[This post was written by Charlie Baker, President and CEO of Harvard Pilgrim Health Care, Inc., one of New England’s leading non-profit health plans.]
I heard this idea promoted at a luncheon I was at last week — that the best way to fix health care in the U.S. would be to move to a “Medicare-For-All” system. Needless to say, I find this odd — since I think many of the things people hate most about our existing system — too procedure driven, doesn’t support primary care and prevention, favors technology over face-to-face interaction, doesn’t support multi-disciplinary approaches to care delivery, etc. — derive from the rules of the game set up and enforced by…Medicare!!! Yikes!
But aside from that, the two things I always hear about why it’s a good idea are — Medicare has lower Administrative costs than private health plans and they’re a ”better” payer than the private plans. Hmmm…Let’s take the first one. What I’ve heard before is that Medicare only spends 4% of its money on a per beneficiary basis on administration, while the plans spend 14% per member on administration — a big difference. This is interesting, but misleading.
Medicare beneficiaries are over the age of 65. They spend almost three times as much money on health care as a typical private plan member — most of whom are under the age of 65. If the Medicare member typically spends $800 per month on health care, and 4% of that is spent on administration, that’s $32 a month on administration. If the private health plan member typically spends $300 per month on health care, and 14% of that is spent on administration, that’s $42 a month — a much smaller difference. But we’re not done yet. Medicare is part of the federal government, so its capital costs (buildings, IT, etc.) and benefit costs (health insurance for its employees and retirees (!), pension benefits, etc.) are funded somewhere else in the federal budget, not in the Medicare administrative budget.
Private plans have to pay for these items themselves. That’s worth about $5-6 per member per month, and needs to come out of the health plan number for a fair comparison. Now we’re almost even. And finally, Medicare doesn’t actually process and pay claims for all of its beneficiaries. It contracts with health plans around the country to do much of this for them. That’s not in their administrative number, either — and it is, needless to say, in the private health plan number.
People push and pull these numbers all the time, and there may be “some” difference between Medicare and the private health plans on administrative spending as a percent of total spending. But it’s not huge, if you try to compare apples to apples.
On the payment issue, the numbers I’ve seen suggest that nationwide, private plans — on average — pay somewhere between 120 and 125 percent of what Medicare pays for hospital and physician services. In other words, private plans pay MORE than Medicare pays, not less! If people want Medicare For All, they need to be prepared to either dramatically raise Medicare rates and payment — and therefore, Medicare costs — by a lot of money — 20 to 25% by this estimate — or kick the bejeebers out of the physician and hospital communities and make them eat the difference.
Being with the wrong doctor can have grave consequences – literally. As a practicing physician, I’m the first to admit that no doctor is perfect, especially me. I’m in a field that is eternally humbling, with my next mistake potentially hiding just around the corner. The stakes are enormous and the number of tasks I must juggle often daunting. From my point of view, I’m trying my best. But from the patient’s point of view, that may not be enough. So how do you know when it’s time to call it quits with your doctor? Here are ten reasons to make you think twice about continuing with the status quo:
1) You feel your doctor isn’t listening to you.
Listening isn’t waiting to speak. One of my favorite and most beloved teachers, Dr. Alfred Markowitz, once told me, “If you let patients talk long enough, they’ll actually tell you what’s the matter.” Studies show that, on average, doctors let patients talk for 18-23 seconds before interrupting. Patients are allowed to finish their opening statement of concerns about 25 percent of the time.
You want a physician who not only is willing to hear what you’re saying but who’s intrigued by interpreting nuances of words and body language, who notices when you hesitate a millisecond before answering a question that’s hit a hidden sore spot. Don’t be shy about confronting a doctor who isn’t listening. And leave if your concerns aren’t addressed.
2) Your doctor can’t communicate effectively with you.
Your doctor not only needs to be a great listener but has to be able to explain things to you in a way that you can understand. You’ll know it when you don’t hear it.
3) The doctor isn’t taking you seriously.
This is a deal breaker. It may happen if your doctor jumps to a conclusion about the cause of your symptoms before considering other possibilities. Even if you’re a hypochondriac, your hypochondria needs to be seriously addressed. And even hypochondriacs get real illnesses.
4) You have a problem with the office staff.
Office personnel represent the doctor. If they’re unfriendly or unkind then you’re starting off on the wrong foot. And it gets worse if they’re inefficient. Messages must be given to the doctor, insurance forms filed, tests properly scheduled and results reported. Last week, a survey of primary care practices found that patients were not told of abnormal results an average of 7 percent of the time.
