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InternalMed_Harrison. tobacco control measures in most countries just as clearly illustrates the difficulties encountered in such intersectoral work and the unrealized potential of public policies to improve health. At the local level, primary care services can help enact health-promoting public policies in other sectors.


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InternalMed_Harrison. Leadership Reforms to Make Health Authorities More Responsive The Declaration of Alma Ata emphasized the importance of participation by people in their own health care. In fact, participation is important at all levels of decision-making. Contemporary health challenges require new models of leadership that acknowledge the role of government in reducing disparities in health but that also recognize the many types of organizations that provide health care services. Governments need to guide and negotiate among these different groups, including nongovernmental organizations (NGOs) and the private sector, and to provide strong regulation where necessary. This difficult task requires a massive reinvestment in leadership and governance capacity, especially if action by different sectors is to be effectively implemented. Moreover, disadvantaged groups and other actors are increasingly expecting that their voices and health needs will be included in the 6 decision-making process. The complex


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InternalMed_Harrison. effectively implemented. Moreover, disadvantaged groups and other actors are increasingly expecting that their voices and health needs will be included in the 6 decision-making process. The complex landscape for leadership at the national level is mirrored in many ways at the international or global level. The transnational character of health and the increasing interdependence of countries with respect to outbreak diseases, climate change, security, migration, and agriculture place a premium on more effective global health governance.


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InternalMed_Harrison. Aspects of the primary health care approach described above, with an emphasis on primary care services, have been implemented to varying degrees in many lowand middle-income countries over the past half-century. As discussed above, some of these experiences inspired and informed the Declaration of Alma Ata, which itself led many more countries to attempt to implement primary health care. This section describes the experiences of a selection of lowand middle-income countries in improving primary care services that have enhanced the health of their populations.


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InternalMed_Harrison. Before Alma Ata, few countries had attempted to develop primary health care on a national level. Rather, most focused on expanding primary care services to specific communities (often rural villages), making use of community volunteers to compensate for the absence of facility-based care. In contrast, in the post–World War II period, China invested in primary care on a national scale, and life expectancy doubled within roughly 20 years. The Chinese expansion of primary care services included a massive investment in infrastructure for public health (e.g., water and sanitation systems) linked to innovative use of community health workers. These “barefoot doctors” lived in and expanded care to rural villages. They received a basic level of training that enabled them to provide immunizations, maternal care, and basic medical interventions, including the use of antibiotics. Through the work of the barefoot doctors, China brought low-cost universal basic health care coverage to its entire


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InternalMed_Harrison. maternal care, and basic medical interventions, including the use of antibiotics. Through the work of the barefoot doctors, China brought low-cost universal basic health care coverage to its entire population, most of which had previously had no access to these services.


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InternalMed_Harrison. In 1982, the Rockefeller Foundation convened a conference to review the experiences of China along with those of Costa Rica, Sri Lanka, and the state of Kerala in India. In all of these locations, good health care at low cost appeared to have been achieved. Despite lower levels of economic development and health spending, all of these jurisdictions, along with Cuba, had health indicators approaching—or in some cases exceeding—those of developed countries. Analysis of these experiences revealed a common emphasis on primary care services, with expansion of care to the entire population free of charge or at low cost, combined with community participation in decision-making about health services and coordinated work in different sectors (especially education) toward health goals. During the three decades since the Rockefeller meeting, some of these countries have built on this progress, while others have experienced setbacks. Recent experiences in developing primary care services show


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InternalMed_Harrison. three decades since the Rockefeller meeting, some of these countries have built on this progress, while others have experienced setbacks. Recent experiences in developing primary care services show that the same combination of features is necessary for success. For example, Brazil—a large country with a dispersed population—has made major strides in increasing the availability of health care in the past quarter century. In this millennium, the Brazilian Family Health Program has expanded progressively across the country, with almost all areas now covered. This program provides communities with free access to primary care teams made up of primary care physicians, community health workers, nurses, dentists, obstetricians, and pediatricians. These teams are responsible for the provision of primary care to all people in a specified geographic area—not only those who access health clinics. Moreover, individual community health workers are responsible for a named list of people within the


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InternalMed_Harrison. primary care to all people in a specified geographic area—not only those who access health clinics. Moreover, individual community health workers are responsible for a named list of people within the area covered by the primary care team. Problems with access to health care persist in Brazil, especially in isolated areas and urban slums. However, solid evidence indicates that the Family 3.96 –2.08 –4.24 –6.82 –6.97 –6.77 –8.38 –5.64 High HDI Low HDI


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InternalMed_Harrison. FIGURE 13e-8 Improvements in childhood mortality following the Family Health Program in Brazil. HDI, Human Development Index; PSF, Program Sae da Família (Family Health Program). (Source: Ministry of Health, Brazil.) Health Program has already contributed to impressive gains in population health, particularly in terms of childhood mortality and health inequities. In fact, this program has already had an especially marked impact on childhood mortality reduction in less developed areas (Fig. 13e-8).


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InternalMed_Harrison. Chile has also built on its existing primary care services in the past decade, aiming to improve the quality of care and the extent of coverage in remote areas, above all for disadvantaged populations. This effort has been made in concert with measures aimed at reducing social inequalities and fostering development, including social welfare benefits for families and disadvantaged groups and increased access to early-childhood educational facilities. As in Brazil, these steps have improved maternal and child health and have reduced health inequities. In addition to directly enhancing primary care services, Brazil and Chile have instituted measures to increase both the accountability of health providers and the participation of communities in decision-making. In Brazil, national and regional health assemblies with high levels of public participation are integral parts of the health policy– making process. Chile has instituted a patient’s charter that explicitly specifies the rights of


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InternalMed_Harrison. health assemblies with high levels of public participation are integral parts of the health policy– making process. Chile has instituted a patient’s charter that explicitly specifies the rights of patients in terms of the range of services to which they are entitled.


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InternalMed_Harrison. Other countries that have made recent progress with primary health care include Bangladesh, one of the poorest countries in the world. Since achieving its independence from Pakistan in 1971, Bangladesh has seen a dramatic increase in life expectancy, and childhood mortality rates are now lower than those in neighboring nations such as India and Pakistan. The expansion of access to primary health care services has played a major role in these achievements. This progress has been spearheaded by a vibrant NGO community that has focused its attention on improving the lives and livelihoods of poor women and their families through innovative and integrated microcredit, education, and primary care programs.


