed that the program saved Highmark an average of $17,000 per patient annually.
The lifestyle approach is gaining some traction. The Take Back Your Health Act, proposed by Democratic Senator from Oregon Ron Wyden, embraces a pay-for-performance model through which doctors are rewarded for the success of a “comprehensive lifestyle program” for Medicare patients diagnosed with coronary heart disease, type 2 diabetes, obesity, prostate cancer or breast cancer.
“When lifestyle is offered as a treatment, it’s as effective and often more effective than what we’re now doing, at a fraction of the cost,” says Ornish. “We pay for all these interventions that are dangerous, invasive, expensive and largely ineffective, and yet interventions that have been scientifically proven to reverse disease are a simple change of lifestyle.”
4. Use alternative and complementary therapies
Another way to reduce costs is to use alternative and complementary therapies—including homeopathy, naturopathy, yoga and herbal medicine—that can supplement and sometimes even replace conventional methods. One alternative healing method that’s beginning to find its way into hospitals is acupuncture, which has been shown, among other benefits, to help relieve pain, stress and nausea in pre- and post-operative care.
Beth Israel’s Department of Integrative Medicine is bringing acupuncture into the hospital free of charge as part of a fellowship program for Chinese medicine practitioners. “The future of acupuncture is to be a part of best practices in the conventional setting,” says Arya Nielsen, who leads the program. “The research is just too good.”
Acupuncture fellows each spend eight hours a week in the hospital. Any patient who wants their services can request it. Recently, a woman with an extremely painful open wound in her abdomen requested the treatment after witnessing a fellow patient receive acupuncture in her room. The woman rated her pain levels at ten out of ten, and she had already received as much morphine as was safe. After a session with acupuncture fellow Christina Rodriguez de la Mar, though, her self-reported pain level droppped to two or three. Nielsen says the session was “very eye opening for the nurses and doctors” who witnessed it.
The goal is to train both acupuncturists and conventional doctors in the benefits of this technique so that it can be incorporated into Beth Israel’s best practices. “Even if physicians have time to read the acupuncture studies, what really makes it gel is when they see the results on the patient they treat,” says Nielsen. “The proof is in working side by side and people being able to experience what this therapy can do.”
According to Nielsen, studies of the cost-effectiveness of acupuncture in the U.K. showed that the method rivalled conventional treatment for several conditions in terms of long-term efficacy and cost. But such studies have not been conducted in the U.S., where acupuncture is rarely covered by insurance providers. Nielsen is confident that in time certain uses of acupuncture will be covered by insurers. Insurance companies will “start to see it’s a win-win because it lessens patients’ stays at the hospital,” she says.
Though acupuncture can be pricey—a session costs anywhere between $70 and $300—it can also help reduce the cost of expensive treatments for life-threatening illnesses like cancer. “For many types of cancer, conventional medicine has had only modest successes,” says Dana Ullman, a homeopath in Berkeley, California. Chemotherapy and radiation—which Ullman refers to as the “Vietnamization of the body”—don’t always work well, he argues. That’s why he believes some patients choose alternative treatments, typically in addition to conventional ones. These treatments “nourish, nurture and augment the body’s own defenses. Adding treatments like homeopathy, acupuncture and herbal medicine will mean reducing the number of high-tech visits to the surgery room and rounds of chemotherapy, which are far much more expensive.”
AAIM’s Chen points out that chemotherapy, surgery and radiation dramatically change a patient’s life, and people need strong support from family and friends to adapt to these changes. “Treating cancer should involve both conventional and alternative medicine,” according to Chen. Patients “also need some lifestyle changes: smoking cessation, minimizing alcohol intake, a low-fat, high-fiber diet. Besides that, because the treatment may cause nausea and pain, patients may benefit from acupuncture, meditation, yoga and tai chi. This will help them cope with pain better.”
5. Treat the person, not just the disease
The pleasant fragrance of crushed hay drying in the summer sun fills the air of the small hospital room as nurse Béatrice Fleury pours a still steaming infusion of yarrow over a piece of cotton and then wrings it out. The aroma of the medicinal herb wafts over to the bed where Eliane Perrot is waiting for her body wrap. When the compress and a hot water bottle have been gingerly applied to her lower back and secured by a soft cloth sash, she leans back with a contented sigh. The compress will help her liver better metabolize the toxins that have accumulated in it after months of breast cancer therapy. The wrap’s warmth will also create a sense of temporary well-being, a precious feeling for the frail, exhausted 65-year-old.