5) You’re kept waiting too long.
Doctors can be delayed by unpredictable medical emergencies. But if it happens consistently then the doctor is probably scheduling inefficiently. A clue you’ve been in the waiting room too long: if you pass completely through menopause while waiting to discuss your hot flashes.
6) It takes too long to get an appointment.
Routine annual visits can be scheduled months in advance but new problems and ongoing medical complaints need to be addressed in a timely fashion.
7) The doctor’s too busy.
This may develop over time, as the practice grows. If messages are going unreturned, insist on talking to the doctor. If the problem continues or the doctor always seems to be in a hurry then you may need to find somebody else.
8) Your doctor gets annoyed by questions.
This may be a reflection of other problems listed above such as the doctor being too busy or not taking you seriously. Whatever the cause, it’s unacceptable. Not only are patients entitled to careful consideration of questions, those questions may provide doctors with important clues. “Why do I get a stomach ache every time I eat a slice of toast?” may lead to the diagnosis of celiac disease, a condition in which gluten – a component of wheat, rye, and barley – is toxic to the body. If a doctor doesn’t immediately know the answer, a perfectly good response is, “I don’t know but I’ll research it and get back to you.”
9) Your doctor is too arrogant.
God save us from the brilliant doctors. You probably need to be a B+ student to be smart enough to learn everything you need to be a great doctor. But you also need to be A+ in empathy, listening, carefulness, keeping an open mind, logic, and common sense. Doctors who think they are brilliant scare the heck out of me. I’ve seen them make huge mistakes as they take short cuts or rely on their instincts without seeking help from others or adequately listening to their patients.
10) It just doesn’t feel right.
As with any relationship, sometimes you can’t put it into words but you just know it’s wrong. Don’t fight your instincts.
For this week’s episode of CBS Doc Dot Com, I visit the Mount Sinai School of Medicine in New York City and speak to Erica Friedman, the director of the Morchand Center, where budding doctors are schooled on bedside manner by treating actors pretending to be patients.
I went to a great grand rounds the other day about osteoporosis and learned that all teenage girls should be taking about 1,500 mg of calcium with Vitamin D a day in addition to a multivitamin. Three glasses of milk provide about 1,200 mgs, but most teens are not drinking that much milk. Dark green vegetables are another good source of calcium.Exercise and weight-bearing activity is also important in the prevention of osteoporosis.
Calcium is a mineral that gives strength to your bones. Calcium is also necessary for many of your body’s functions, such as blood clotting and nerve and muscle function. During the teenage years (particularly ages 11-15), your bones are developing quickly and are storing calcium so that your skeleton will be strong later in life. Nearly half of all bone is formed during these years.
Women develop most of their bone strength before they are between 25 and 35. After that, bone is broken down faster than it is created, leading to a small loss of bone mass every year. For women, bone loss accelerates during menopause, but slows again around age 60.
There are specific risk factors for osteoporosis that teens should know:
Being white;
Having irregular periods;
Doing little or no exercise;
Not getting enough calcium in your diet; Being below a normal weight;
Having a family history of osteoporosis;
Smoking; and
Drinking large amounts of alcohol.
Osteoporosis can be prevented, but teens need to start early.
Being the first group of parents to have to have to parent an all digital generation of kids, it’s no wonder our brains go on overload trying to sort out not only how to use all things digital but keep our developing kids safe and thriving in their ever digital lives.
I talked about these issues today on Fox25 Boston and highlighted the new social media and sexting tips out from the American Academy of Pediatrics in honor of Internet safety month. Here’s the clip of the segment with all the details:
To remember the key points of the new AAP tips, I came up with the mnemonic “TECH”:
T: talk to your kids about their technology use and what they think of technology and the issues they hear about online.
E: educate yourself about the technology your kids are using, your kids about the issues, and your community about the need for youth education programs in schools as support for the issues
C: check your kids online profiles and logs often, and sometimes without warning
H: have a family tech use plan and follow-through when violations occur.
We know how to parent off line. We know how to create consequences when curfews are broken and expectations for social rules and proper behavior are not met. What we have to do now is modify our already great parenting skills to the online world. These tips are the first step!
Plus, keep in mind, you are not alone. Not only are all the parents around you in the same boat but you have experts like me here to help answer your questions about the high tech lives of kids.