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InternalMed_Harrison. The above examples, along with others from the past 30 years in countries such as Thailand, Malaysia, Portugal, and Oman, illustrate how the implementation of a primary health care approach, with a greater emphasis on primary care, has led to better access to health care services—a trend that has not been seen in many other lowand middle-income countries. This trend, in turn, has contributed to improvements in population health and reductions in health inequities. However, as these nations have progressed, other countries have shown how previous gains in primary care can easily be eroded. In sub-Saharan Africa, undermining of primary care services has contributed to catastrophic reversals in health outcomes catalyzed by the HIV/AIDS epidemic. Countries such as Botswana and Zimbabwe implemented primary health care strategies in the 1980s, increasing access to care and making impressive gains in child health. Both countries have since been severely affected by HIV/AIDS, with pronounced


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InternalMed_Harrison. Percentage of total health expenditure FIGURE 13e-9 Changes in source of health expenditure in China over the past 40 years. (Source: World Health Organization: Primary Health Care: Now More Than Ever. World Health Report 2008.) decreases in life expectancy. However, Zimbabwe has also seen political turmoil, a decline of health and other social services, and the flight of health personnel, whereas Botswana has maintained primary care services to a greater extent and has managed to organize widespread access to antiretroviral therapy for people living with HIV/AIDS. Zimbabwe’s health situation has therefore become more desperate than that in Botswana.


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InternalMed_Harrison. China provides a particularly striking example of how changes in health policy relevant to the organization of health systems (Fig. 13e-9) can have rapid, far-reaching consequences for population health. Even as the 1982 Rockefeller conference was celebrating China’s achievements in primary care, its health system was unraveling. The decision to open up the economy in the early 1980s led to rapid privatization of the health sector and the breakdown of universal health coverage. As a result, by the end of the 1980s, most people, especially the poorer segments of the population, were paying directly out of pocket for health care, and almost no Chinese had insurance—a dramatic transformation. The “barefoot doctor” schemes collapsed, and the population either turned to care paid for at hospitals or simply became unable to access care. This undermining of access to primary care services in the Chinese system and the resulting increase in impoverishment due to illness contributed to the


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InternalMed_Harrison. or simply became unable to access care. This undermining of access to primary care services in the Chinese system and the resulting increase in impoverishment due to illness contributed to the stagnation of progress in health in China at the same time that incomes in that country increased at an unprecedented rate. Reversals in primary care have meant that China now increasingly faces health care issues similar to those faced by India. In both countries, rapid economic growth has been linked to lifestyle changes and noncommunicable disease epidemics. The health care systems of the two nations share two negative features that are common when primary care is weak: a disproportionate focus on specialty services provided in hospitals and unregulated commercialization of health services. China and India have both seen expansion of private hospital services that cater to middle-class and urban populations who can afford care; at the same time, hundreds of millions of people in rural areas


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InternalMed_Harrison. and India have both seen expansion of private hospital services that cater to middle-class and urban populations who can afford care; at the same time, hundreds of millions of people in rural areas now struggle to access the most basic services. Even in the former groups, a lack of primary care services has been associated with late presentation with illness and with insufficient investment in primary prevention approaches. This neglect of prevention poses a risk of large-scale epidemics of cardiovascular disease, which could endanger continued economic growth. In addition, the health systems of both countries now depend for the majority of their funding on out-of-pocket payments by people when they use services. Thus substantial proportions of the population must sacrifice other essential goods as a result of health expenditure and may even be driven into poverty by this cost. The commercial nature of health services with inadequate or no regulation has also led to the proliferation


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InternalMed_Harrison. goods as a result of health expenditure and may even be driven into poverty by this cost. The commercial nature of health services with inadequate or no regulation has also led to the proliferation of charlatan providers, inappropriate care, and pressure for people to pay for expensive and sometimes unnecessary care. Commercial providers have limited incentives to use interventions (including public health measures) that cannot be charged for or that are what the person who is paying can afford.


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InternalMed_Harrison. Faced with these problems, China and India have implemented measures to strengthen primary health care. China has increased government funding of health care, has taken steps toward restoring health insurance, and has enacted a target of universal access to primary care services. India has similarly mobilized funding to greatly expand primary care services in rural areas and is now duplicating this process in urban settings. Both countries are increasingly using public resources from their growing economies to fund primary care services.


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InternalMed_Harrison. These encouraging trends are illustrative of new opportunities to implement a primary health care approach and strengthen primary care services in lowand middle-income countries. Brazil, India, China, and Chile are being joined by many other lowand middle-income countries, including Indonesia, Mexico, the Philippines, Turkey, Rwanda, Ethiopia, South Africa, and Ghana, in ambitious initiatives mobilizing new resources to move toward universal coverage of health services at affordable cost.


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InternalMed_Harrison. Global public health targets will not be met unless health systems are significantly strengthened. More money is currently being spent on health than ever before. In 2005, global health spending totaled $5.1 trillion (U.S.)—double the amount spent a decade earlier. Although most expenditure occurs in high-income countries, spending in many emerging middle-income countries has rapidly accelerated, as has the allocation of monies for this purpose by both governments in and donors to low-income countries. These twin trends—greater emphasis on building health systems based on primary care and allotment of more money for health care—provide opportunities to address many of the challenges discussed above in lowand middle-income countries.


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InternalMed_Harrison. Accelerating progress requires a better understanding of how global health initiatives can more effectively facilitate the development of primary care in low-income countries. A review by the WHO Maximizing Positive Synergies Collaborative Group looked at programs funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Global Alliance for Vaccines and Immunisation (GAVI); the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR); and the World Bank (on HIV/AIDS). This group found that global health initiatives had improved access to and quality of the targeted health services and had led to better information systems and more adequate financing. The review also identified the need for better alignment of global health initiatives with other national health priorities and systematic exploitation of potential synergies. If global health initiatives implement programs that work in tandem with other components of national health systems without undermining staffing and


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InternalMed_Harrison. systematic exploitation of potential synergies. If global health initiatives implement programs that work in tandem with other components of national health systems without undermining staffing and procurement of supplies, they have the potential to contribute substantially to the capacity of health systems to provide comprehensive primary care services.


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InternalMed_Harrison. Even in the aftermath of the global financial crisis, global health initiatives continue to draw significant funding. In 2009, for example, U.S. President Barack Obama announced increasing development assistance from the United States for global health, earmarking $63 billion over the period 2009–2014 for a Global Health Initiative. New funding is also promised through a range of other initiatives focusing particularly on maternal and child health in low-income countries. The general trend is to coordinate this funding in order to reduce fragmentation of national health systems and to concentrate more on strengthening these systems. Comprehensive primary care in low-income countries must inevitably deal with the rapid emergence of chronic diseases and the growing prominence of injury-related health problems; thus, international health development assistance must become more responsive to these needs.


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InternalMed_Harrison. Beyond the new streams of funding for health services, other opportunities exist. Increased social participation in health systems can help build primary care services. In many countries, political pressure from community advocates for more holistic and accountable care as well as entrepreneurial initiatives to scale up community-based services through NGOs have accelerated progress in primary care without major increases in funding. Participation of the population in the provision of health care services and in relevant decision-making often drives services to cater to people’s needs as a whole rather than to narrow public health priorities.


