Move over, Bernie Madoff!
It's not just our financial system that‘s taken a hit from Ponzi schemes. Our health care system is in a similar mess.
"My present view of the health care system is that it is another form of a Ponzi scheme," nutritional scientist Jeffrey Bland, PhD, told me at the Summit on Integrative Medicine and the Health of the Public. The Summit was convened by the Institute of Medicine (IOM) in Washington, DC, February 25-27, and sponsored by the Bravewell Collaborative, a philanthropic group devoted to transforming health care.
Under managed care, doctors are forced to recruit as many patients as they can for a flat fee (known as capitation) that covers their care, "hopefully not to have to see them, which uses up time," Bland said. The result? "When people get sick they're in somebody else's health plan, since people tend to change health plans every two to three years," Bland added. "So it is a form of a Ponzi system that doesn't talk about patients. It talks about throughput. It talks about cost effectiveness." And people are treated like billable commodities rather than human beings in need of care.
"Throughput" (the flow of patients through the health care system) is the antithesis of "patient-centered" care, a concept considered one of the cornerstones of Integrative Medicine.
Like other fields, or movements, (as it was occasionally labeled) Integrative Medicine, is not immune from squabbles over terminology. Some advocates object to the term "patient," claiming that it pathologizes people. Others find "medicine" MD-centric. So "patient-centered medicine" becomes "person-centered care."
Then there's relationship-centered care, based on the premise that no patient-woops! person-is an island, which brings not only healthcare practitioners, but also loved ones and caregivers into the equation.
And nearly everyone seems to despise the term "medical consumers."
The concept of "patient-centered care" is neither new nor alternative, having been identified as one of the six dimensions of health care in need of improvement by IOM's Quality Chasm Report in 2001. (The other dimensions were safety, effectiveness, timeliness, efficiency, and equity.) [Institute of Medicine. Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academy Press, 2001)]
One of the Chasm Report's architects, Donald Berwick, MD, a clinical professor of pediatrics and health care policy at the Harvard Medical School, challenged Summit attendees with three questions:
"Regarding your health and health care," he asked, "What do you want?"
We discussed our answers with a partner. Then Berwick asked, "Regarding your health and health care," he asked, "What do you really want?" which was followed by "What do you really, really want?"
Before sharing his own answers, Berwick movingly shared his own experience with health care. While in medical school many years ago, Berwick dislocated his knee twice, undergoing surgery with a procedure that is now totally discredited. The operation left him prone to severe osteoarthritis, which has caused him a great deal of pain over the years. But despite his pain, Berwick has developed a passion for skate-skiing, a form of cross-country skiing.
"What I want," Berwick said, "is safe, effective, evidence-based care for my knee. What I really want is to skate-ski on my knee. What I really, really want: Five minutes in a sun-filled blue-sky 20-degree February afternoon in complete silence, leaning on my ski poles in [a] little stand of birches [in New Hampshire] watching one busy red squirrel [going up and down the trees]."
But, he lamented, not one of the physicians, nurses, or physical therapists who have cared for him over the past 20 years know of the "deep, meaningful connection" between him and his right knee. "To this crucial degree, my care is dis-integrated," he said. "My health care makes no connection whatsoever between my experience of care and my soul."
Bridging that connection is one of the goals of Integrative Medicine, and the Summit at the Institute of Medicine should be an important step in that direction.