I had a great chat after the segment with many FoxNews25 viewers and will post what we talked about soon so everyone can benefit. In the meantime, if you have questions about your own “Networked Family” or a story to share from your own “Networked Family” archives, email me at ideas@pediatricsnow.com.
*This blog post was originally published at Dr. Gwenn Is In*
When patients ask me if a chiropractor can help them with their problem, I often think to myself, “OK, do I give them the short answer or the long answer?” The difficulty is often in the fact that chiropractic is a diverse profession and it is difficult to even characterize what a “typical” chiropractor is likely to do. As a chiropractor once admitted to me – there are a great many things that happen under the umbrella of “chiropractic.”
In this article I will summarize some of the history and practice of chiropractic, highlighting what I consider to be many of the enduring problems with this profession.
History
Chiropractic was founded in 1895 by Daniel David Palmer, a grocer with an intense interest in metaphysics. Prior to his “discovery” of chiropractic, D.D. Palmer was a magnetic healer. He also had interests in phrenology (diagnosing disease based on the bumps of the skull) and spiritualism. Palmer reported to have discovered the principle of chiropractic when he allegedly cured a janitor of his deafness by manipulating his neck. The fact that the nerve which conveys sound information from the ears to the brain does not pass through the neck did not seem to bother Palmer, if he was even aware of this fact.
Palmer created the term “chiropractic,” which literally means “done by hand,” to refer to his new therapy. He argued that all disease is caused by subluxated bones, which 95% of the time are spinal bones, and which disrupt the flow of innate intelligence. He did not subject his ideas to any form of research, but rather went directly to treating patients and to teaching his principles to the first generation of chiropractors.
Subluxation Theory
Palmer believed in the pre-scientific vitalistic notion that health stems from the flow of a spiritual life force. Although vitalism was rapidly declining within scientific thought by the end of the 19th century, it was the centerpiece of early philosophies of health in most cultures. Palmer borrowed this ancient belief and renamed it “innate intelligence” which he claimed flowed from the brain to the rest of the body through the spinal cord and peripheral nerves. All disease, he argued, results from disruption in the flow of innate intelligence. Disruption in flow is caused by spinal subluxations, which are small misalignments in the spine that compress the spinal nerves.
Therefore, liver disease is caused by a subluxation which compresses the spinal nerve which supplies the liver with life force, depriving it of its vital innate intelligence. Palmer therefore believed he could cure by fixing these misalignments with manipulation.
This idea has remained the cornerstone of chiropractic despite advances in neurobiology and anatomy which have failed to show any evidence for innate intelligence or chiropractic subluxations. Many continue to ascribe all disease to the blockage of innate intelligence despite scientific advances in medicine which have discovered infectious, genetic, autoimmune, degenerative, nutritional, and other causes for many of the diseases which plague mankind.
Chiropractic was also not the only tradition based upon manipulating the bones. Of note, osteopathic doctors also developed an art of bone manipulation in order to heal, but they believed they were unblocking blood flow through arteries. Osteopathy and chiropractic had similar roots, but took very different paths, as we will see.
D.D. Palmer’s son, B.J. Palmer, became involved in the chiropractic movement early on, during the formative years. B.J shared his father’s metaphysical bent (prior to chiropractic, he worked with a mesmerist and worked in the circus), his tendency to make sweeping statements about health without justification, and his ignorance of contemporary scientific knowledge. He was reported to state, for example, “When I saw there was no use for a sympathetic nervous system, I threw it out, and then just had to put something better in its place, so I discovered Direct Mental Impulse.” B.J. also “discovered” a non-existent “Duct of Palmer” connecting the spleen to the stomach. In 1907 B.J. engineered a hostile take over of his father’s school of chiropractic.
B.J. Palmer set the tone that would later dominate the field of chiropractic. He emphasized salesmanship, advertising, and practice building. He was highly critical of medicine, stating that M.D. stands for “more death.” He continuously sought new methods for increasing revenues, such as his neurocalometer, which would pinpoint subluxations by measuring skin temperature and he decreed must be rented from him by other practitioners at exorbitant fees.
From the beginning chiropractors were also politically aggressive. They sought licensure as a protection from the growing scientific medicine with which they were completely at odds. Many legislators were reluctant to license chiropractors for this reason, but as more and more states voted in licensure, it became increasingly difficult to fight. Additionally, many legislators looked upon licensure as way of controlling the scope of chiropractic. By 1925, 32 states had instituted licenses for chiropractors. The struggle ended in 1974 when Louisiana instituted licensing.