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InternalMed_Harrison. Participation and innovation can help address critical issues related to the health workforce in lowand middle-income countries by establishing effective people-centered primary care services. Many primary care services do not need to be delivered by a physician or a nurse. Multidisciplinary teams can include paid community workers who have access to a physician if necessary but who can provide a range of health services on their own. In Ethiopia, more than 30,000 community health workers have been trained and deployed to improve access to primary care services, and there is increasing evidence that this measure is contributing to better health outcomes. In India, more than 600,000 community health advocates have been recruited as part of expanded rural primary care services. In Niger, the deployment of community health workers to deliver essential child health interventions (as a component of integrated community case management) has had impressive results in reducing childhood


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InternalMed_Harrison. the deployment of community health workers to deliver essential child health interventions (as a component of integrated community case management) has had impressive results in reducing childhood mortality and decreasing disparities. After the Declaration of Alma Ata, experiences with community health workers were mixed, with particular problems about levels of training and lack of payment. Current endeavors are not immune from these concerns. However, with access to physician support and the deployment of teams, some of these concerns may be addressed. Growing evidence from many countries indicates that shifting appropriate tasks to primary care workers who have had shorter, less expensive training than physicians will be essential to address the human resources crisis.


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InternalMed_Harrison. Finally, recent improvements in information and communication technologies, particularly mobile phone and Internet systems, have created the potential for systematic implementation of e-health, telemedicine, and improved health data initiatives in lowand middle-income countries. These developments raise the tantalizing possibility that health systems in these countries, which have long lagged behind those in high-income countries but are less encumbered by legacy systems that have proved hard to modernize in many settings, could leapfrog their wealthier counterparts in exploiting these technologies. Although the challenges posed by poor or absent infrastructure and investment in many lowand middle-income countries cannot be underestimated and will need to be addressed to make this possibility a reality, the rapid rollout of mobile networks and their use for health and other social services in many low-income countries where access to fixed telephone lines was previously very limited


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InternalMed_Harrison. a reality, the rapid rollout of mobile networks and their use for health and other social services in many low-income countries where access to fixed telephone lines was previously very limited offer great promise in building primary care services in lowand middle-income countries.


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InternalMed_Harrison. As concern continues to mount about glaring inequities in global health, there is a growing commitment to redress these egregious shortfalls, as exemplified by global mobilization around the United Nations’ Millennium Development Goals and the early discussions on what targets should build on these goals in the post-2015 era. This commitment begins first and foremost with a clear vision of the fundamental importance of health in all countries, regardless of income. The values of health and health equity are shared across all borders, and primary health care provides a framework for their effective translation across all contexts.


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InternalMed_Harrison. The translation of these fundamental values has its roots in four types of reforms that reflect the distinct but interlinked challenges of (re)orienting a society’s resources on the basis of its citizens’ health needs: (1) organizing health care services around the needs of people and communities; (2) harnessing services and sectors beyond health care to promote and protect health more effectively; (3) establishing sustainable and equitable financing mechanisms for universal coverage; and (4) investing in effective leadership of the whole of society. This common primary health care agenda highlights the striking similarity, despite enormous differences in context, in the nature and direction of the reforms that national health systems must undertake to promote greater equity in health. This shared agenda is complemented by the growing reality of global health interconnectedness due, for example, to shared microbial threats, bridging of ethnolinguistic diversity, flows in migrant


InternalMed_Harrison

InternalMed_Harrison. This shared agenda is complemented by the growing reality of global health interconnectedness due, for example, to shared microbial threats, bridging of ethnolinguistic diversity, flows in migrant health workers, and mobilization of global funds to support the neediest populations. Embracing solidarity in global health while strengthening health systems through a primary health care approach is fundamental to sustained progress in global health.


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InternalMed_Harrison. Complementary, alternative, and Integrative health practices Josephine P. Briggs The search for health includes many beliefs and practices that are outside conventional medicine. Physicians are important sources for 14e Acupuncture and acupressure A family of procedures involving stimulation of defined anatomic points, a component of the major Asian medical traditions; most common application involves the insertion and manipulation of thin metallic needles Alexander technique A movement therapy that uses guidance and education to improve posture, movement, and efficient use of muscles for improvement of overall body functioning Guided imagery The use of relaxation techniques followed by the visualization of images, usually calm and peaceful in nature, to invoke specific images to alter neurologic function or physiologic states Hypnosis The induction of an altered state of consciousness characterized by increased responsiveness to suggestion


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InternalMed_Harrison. Hypnosis The induction of an altered state of consciousness characterized by increased responsiveness to suggestion Massage Manual therapies that manipulate muscle and connective tissues to promote muscle relaxation, healing, and sense of well-being Meditation A group of practices, largely based in Eastern spiritual traditions, intended to focus or control attention and obtain greater awareness of the present moment, or mindfulness Reflexology Manual stimulation of points on hands or feet that are believed to affect organ function Rolfing/structural integration A manual therapy that attempts to realign the body by deep tissue manipulation of fascia Spinal manipulation A range of manual techniques, employed by chiropractors and osteopaths, for adjustments of the spine to affect neuromuscular function and other health outcomes Tai chi A mind-body practice originating in China that involves slow, gentle movements and sometimes is described as “moving meditation”


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InternalMed_Harrison. Tai chi A mind-body practice originating in China that involves slow, gentle movements and sometimes is described as “moving meditation” Therapeutic touch Secular version of the laying on of hands, described as “healing meditation” Yoga An exercise practice, originally East Indian, that combines breathing exercises, physical postures, and meditation Ayurvedic medicine The major East Indian traditional medicine system; treatment includes meditation, diet, exercise, herbs, and elimination regimens (using emetics and diarrheals) Curanderismo A spiritual healing tradition common in Latin American communities that uses ritual cleansing, herbs, and incantations Native American medicine Diverse traditional systems that incorporate chanting, shaman healing ceremonies, herbs, laying on of hands, and smudging (ritual cleansing with smoke from sacred plants) Tibetan medicine A medical system that uses diagnosis by pulse and urine examination; therapies include herbs, diet, and massage


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InternalMed_Harrison. Tibetan medicine A medical system that uses diagnosis by pulse and urine examination; therapies include herbs, diet, and massage Traditional Chinese medicine A medical system that uses acupuncture, herbal mixtures, massage, exercise, and diet Unani medicine An East Indian medical system, derived from Persian medicine, practiced primarily in the Muslim community; also called “hikmat” Anthroposophic medicine A spiritually based system of medicine that incorporates herbs, homeopathy, diet, and a movement therapy called eurythmy Chiropractic Chiropractic care involves the adjustment of the spine and joints to alleviate pain and improve general health; primarily used to treat back problems, musculoskeletal complaints, and headaches Homeopathy A medical system with origins in Germany that is based on a core belief in the theory of “like cures like”—compounds that produce certain syndromes, if administered in very diluted solutions, will be curative


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InternalMed_Harrison. Naturopathy A clinical discipline that emphasizes a holistic approach to the patient, herbal medications, diet, and exercise; practitioners have degrees as doctors of naturopathy Osteopathy A clinical discipline, now incorporated into mainstream medicine, that historically emphasized spinal manipulative techniques to relieve pain, restore function, and promote overall health information and guidance about health matters, but our patients also rely on a wide range of other sources including family and friends, cultural traditions, alternative practitioners, and increasingly the Internet, popular media, and advertising. It is essential for physicians to understand what patients are doing to seek health, as this understanding is important to harness potential benefits and to help patients avoid harm.


