I recently gave a commencement talk at Northwestern Health Sciences University, the day before Episode One of the last season of Game of Thrones. I chose to inject the sacredness of that day by referencing that other world by presenting the landscape of health and medicine that the graduates were entering as a jockeying between three Houses. In power on the Iron Throne: the House of Volume/Industry. The other two Houses are each insurgencies: the House of Integrative Health and the House of Value-Based Medicine. Can this life-and-death game play out favorably with an alliance between the two insurgencies in a field of health creation?
Presently, I can’t think of the struggle in US medicine except as these 3 Houses. I am herewith visiting the gestalt on you. The full talk (25 minutes) is here on Northwestern’s YouTube channel (starting at minute 56). Here’s the Cliff’s Notes version.
The House of Volume
The medical insurance industry with it’s 80/20 rule makes more money over time when medical costs soar. Fee for service is good. Disease is good. Medical specialists and the hospital CEOs who earn high six-digits or more pander to and benefit from their medical specialists’ success. More stents, hip replacements, chemo treatments, and etc. prime specialists’ $341,000/year average salary. These medical delivery organizations boast of their ability to create jobs, consuming ever larger portions of the common good. Capping it all, are the known, corrupting self interests of the pharmaceutical companies and the expected capitalist impulses to sell more of medical device makers. All benefit financially when they produce more. Continuously managing ever-advancing disease is good. Creating health? Not so much.
One doesn’t see interest in conscious capitalism in the House of Volume. For good reason. If one is too conscious, one might continuously be haunted by the failures, destruction, and lack of prevention and respect for the whole person that would birth each of the other two Houses into being. With the cost of medicine at $3.3-trillion per year and rising, the House of Volume/Industry, is firmly ensconced on the Iron Throne – the power seat.
The House of Integrative Health
A grassroots popular movement for a more preventive, health-focused, whole person, less drug-reliant medicine birthed the House of Integrative Health. Separate tribes formed in the late 1970s, in reaction to the House of Volume’s failures and promoting a new healthcare ethos: holistic medicine doctors, mindfulness scientists, naturopathic doctors, holistic nurses, chiropractors, acupuncturists, nutritionists, patient-centered care advocates, wellness supports and more. Each developed in silos until the 1990s when, clumped as patient interest in complementary and alternative medicine, they began to find shared value sets that distinguished them from the House of Volume. Their authors’ reported stats that gave the lie to “the best medicine in the world” story line.
The House of Integrative Health’s relationship-based, health-focused, relatively low cost general practice services preferred the least invasive treatments. In the mid-1990s, allies inside academic medicine began heralding “integrative medicine” as a distinct force for change Within a few years, the not-for-profit foundations for the House of Integrative Health were laid: Integrative Health Policy Consortium, the Academic Consortium for Integrative Medicine and Health – with support from the Bravewell Collaborative – the Academic Collaborative for Integrative Health, and multiple collaborations with the Samueli Institute. At a 2009 summit at the National Academy of Medicine, the set of converging interests declared “integrative health” as the shared brand and vessel. New umbrella organizations, Integrative Medicine for the Underserved and Academy of Integrative Health and Medicine, further potentiated the House of Integrative Health. While the House of Volume’s penchant for production of high-cost services perversely incentivized them against alliance, the development of the House of Value-Based Medicine, open doors. The House of Integrative Health has recently shown surprising influence, as noted below.
The House of Value Based Medicine
The House of Volume always had its dissidents who pushed for a more values-based medicine. These sought to promote primary care. They started the network of community health centers, connecting to determinants of health and a bio-psycho-social model. To shift financial incentives, they promoted health maintenance organizations (HMOs). They sought to create more interprofessional respect and break the dictatorial grip of medical specialists. They pointed out that much of what the industry was doing was based on agreements from medical doctor experts who earned their livings off their practices and thus has profound conflicts of interest – and began talking up the need for evidence.
The present foundation of the House of Value-Based Medicine was ultimately laid with To Err is Human, the 1999 National Academy of Medicine report that concluded that 100,000 are killed each year from the regular practice of medicine. Further exploration estimated that a third to one half of what is done is waste. (Fifteen years later, values-minded reformers put the death toll at 250,000/year, making the House of the Volume the nation’s third largest cause of death.) For Game of Thrones fans, I suggest in this column that we might consider these “the army of the dead” – white walkers spurring the House of Values Based Medicine toward transforming the House of Volume. As shaped by the Institute for Healthcare Improvement (IHI) and its co-founder Don Berwick, MD, their values centered on the Triple Aim: bettering patient experience, reducing per capita costs and improving population health. Tools are team care, interprofessionalism, and above all shifting financial incentive structures from volume to value through accountable care and other means.
Notably, a 2013 survey found that leaders of the House of Integrative Health believe the House of Value-Based Medicine is much more aligned framework than the House of Volume. Is there a basis for alliance?
The Emerging and Prospective Alliance for Health Creation
Working with patients toward health – creating health – may belong on the family shield of the House of Integrative Health. Of attendees at a early 2000 Integrative Medicine Industry Leadership Summit, 84% agreed that “complementary and alternative medicine is a tool of our deeper mission of transformation, which will only be successful if we help birth a thriving U.S. industry of health creation.” A dozen years later, at a major annual gathering of the House of Value-Based Medicine, one witnesses the teeing up of the same concept. IHI’s Berwick devoted his 2013 keynote, “The Nature of Transformation,” to describing a needed 30-year transformational process away from focusing solely on disease management toward “health creation.” In it, Berwick credited integrative health leaders as his mentors. In his talk, he first educates his audience on the literature on mindfulness and its relationship to health and well-being, from Richard Davidson, PhD, Herbert Benson, MD, and Jon Kabat-Zinn, PhD. Then Berwick credits his learning from the former director of the NIH Office of Alternative Medicine and later of the Samueli Institute, Wayne Jonas, MD:
Dr. Jonas proposes that health and health creation – salutogensis – should become the defining concept for a new healthcare system. He offers ideas for defining it. He calls it the optimal healing environment.
The mind-meld at the top of the Houses of Value Based Medicine and that of Integrative Health is evident here. The respect and mentoring runs both ways. House of Integrative Health leaders Tracy Gaudet, MD and Ben Kligler, MD, MPH are presently guiding the Veterans Administration toward a Whole Health for Life model. In a recent column describing their approach, Gaudet and Kligler return the compliment to Berwick, the moral suasion chief at the House of Value Based Medicine:
We take some of the inspiration for our model from Donald Berwick, the Institute for Healthcare Improvement cofounder and former administrator for the Center for Medicare and Medicaid Services. Berwick and colleagues called on leaders of the nation’s hospitals and medical delivery organizations to engage “new rules for radical redesign of health care.” This followed his call for a 30-year refocus on “health creation” or “salutogenesis.”
The present work to re-create the nation’s model for chronic pain treatment amidst the crisis from over-reliance on pharmaceuticals is the meeting ground for these two Houses. In Berwick’s call for a transformation toward health creation he postulates that “the redesign we need may be even more radical than we have imagined.” The cultural and financial obstacles are significant:
Together, these wed a popular movement with an internal reform effort to shift the perilous course of the House of Volume/Industry. In concert with consumers-as-voters, the two insurgent Houses might pass laws and provide incentives to dethrone those feeding off the spoils of the House of Volume’s perverse incentives.