Many states then began to pass basic science board requirements for licensure, making chiropractors pass the same tests of basic science knowledge as medical and osteopathic students. This was justified by the fact that chiropractors were presenting themselves as primary practitioners. However, where roughly 86 percent of medical students passed their basic science boards between 1927 and 1953, only 23 percent of chiropractors did. Chiropractors who could not pass the boards either moved to another state without the requirement, or practiced without a license. Between 1967 and 1979 all of the basic science laws for chiropractors were repealed.
Over the years chiropractic has never ceased its tireless struggle for growth and acceptance. Despite the fact that scientific medicine has continued to progress and chiropractic has never shed its pseudoscientific origins, they have been quite successful. After licensure, they gained coverage under Medicare. They have also successfully sued the AMA to stop their antichiropractic campaign. Today they continue to lobby hard for increased coverage and access under health insurance and HMO policies.
Straights, Mixers, and Reformers
Almost since the beginning, chiropractic has been fraught with many internal schisms. Today there is a wide range of differences between individual chiropractors, but most can be placed within one of three basic types.
Straight chiropractors consider themselves the only true or pure chiropractors because they limit their practice to the identification and treatment of spinal subluxations. They adhere strictly to Palmer’s concept of disease and believe that all ailments can be treated through manipulation to restore the flow of innate intelligence. Once freely flowing, they believe innate intelligence has unlimited power to naturally heal the body.
Straight chiropractors are the most extreme in their anti-scientific views. They openly advocate a philosophical rather than a scientific basis for health care, calling mainstream medicine “mechanistic” and “allopathic.” They call physicians “drug pushers” and disparage the use of surgery. They are careful not to give diseases names, but none-the-less they claim to cure disease with their adjustments. They oppose vaccinations. They also openly advocate the replacement of scientific medicine with chiropractic as primary health care. The statements of Dr. Wilson A. Morgan (who just passed away earlier this month), previous Executive Officer of Life College School of Chiropractic, are typical:
“Chiropractic: The health care system whose time as the official guardian of the public’s health is fast approaching!”
“On the other hand, it is equally appropriate for chiropractors to be viewed as generalists in that the far-reaching effects of their highly specific spinal adjustments usually are followed by the decrease and often disappearance of a very broad array of symptoms, disabilities and pathological conditions.”
“Unlike the medical profession, chiropractic has a very strong philosophical basis, which no doubt has contributed to its having been labeled ‘unscientific’ by the more mechanistically-oriented scientific community.”
“It appears that education will prove to be the best strategy in the ‘war on drugs,’ including education about the dangers of drugs available on the street and also those available from the physician as prescriptions.”
Mixers, comprising the largest segment of chiropractors, may at first seem more rational. They accept that some disease is caused by infection or other causes and they do not limit their practice to fixing subluxations. Most chiropractors in this group, however, do not supplement subluxation theory with scientific medicine, but rather with an eclectic array of pseudoscientific alternative practices. Mixers commonly prescribe homeopathic and herbal remedies, practice acupuncture and therapeutic touch, diagnose with iridology, contour analysis, and applied kinesiology, and adhere to the philosophy of naturopathy. This broad use of unproven, unscientific, and fanciful so-called “alternative” practices clearly indicates an antiscience attitude, as well as a lack of scientific knowledge, on the part of those chiropractors who employ them.
The rhetoric of Mixers indicates that they are attempting to become accepted into the scientific mainstream, rather than replace scientifically based medicine with a philosophy based approach. They no longer openly oppose immunization, like straights do, but they do advocate the freedom to choose whether or not to be immunized. Their appeal to freedom is emotionally effective, especially in the United States, but it fails to recognize that immunization is far less effective in eliminating or containing infectious diseases when it is not given to everyone. They also advocate a role for chiropractors as a primary care portal of entry system within HealthCare, despite the fact that they lack adequate training as generalists skilled in medical diagnosis.
A small minority of chiropractors, numbering only about 1,000, or 2% of all chiropractors (these are rough estimates because accurate figures are lacking), have been openly critical of their own field. They have called for absolute rejection of the subluxation theory of illness, disposing of pseudoscientific and unethical practices by chiropractors, and the restriction of chiropractic to treating acute musculoskeletal symptoms. They are attempting to bring their field into the scientific mainstream.