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InternalMed_Harrison. The phrase complementary and alternative medicine is used to describe a group of diverse medical and health care systems, practices, and products that have historic origins outside mainstream medicine. Most of these practices are used together with conventional therapies and therefore have been called complementary to distinguish them from 14e-1 alternative practices, those used as a substitute for standard care. Use of dietary supplements; mind-body practices such as acupuncture, massage, meditation, and hypnosis; and care from a traditional healer all fall under this umbrella. Brief definitions for some of the common complementary and alternative health practices are provided in Table 14e-1. Although some complementary health practices are implemented by a complementary health care provider such as a chiropractor, acupuncturist, or naturopathic practitioner, or by a physician, many of these practices are undertaken as “self-care.” Most are paid for out of pocket.


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InternalMed_Harrison. In the last decade or so, the terms integrative care and integrative medicine have entered the dialogue. A 2007 national survey conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics found that 42% of hospices had integrated complementary health practices into the care they provide. Integration of select complementary approaches is also common in Veterans Administration and Department of Defense facilities, particularly as part of management of pain and post-traumatic stress disorder. The term integrative medicine is usually used to refer to a style of practice that places strong emphasis on a holistic approach to patient care while focusing on reduced use of technology. Physicians advocating


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InternalMed_Harrison. Chapter 14e Complementary, Alternative, and Integrative Health Practices this approach generally include selected complementary health practices in the care they offer patients, and many have established practice settings that include complementary health practitioners. Although this approach appears to be attractive to many patients, the heavy use of dietary supplements and the weaknesses in the evidence base for a number of the interventions offered in integrative practices continue to attract substantial concern and controversy.


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InternalMed_Harrison. Until a decade ago or so, “complementary and alternative medicine” could be defined as practices that are neither taught in medical schools nor reimbursed, but this definition is no longer workable, since medical students increasingly seek and receive some instruction about complementary health practices, and some practices are reimbursed by third-party payers. Another definition, practices that lack an evidence base, is also not useful, since there is a growing body of research on some of these modalities, and some aspects of standard care do not have a strong evidence base.


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InternalMed_Harrison. By its nature, the demarcation between mainstream medicine and complementary health practices is porous, varying from culture to culture and over time. Traditional Chinese medicine and the Indian practice of Ayurvedic medicine were once the dominant health teachings in those cultures. Certain health practices that arose as challenges to the mainstream have been integrated gradually into conventional care. Examples include the teachings of Fernand Lamaze that led to the widespread use of relaxation techniques during childbirth, the promotion of lactation counseling by the La Leche League, and the teaching of Cicely Saunders and Elizabeth Kler-Ross that established the hospice movement.


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InternalMed_Harrison. The late nineteenth century saw the development of a number of healing philosophies by care providers who were critical of the medicine of the time. Of these, naturopathy and homeopathy, which arose in Germany, and chiropractic and osteopathy, which developed in the United States, have continued to endure. Osteopathic medicine is currently thoroughly integrated into conventional medicine, although the American Medical Association (AMA) labeled it a cult as late as 1960. The other three traditions have remained resolutely separate from mainstream medicine, although chiropractic care is available in some conventional care settings.


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InternalMed_Harrison. The first large survey of use of these practices was performed by David Eisenberg and associates in 1993. It surprised the medical community by showing that more than 30% of Americans use complementary or alternative health approaches. Many studies since that time have extended those conclusions. Subsequently, the National Health Interview Survey (NHIS), a large, national survey conducted by the National Center for Health Statistics, a component of the Centers for Disease Control and Prevention, has addressed the use of complementary health practices and largely confirmed those results. The NHIS is a household survey of many kinds of health practices in the civilian population; it uses methods that create a nationally representative sample and has a sample size large enough to permit valid estimates about some subgroups. In 2002, 2007, and 2012, the survey included a set of questions that addressed complementary and alternative health approaches. Information was obtained from 31,000


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InternalMed_Harrison. estimates about some subgroups. In 2002, 2007, and 2012, the survey included a set of questions that addressed complementary and alternative health approaches. Information was obtained from 31,000 adults in 2002 and 23,300 adults and 9400 children in 2007. Only preliminary data are available from the 2012 survey. In all three surveys, approximately 40% of adults report using some form of complementary therapy or health practice. In the 2007 study, 38% of adults and 12% of children had used one or more modalities. These surveys yield the estimate that nonvitamin, nonmineral dietary supplements are used by approximately 18% of the population. The most prevalent mind-body practices are relaxation techniques and meditation, chiropractic, and therapeutic massage. Americans are willing to pay for these services; the estimated out-of-pocket expenditure for complementary health practices in 2007 was $34 billion, representing 1.5% of total health expenditures and 11% of out-of-pocket costs.


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InternalMed_Harrison. The appeal of unproven complementary health approaches continues to perplex many physicians. Many factors contribute to these choices. Some patients seek out complementary health practitioners because they offer optimism or greater personal attention. For others, alternative approaches reflect a “self-help” approach to health and wellness or satisfy a search for “natural” or less invasive alternatives, since dietary supplements and other natural products are believed, correctly or not, to be inherently healthier and safer than standard pharmaceuticals. In NHIS surveys, the most common health conditions cited by patients for use of complementary health practices involve management of symptoms often poorly controlled by conventional care, particularly back pain and other painful musculoskeletal complaints, anxiety, and insomnia.


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InternalMed_Harrison. PRACTITIONER-BASED DISCIPLINES Licensure and Accreditation At present, six fields of complementary health practice—osteopathic manipulation, chiropractic, acupuncture and traditional Chinese medicine, therapeutic massage, naturopathy, and homeopathy—are subject to some form of educational accreditation and state licensure. Accreditation of educational programs is the responsibility of professional organizations or commissions under federal oversight by the Department of Education. Licensure, in contrast, is strictly a state matter, generally determined by state legislatures. Legal recognition establishes public access to therapies even when there is no scientific consensus about their clinical value.


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InternalMed_Harrison. Osteopathic Manipulative Therapy Founded in 1892 by the physician Andrew Taylor Still, osteopathic medicine was originally based on the belief that manipulation of soft tissue and bone can correct a wide range of diseases of the musculoskeletal and other organ systems. Over the ensuing century, the osteopathic profession has welcomed increasing integration with conventional medicine. Today, the postgraduate training, practice, credentialing, and licensure of osteopathic physicians are virtually indistinguishable from those of allopathic physicians. Osteopathic medical schools, however, include training in manual therapies, particularly spinal manipulation. Approximately 70% of family practice osteopathic physicians perform manipulative therapies on some of their patients.