Alternative treatments like the yarrow wrap are the order of the day at the Paracelsus Spital in the Swiss town of Richterswil, some 12 miles south of Zurich. Founded in 1994, the clinic is one of a handful of hospitals in Europe devoted to complementary healing. In addition to orthodox treatments and drugs, the conventionally-schooled doctors here also use therapies and medications based on the holistic approach to medicine inspired by anthroposophy and Waldorf education founder Rudolf Steiner.
“If you want to understand a person’s disease and support his self-healing powers, it’s of central importance to look at the human being as a whole—body, spirit and soul,” says Paracelsus medical director Erich Skala. “This may require more time and effort, but it’s how you treat the causes and not just the symptoms.” (For more on the Paracelsus hospital, see “Getting back in balance” below.)
Since anthroposophic physicians consider personalized care essential to recovery, diligent nursing is an important element at Paracelsus. While she applies the yarrow wrap, Fleury is so unhurried and friendly that you wouldn’t believe she’s on a tight schedule. She takes her time waving the hot compress around until Perrot feels comfortable with the temperature; she shakes out the pillow; she smoothes the bed covers. All the while, she chats softly: “This compress will stay in place for 30 minutes, then I’ll remove it and afterwards you’ll rest for another half hour. So, are you sure you are comfortable like this?” When Perrot says she’s comfortable, Fleury quietly leaves the room. “I’m not just a case here,” Perrot says, “not just a number or a problem. They treat me like a human being. And that’s so important.”
The personal care at Paracelsus comes at a price—about $700 per day, some $100 more than the average for other private Swiss clinics with similar medical approaches. The cost is covered by the Swiss public health care system. Despite the expense, the acceptance of integrative medicine among the Swiss public is great. In a May referendum, 67 percent of voters supported the proposition that complementary treatments should be formally recognized in Switzerland’s constitution so that they can be better integrated into the health care system. However, the medical community is less convinced, but Lukas Rist, Paracelsus’ chief administrator, hopes this will change as research confirms the benefits of complementary medicine. To help this process along, the clinic set up its own research department to measure its clinical outcomes.
The Preventive Medical Group’s Dunphy believes the Paracelsus approach is exactly the kind of thing the U.S. needs. “You have to take time to get to know the patients and listen to their stories,” he says. “I want to know their personal history, their traumas, how they do at work, what they eat and at what times of the day—and then I know what to do about their problem.”
Of course, the bottom line in the debate about health care is cost.
Proponents of integrative health argue that the promotion of prevention, healthy food and positive lifestyle changes, as well as using complementary methods to treat the whole person and not just the disease, will result in “the biggest return on investment this nation could ever have,” in the words of Georgetown University’s Novelli.
Kenneth R. Pelletier, clinical professor of medicine at the University of Arizona School of Medicine and the University of California School of Medicine, has been putting hard numbers behind the arguments for integrative health. Pelletier studied the cost-effectiveness of corporate programs to promote health and manage disease among employees. The programs encompassed everything from subsidized gym memberships and stop smoking classes to biometric screening and smaller portions in the cafeteria. Pelletier found that companies with such programs in place had healthier, more productive workforces, fewer sick days and less staff turnover.
He estimates that it takes on average just over three years before firms see a financial return on this kind of investment. “These reviews clearly indicate that comprehensive interventions do evidence both clinical and cost effectiveness,” says Pelletier. “There’s a very good payback. It makes us think about health as an investment.”
More money, more pills and more technology don’t necessarily lead to better health. Advocates of integrative medicine take a “less is more” approach—less needless medications and medical procedures and more prevention and personal lifestyle changes can add up to big financial savings and big improvements in quality of life.
Perhaps the best news of all is, you don’t need to wait for the legislators on Capitol Hill to make this investment in your health. This is one prescription you can fill yourself, starting right now.
Marco Visscher is Ode’s managing editor, Ursula Sautter is a contributor from Bonn, Germany, Carmel Wroth is Ode’s feature writer.