Occasionally chiropractic reformers have attempted to forge a new profession, entirely shedding the pseudoscience attached to the chiropractic brand. About ten years ago one group in Canada renamed themselves “Orthopractors,” and considered the new discipline of orthopractic as distinct from chiropractic. Orthopractic is the use of manipulation to provide symptomatic relief from uncomplicated acute back strain. They do not believe in maintenance therapy, treating medical ailments, or the use of pseudoscientific alternative practices.
Unfortunately, this reform effort died because “orthopractic” did not exist as a legal entity. This also partly explains why the “chiropractic” label persists and covers such a wide range of philosophy and practice – because it exists as a recognized licensed profession. It has a regulatory inertia that is hard to combat.
To further complicate things, spinal manipulation exists outside of the chiropractic profession, and not all manipulation is chiropractic manipulation. Some physiatrists, sports medicine doctors, and osteopaths legitimately employ manipulative therapy to relieve muscle strain, mobilize joints, and improve function. Chiropractors do this as well. But some chiropractors also do chiropractic manipulation designed to realign the spine and reduce imaginary chiropractic subluxations.
The Evidence – Subluxations
In the past 100 years, there has been very little research conducted into the basic principles of straight chiropractic. There is no research that indicates the existence of innate intelligence or that such a force plays any role in health and disease. Further, the evidence strongly suggests that chiropractic subluxations are a figment of the chiropractic imagination. And it also seems that spinal manipulation is not capable of realigning the vertebra of the spine.
A study carried out by Edmund Crelin, Ph.D. investigated the amount of force necessary to displace vertebral bones of the spine in order to cause impingement of a spinal nerve. The study was carried out on six corpses within 8 hours after death. His conclusion was that the amount of force necessary to actually displace the vertebra was great enough to break the spine, arguing strongly that chiropractic manipulation cannot significantly affect spinal alignment, and that misaligned spines do not caused pinched nerves (Crelin, 1973).
Pinched or impinged spinal nerves do occur, but they are caused by herniated discs, fractures, tumors, or overgrowth of the vertebral bones. When spinal nerves are impinged they cause pain, numbness, and tingling and may cause a decrease or loss of deep tendon reflexes and weakness of the muscles supplied by the affected nerve. Impinged nerves are not caused by subluxations nor do they result in diseases of the organs. Believers in subluxation theory must claim, implausibly, that nerve impingement causes only a blockage of innate intelligence without causing any of the known signs and symptoms of such impingement.
Ironically, spinal manipulation is contraindicated in cases of actual nerve impingement and should not be performed. In medical studies of manipulation, such as the RAND study, often cited by chiropractors as evidence for manipulation, spinal nerve impingement was considered a reason not to have manipulation and therefore was a criteria for exclusion from the study.
Another source of evidence that the chiropractic theory of subluxations and innate intelligence is completely false comes from the unfortunate victims of spinal trauma. There are many victims of complete transection, or disruption, of the cervical spinal cord in the neck. Such a complete injury leaves its victim quadraplegic, unable to move the arms or legs. If the injury is high enough in the spinal cord the victim may not even be able to breath on their own. In such victims no impulses from the brain are able to travel below the spinal cord in the neck, and therefore most of the communication between the brain and the body is interrupted. Certainly, this is a much more dramatic and complete interference of nerve flow than that of an impinged spinal nerve.
Yet, in these patients, the organs continue to work without difficulty and diseases do not develop at any higher rate than those without such an injury. Of course, there are some effects from the disruption of the autonomic nervous system, that part of the nervous system which regulates the bladder, the degree of bowel motility, and other functions. But all effects of spinal cord damage are caused by known neurological injury. If subluxation theory were correct, then patients with high spinal cord injuries would be ravaged by every conceivable disease.
So chiropractors cannot realign the spine to fix imaginary subluxations and restore the flow of nonexistent innate intelligence. Subluxation theory is pure pseudoscience, like homeopathy or therapeutic touch, and has no place in a 21st century scientific health care system.
Despite the extreme scientific implausibility of subluxation theory, specific applications have been tested with clinical research – with predictable results. For example, many chiropractors will use manipulation to treat asthma is children. The results of this research are soundly negative – chiropractic does not work on asthma.
Despite this many chiropractors persist in treating asthma. This led Simon Singh to write in the Guardian in 2008 that the British Chiropractic Association, which does advocate chiropractic for childhood asthma, “promotes bogus therapies.” In response to this statement the BCA notably did not provide the evidence that Singh claimed was missing. Rather, they sued him for libel (the case is ongoing).
Next week I will cover the evidence for musculoskeletal uses of chiropractic.
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