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InternalMed_Harrison. Chiropractic The practice of chiropractic care, founded by David Palmer in 1895, is the most widespread practitioner-based complementary health practice in the United States. Chiropractic practice emphasizes manual therapies for treatment of musculoskeletal complaints, although the scope of practice varies widely, and in some rural areas, chiropractors may serve a primary care role, due in part to the lack of other providers. According to the NHIS, approximately 8% of Americans receive chiropractic manipulation in a given year.


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InternalMed_Harrison. Since the mid-1970s, chiropractors have been licensed in all 50 states and reimbursed by Medicare. Chiropractic educational standards mandate 2 years of undergraduate training, 4 years of training at an accredited school of chiropractic, and in most states, successful completion of a standardized board examination. Postgraduate training is not required. The U.S. Department of Labor estimates that there are 52,000 licensed chiropractors (2010 figure). There is substantial geographic variation, with greater numbers of practitioners and greater use in the midwest, particularly in rural areas, and lower use in the southeast.


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InternalMed_Harrison. Historically, the relationship between the medical and chiropractic professions has been strained. Extending through the 1970s, the AMA set forth standards prohibiting physicians consulting or entering into professional relationships with chiropractors, but in 1987, after a decade of complex litigation, the U.S. District Court found the AMA in violation of antitrust laws. An uneasy truce has followed, with continued physician skepticism, but also evidence for robust patient demand and satisfaction.


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InternalMed_Harrison. The role of both osteopathic and chiropractic spinal manipulative therapies (SMTs) in back pain management has been the subject of a number of carefully performed trials and many systematic reviews. Conclusions are not consistent, but the most recent guidelines from the American College of Physicians and the American Pain Society conclude that SMT is associated with small to moderate benefit for low-back pain of less than 4 weeks in duration (evidence level B/C) and moderate benefit (evidence level B) for subacute or chronic lowback pain. The evidence of benefit for neck pain is not as extensive, and continued concern that cervical manipulation may occasionally precipitate vascular injury clouds a contentious debate.


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InternalMed_Harrison. Naturopathy Naturopathy is a discipline that emerged in central Europe in the nineteenth century as part of the Natural Cure movement and was introduced to the United States in the early twentieth century by Benjamin Lust. Fifteen states currently license naturopathic physicians, with considerable variation in the scope of practice. The naturopathic profession is actively seeking licensure in other states. There are estimated to be approximately 3000 licensed naturopathic physicians in the United States. There is also a robust naturopathy presence in Canada. Conventional and unconventional diagnostic tests and medications are prescribed, with an emphasis on relatively low doses of drugs, herbal medicines, healthy diet, and exercise. While there is some support for success of naturopathic practitioners in motivating healthy behaviors, concern exists about the heavy promotion of dietary supplements, most with little rigorous evidence.


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InternalMed_Harrison. Homeopathy Homeopathy was widespread in the United States in the late nineteenth and early twentieth centuries and continues to be a common alternative practice in many European countries, but estimates from the NHIS suggest that less than 1.5% of Americans visit a homeopathic practitioner in any given year. In the United States, licensure as a homeopathic physician is only possible in three states (Arizona, Connecticut, and Nevada) where it is restricted to licensed physicians. The number of practitioners is uncertain, however, because some states include homeopathy within the scope of practice of other fields, including chiropractic and naturopathy, and some practitioners may self-identify as homeopathic practitioners. As discussed below, the regulatory framework for homeopathic remedies differs from other dietary supplements. Homeopathic remedies are widely available and commonly recommended by naturopathic physicians, chiropractors, and other licensed and unlicensed practitioners.


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InternalMed_Harrison. Therapeutic Massage The field of therapeutic massage is growing rapidly, as use by the public is increasing. According to U.S. Department of Labor statistics, there are approximately 155,000 licensed massage therapists employed in the United States, and by 2020, this number is projected to grow by 20%. Forty-three states and the District of Columbia currently have laws regulating massage therapy; however, there is little consistency, and in some states, regulation is by town ordinance. States that do provide licensure for massage therapists typically require a minimum of 500 hours of training at an accredited institution, as well as meeting specific continuing education requirements and carrying malpractice insurance. Massage training programs generally are approved by a state board, but some may also be accredited by an independent agency, such as the Commission on Massage Therapy Accreditation (COMTA). The development of regulatory standards for therapeutic massage has not yet


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InternalMed_Harrison. but some may also be accredited by an independent agency, such as the Commission on Massage Therapy Accreditation (COMTA). The development of regulatory standards for therapeutic massage has not yet caught up with the evolution of the field or the high demand. Many techniques used are also employed by physical therapists.


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InternalMed_Harrison. Acupuncture and Traditional Chinese Medicine A venerable component of traditional Chinese medicine, with a history of use that extends at least 2000 years, acupuncture became better known in the United States in 1971, when New York Times reporter James Reston wrote about how doctors in China used needles to ease his pain after surgery. More than 3 million adults in the United States use acupuncture, according to NHIS data. In a number of European countries, acupuncture is performed primarily by physicians. In the United States, the training and licensure processes for physicians and nonphysicians differ. Currently, acupuncture is licensed in 42 states and the District of Columbia, with licensure standards varying within the scope of practice of each state. Licensure for nonphysicians generally requires 3 years of accredited training and the successful completion of a standardized examination. The main accrediting organization is the Accreditation Commission for Acupuncture and


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InternalMed_Harrison. generally requires 3 years of accredited training and the successful completion of a standardized examination. The main accrediting organization is the Accreditation Commission for Acupuncture and Oriental Medicine. Acupuncture is included in doctor of medicine (MD) and doctor of osteopathic medicine (DO) licensure in 31 states, with 11 states requiring additional training for physicians performing acupuncture.


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InternalMed_Harrison. Mind-body practices are a large and diverse group of techniques that are administered or taught to others by a trained practitioner or teacher. Examples include acupuncture, massage therapy, meditation, relaxation techniques, spinal manipulation, and yoga. These approaches are being used more frequently in mainstream health care facilities for both patients and health care providers. Mind-body practices such as meditation and yoga are not licensed in any state, and training in those practices is not subject to national accreditation.


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InternalMed_Harrison. Americans often turn to complementary approaches for help in managing health conditions associated with physical and psychological pain—especially back pain, headache, musculoskeletal complaints, and functional pain syndromes. Chronic pain management is often refractory to conventional medical approaches, and standard pharmacologic approaches have substantial drawbacks. Health care guidelines of the American Pain Society and other professional organizations recognize the value of certain complementary approaches as adjuncts to pharmacologic management.


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InternalMed_Harrison. The evidence base for the effectiveness of these modalities is still relatively incomplete, but a few rigorous examples where there is promise of usefulness and safety include acupuncture for osteoarthritis pain; tai chi for fibromyalgia pan; and massage, yoga, and spinal manipulation for chronic back pain. In addition, new research is shedding light on the effects of meditation and acupuncture on central mechanisms of pain processing and perception and regulation of emotion and attention. Although many unanswered questions remain about these effects, findings are pointing to scientifically plausible mechanisms by which these modalities might yield benefit.


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InternalMed_Harrison. DIETARY SUPPLEMENTS Regulation The Dietary Supplements Health and Education Act (DSHEA), passed in 1994, gives authority to the U.S. Food and Drug Administration (FDA) to regulate dietary supplements, but with expectations that differ in many respects from the regulation of drugs or food additives. Purveyors of dietary supplements cannot claim that they prevent or treat any disease. They can, however, claim that they maintain “normal structure and function” of body systems. For example, a product cannot claim to treat arthritis, but it can claim to maintain “normal joint health.” Homeopathic products predate FDA drug regulations and are sold with no requirement that they be proved effective. Although homeopathic products are widely believed to be safe because they are highly dilute, one product, a nasal spray called Zicam, was withdrawn from the market when it was found to produce anosmia, probably because of a significant zinc content. Homeopathic products, and indeed other


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InternalMed_Harrison. one product, a nasal spray called Zicam, was withdrawn from the market when it was found to produce anosmia, probably because of a significant zinc content. Homeopathic products, and indeed other complementary health products and practices, also convey the very significant risk that individuals will use them instead of effective conventional modalities.


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InternalMed_Harrison. Regulation of advertising and marketing claims is the purview of the Federal Trade Commission (FTC). The FTC does take legal action against promoters or websites that advertise or sell dietary supplements with false or deceptive statements.


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InternalMed_Harrison. Inherent Toxicity Although the public may believe that “natural” equates with “safe,” it is abundantly clear that natural products can be toxic. Misidentification of medicinal mushrooms has led to liver failure. Contamination of tryptophan supplements caused the eosinophiliamyalgia syndrome. Herbal products containing particular species of Aristolochia were associated with genitourinary malignancies and interstitial nephritis. In 2013, dietary supplements containing 1,3-dimethylamylamine (DMAA), often touted as a “natural” stimulant, led to cardiovascular problems, including heart attacks. Among the most controversial dietary supplements is Ephedra sinica, or ma huang, a product used in traditional Chinese medicine for short-term treatment of asthma and bronchial congestion. The scientific basis for these indications was revealed when ephedra was shown to contain the ephedrine alkaloids, especially ephedrine and pseudoephedrine. With the promulgation of the DSHEA regulations,


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InternalMed_Harrison. basis for these indications was revealed when ephedra was shown to contain the ephedrine alkaloids, especially ephedrine and pseudoephedrine. With the promulgation of the DSHEA regulations, supplements containing ephedra and herbs rich in caffeine sold widely in the U.S. marketplace because of their claims to promote weight loss and enhance athletic


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InternalMed_Harrison. Chapter 14e Complementary, Alternative, and Integrative Health Practices performance. Reports of severe and fatal adverse events associated with use of ephedra-containing products led to an evidence-based review of the data surrounding them, and in 2004, the FDA banned their sale in the United States. Another major current concern with dietary supplements is adulteration with pharmacologic active compounds. Multi-ingredient products marketed for weight loss, body building, “sexual health,” and athletic performance are of particular concern. Recent FDA recalls have involved contamination with steroids, diuretics, stimulants, and phosphodiesterase type 5 inhibitors.


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InternalMed_Harrison. Herb-Drug Interactions A number of herbal products have potential impact on the metabolism of drugs. This effect was illustrated most compellingly with the demonstration in 2000 that consumption of St. John’s wort interferes with the bioavailability of the HIV protease inhibitor indinavir. Later studies showed its similar interference with metabolism of topoisomerase inhibitors such as irinotecan, with cyclosporine, and with many other drugs. The breadth of interference stems from the ability of hyperforin in St. John’s wort to upregulate expression of the pregnane X receptor, a promiscuous nuclear regulatory factor that promotes the expression of many hepatic oxidative, conjugative, and efflux enzymes involved in drug and food metabolism.


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InternalMed_Harrison. Because of the large number of compounds that alter drug metabolism and the large number of agents some patients are taking, identification of all potential interactions can be a daunting task. Several useful Web resources are available as information sources (Table 14e-2). Clearly, attention to this problem is particularly important with drugs with a narrow therapeutic index, such as anticoagulants, antiseizure medications, antibiotics, immunosuppressants, and cancer chemotherapeutic agents.


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InternalMed_Harrison. Physicians regularly face difficult challenges in providing patients with advice and education about complementary practices. Of particular concern to all physicians are practices of uncertain safety and practices that raise inappropriate hopes. Cancer therapies, antiaging regimens, weight-loss programs, sexual function, and athletic performance are frequently targeted for excessive claims and irresponsible marketing. A number of Internet resources provide critical tools for patient education (Table 14e-3). Because many complementary health products and practices are used as self-care and because many patients research these approaches extensively on the Internet, directing patients to responsible websites can often be very helpful. http://www.medscape.com/druginfo/druginterchecker?cid=med This website is maintained by WebMD and includes a free drug interaction checker tool that provides information on interactions between two or more drugs, herbals, and/or dietary supplements.


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InternalMed_Harrison. This website is maintained by WebMD and includes a free drug interaction checker tool that provides information on interactions between two or more drugs, herbals, and/or dietary supplements. http://naturaldatabase.therapeuticresearch.com This website provides an interactive natural product–drug interaction checker tool that identifies interactions between drugs and natural products, including herbals and dietary supplements. This service is available by subscription. A PDA version is available. http://www.naturalstandard.com/tools/ This website provides an interactive tool for checking drug and herb/supplement interactions. This service is available by subscription. A PDA version is available. Abbreviation: PDA, personal digital assistant. The Cochrane Collaboration Complementary Medicine Reviews


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InternalMed_Harrison. Abbreviation: PDA, personal digital assistant. The Cochrane Collaboration Complementary Medicine Reviews This website offers rigorous systematic reviews of mainstream and complementary health interventions using standardized methods. It includes more than 300 reviews of complementary health practices. Complete reviews require institutional or individual subscription, but summaries are available to the public. http://www.cochrane.org/cochrane-reviews MedlinePlus All Herbs and Supplements, A–Z List NLM FAQ: Dietary Supplements, Complementary or Alternative Medicines These National Library of Medicine (NLM) Web pages provide an A–Z database of science-based information on herbal and dietary supplements; basic facts about complementary health practices; and federal government sources on information about using natural products, dietary supplements, medicinal plants, and other complementary health modalities.


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InternalMed_Harrison. http://www.nlm.nih.gov/medlineplus/druginfo/herb_All.html http://www.cochrane.org/cochrane-reviews http://www.nlm.nih.gov/medlineplus/dietarysupplements.html National Institutes of Health National Center for Complementary and Alternative Medicine (NCCAM) This National Institutes of Health NCCAM website contains information for consumers and health care providers on many aspects of complementary health products and practices. Downloadable information sheets include short summaries of complementary health approaches, uses and risks of herbal therapies, and advice on wise use of dietary supplements. http://www.nccam.nih.gov Resources for Health Care Providers: http://www.nccam.nih.gov/health/providers NCCAM Clinical Digest e-Newsletter: http://www.nccam.nih.gov/health/ providers/digest Continuing medical education lectures: http://www.nccam.nih.gov/training/ videolectures


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InternalMed_Harrison. NCCAM Clinical Digest e-Newsletter: http://www.nccam.nih.gov/health/ providers/digest Continuing medical education lectures: http://www.nccam.nih.gov/training/ videolectures The scientific evidence regarding complementary therapies is fragmentary and incomplete. Nonetheless, in some areas, particularly pain management, it is increasingly possible to perform the kind of rigorous systematic reviews of complementary health approaches that are the cornerstone of evidence-based medicine. A particularly valuable resource in this respect is the Cochrane Collaboration, which has performed more than 300 systematic reviews of complementary health practices. Practitioners will find this a valuable source to answer patient questions. Practice guidelines, particularly for pain management, are also available from several professional organizations. Links to these resources are provided in Table 14e-3.


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InternalMed_Harrison. The use of complementary and alternative health practices reflects an active interest in improved health. An array of unproven modalities will always be used by our patients. While some of these choices need to be actively discouraged, many are in fact innocuous and can be accommodated. Some may be genuinely helpful, particularly in the management of troublesome symptoms. The dialogue with patients about complementary health practices is an opportunity to understand patients’ beliefs and expectations and use those insights to help guide health-seeking practices in a constructive way. The late Dr. Stephen Straus contributed this chapter in prior editions, and some material from his chapter has been retained here.


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InternalMed_Harrison. The late Dr. Stephen Straus contributed this chapter in prior editions, and some material from his chapter has been retained here. The Economics of Medical Care Joseph P. Newhouse The purpose of this chapter is to explain to physicians how economists think about physicians’ decision-making with regard to the treatment of patients. Economists’ mode of thinking has shaped health care policy and institutions and thus the environment in which physicians 15e practice, not only in the United States but in many other countries as well. It may prove useful for physicians to understand some aspects of the economists’ way of thinking, even if it sometimes seems foreign or uncongenial.


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InternalMed_Harrison. Physicians see themselves as professionals and as healers, assisting their patients with their health care needs. When economists are patients, they probably see physicians the same way, but when they view doctors through the lens of economics as a discipline, they see physicians—and their patients as well—as economic agents. In other words, economists are interested in the degree to which physicians and patients respond to various incentives in deciding how to deploy the resources over which they exercise choice. Examples of issues that would concern an economist include how much time physicians devote to seeing a patient; which tests they order; what drugs, if any, they prescribe; whether they recommend a procedure; whether they refer a patient; and whether they admit a patient to the hospital. In addition, patients consider the cost when they make a decision about whether to seek care.


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InternalMed_Harrison. To say that economists view physicians and patients as economic agents is not to say that economists consider financial incentives the predominant factor in the decisions that either physicians or patients make about treatment; it is to say only that these incentives have some influence on these decisions. In fact, the role played by financial incentives in medical decision-making may often be dwarfed by the roles played by scientific knowledge, by professional norms and ethics, and by the influence of peers. However, economic policy greatly influences financial incentives, and economists tend to focus on this domain. Their interest stems from fundamental economic questions: What goods and services are produced and consumed? In particular, how much medical care is available, and how much of other goods and services? How is medical care produced? For example, what mix of specific services is used in treating a particular episode of illness? Who receives particular treatments?


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InternalMed_Harrison. Physicians in all societies live and function in economic markets, although those markets differ greatly both from the simple competitive markets depicted in introductory economics textbooks and from country to country, depending on national institutions. Many of the differences between actual medical markets and textbook competitive markets cause what economists term market failure, a condition in which some individuals can be made better off without making anyone else worse off. This chapter explains two features of health care financing that cause market failure: selection and moral hazard. A common response to market failure in medical care is what economists refer to as administered prices, which this chapter also describes. Unfortunately, administered prices exact a cost, leading to what economists call regulatory or government failure. All societies seek a balance between market failure and regulatory failure, a topic addressed in this chapter’s conclusion.


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InternalMed_Harrison. In the idealized competitive market found in economic textbooks, buyers and sellers have the same knowledge about the goods or services they are buying and selling. When one party knows more—or when goods of different quality are being sold at the same price, which is analytically similar—markets can break down in the following sense: There may be a price at which an equally well informed buyer and seller could make a transaction that would make them both better off, but that transaction does not occur because one party knows more than the other. Hence, both the potential buyer and the potential seller are worse off.


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InternalMed_Harrison. The used car market is a classic example of differential information. 15e-1 Owners of used cars (potential sellers) know more about the quality of their cars than do potential buyers. At any specific market price for a certain make and model of car, the only used cars offered will be those whose sellers value them at less than that price. Assuming that quality varies among used cars, those that are offered for sale will differentially be of low quality (“lemons”) relative to the given price. Owners of higher-quality cars may simply hold on to them. If, however, a potential buyer knew that the car was of higher quality, the buyer might be willing to pay enough so that the owner of the higher-quality car would sell. It is for this reason that sellers may offer warranties and guarantees, although these are uncommon (but not unknown) in medical care.


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InternalMed_Harrison. The same thing happens when goods of different quality are sold at the supermarket at the same price. Shoppers are happy to take any box of a particular brand of breakfast cereal or any bottle of a particular soft drink on the shelf because the quality of the contents of any box or bottle is the same; however, that is not the case in the produce section, where shoppers will inspect the fruit they pick up to ensure that the apple is not bruised or the banana overly ripe. At the end of the day, it is the bruised apples and overly ripe bananas that are left in the store. In effect, the seller has not used all the available information in pricing the produce, and buyers exploit that information differential.


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InternalMed_Harrison. Selection affects markets for individual—and, to some degree, small-group—health insurance in a fashion similar to that seen in the used car market and at the produce stand, but in this case it is the buyer of insurance who has more knowledge than the seller. Individuals who use above-average amounts of care—for example, those with a chronic disease or a strong proclivity to seek care for a symptom—will value health insurance more than will those who are healthy or who for various reasons shun medical care even if they are symptomatic. However, the insurer does not necessarily know the risk of those it insures, and so it gears insurance premiums to an average risk, which in some instances is conditional on certain observable characteristics, such as age. Just as shoppers do not want the bruised apples and used car buyers do not want lemons, many healthy people will not want to buy insurance voluntarily if its price mainly reflects its use by those who are sick. (Healthy but very


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InternalMed_Harrison. the bruised apples and used car buyers do not want lemons, many healthy people will not want to buy insurance voluntarily if its price mainly reflects its use by those who are sick. (Healthy but very risk-averse individuals still may be willing to pay premiums well above their expected use.) In an extreme case, healthy people drop out of the insurance pool, premiums rise because the average person left in the pool is sicker, that rise causes still more people to drop out of the pool, premiums rise further, and so forth, until few people remain to buy insurance.


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InternalMed_Harrison. For this reason, no developed country relies primarily on voluntary individual insurance to finance health care, although many countries use it in the supplemental insurance market, and selection is, in fact, often a feature of that market. Instead, governments and/or employers provide or heavily subsidize the purchase of either mandated or voluntary health insurance (e.g., in Canada or Germany, the Medicare and Medicaid programs in the United States and the purchase of insurance in exchanges by lower-income persons) or provide health services directly (e.g., the United Kingdom and the U.S. Veterans Health Administration). In addition, governments or third parties administering individual insurance markets with competing insurers may “risk-adjust” payments to insurers; that is, transfer monies from insurers who enroll better risks (as measured by observable features, such as diagnoses that are not used to rate premiums) to insurers who enroll worse risks. This feature is found in the


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InternalMed_Harrison. from insurers who enroll better risks (as measured by observable features, such as diagnoses that are not used to rate premiums) to insurers who enroll worse risks. This feature is found in the American Medicare Advantage program and American insurance exchanges as well as in Germany and the Netherlands. The idea is to reduce insurers’ incentives to structure their products in order to appeal to good risks, especially when insurers are making choices about networks and formularies.


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InternalMed_Harrison. Moreover, countries that rely on employment-based health insurance, such as the United States and Germany, either mandate taxes to finance that insurance or provide large tax subsidies for its purchase; otherwise, many healthy employees would prefer that the employer give them the money the employer uses to subsidize the insurance as cash wages. Because an employer that offers health insurance will pay lower cash wages than an otherwise equivalent employer that does


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InternalMed_Harrison. CHAPTER 15e The Economics of Medical Care not, larger American employers that, before the Affordable Care Act was implemented in 2014, were not required to offer insurance may not, in fact, have offered it if they had many low-wage employees; the reason is that, if they had offered insurance, the cash wage they could afford to pay would have been below the minimum wage. (For the same reason, these employers typically do not offer a pension benefit.) Many low-wage employers, however, are small businesses that might not be viable if they had to subsidize health insurance. As a result, the Affordable Care Act exempted firms with fewer than 50 employees from any penalties if their employees received a public subsidy and purchased insurance in the exchange. Some self-employed individuals or those who work at small firms may belong to a trade association or a professional society through which they can purchase insurance, but because that purchase is voluntary, it is subject to selection.


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InternalMed_Harrison. How does this situation affect the practice of medicine? Prior to the Affordable Care Act, individual and small-group insurance policies typically had preexisting condition clauses to protect the insurer against selection—that is, to protect the insurer against a person’s purchasing insurance (or more complete insurance) after that person had been diagnosed with a disease that is expensive to treat. Even though there is now a penalty for remaining uninsured, some individuals still choose to do so, and others purchase insurance with substantial amounts of cost sharing that they may not be able to pay if they become sick. Caring for such patients may give the physician a choice between making do with less than clinically optimal treatment and proceeding in a clinically optimal way but leaving the patient with a large bill and possible bankruptcy—and potentially leaving the physician with bill collection issues or unpaid bills.


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InternalMed_Harrison. Selection can arise in a different guise when physicians are reimbursed a fixed amount per patient (i.e., capitation) rather than receiving fee-for-service payments. Depending on the adequacy of any adjustments in the capitated amount for the resources that a specific patient will require (“risk adjustment”), physicians who receive a fixed amount have a financial incentive to avoid caring for sicker patients. Similarly, physicians who receive a capitated amount for their own services but are not financially responsible for hospital care or the services of other physicians may make an excessive number of referrals, just as physicians reimbursed in a fee-for-service arrangement may make too few.


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InternalMed_Harrison. The term moral hazard comes from the actuarial literature; it originally referred to the weaker incentives of an insured individual to prevent the loss against which he or she is insured. A classic example is failure of homeowners in areas prone to brush fires to cut the brush around their houses or possibly install fire-resistant shingles on their roofs because of their expectation that insurance will compensate them if their houses burn down. In some lines of insurance, however, moral hazard is not a substantive issue. Persons who buy life insurance on their own lives are not likely to commit suicide so that their heirs can receive the proceeds. Moreover, despite the brush fire example, homeowner’s insurance probably has little moral hazard associated with it because individuals often cannot replace some valued personal items when a house burns down. In short, if moral hazard is negligible, insured persons take appropriate precautions against the potential loss.


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InternalMed_Harrison. In the context of health insurance, this classic form of moral hazard refers to potentially reduced incentives to prevent illness, but that is probably not a major issue. Sickness and disease generally imply some pain and suffering, not to mention possibly shortened life expectancy. Because there is no insurance for pain and suffering, individuals have strong incentives to try to remain healthy regardless of how much health insurance they have. Put another way, having better health insurance probably does not alter those incentives much.


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InternalMed_Harrison. Instead of weakened incentives to prevent illness, moral hazard in the health insurance context typically refers to the incentives for better-insured individuals to use more medical services. For instance, a patient with back pain or shoulder pain might seek an MRI if it costs him or her little or nothing, even if the physician feels the clinical value of the MRI is negligible. Conversely, the physician may be more cautious in ordering a test that seems likely to produce little information if there are severe financial consequences for the patient.


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InternalMed_Harrison. Some of the strongest evidence on this point comes from the randomized RAND Health Insurance Experiment conducted in the late 1970s and early 1980s. Families whose members were under 65 years of age were randomized to insurance plans in which the amount they had to pay when using services (“cost sharing”) varied from nothing (fully insured care) to a large deductible (catastrophic insurance). All the plans capped families’ annual out-of-pocket payments, with a reduced cap for low-income families. Families with complete insurance used ~40% more services in a year than did families with catastrophic insurance, a figure that did not vary much across the six geographically dispersed sites in which the experiment was run. Although these data come from the era before managed care in the United States, subsequent observational studies in this country and elsewhere have largely confirmed the experiment’s findings with respect to the relationship between variations in care use and variations


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InternalMed_Harrison. States, subsequent observational studies in this country and elsewhere have largely confirmed the experiment’s findings with respect to the relationship between variations in care use and variations in patient payment at the point of service. The difference among the plans was almost entirely related to the likelihood that a patient would seek care. Once care was sought, there appeared to be little difference in how physicians treated their patients in different plans.


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InternalMed_Harrison. One might assume that the additional care provided to fully insured patients would have resulted in improved outcomes, but by and large it did not. In fact, there was little or no difference in average health outcomes among the different health plans, with the important exception that hypertension, especially in patients with low incomes, was better controlled when care was free.


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InternalMed_Harrison. A possible explanation for the paucity of beneficial effects attributable to the additional medical services used by fully insured patients lies in the observations that (1) the additional care targeted both problems for which care can be efficacious and those for which it is not and (2) the population in the experiment, which consisted of non-elderly community-dwelling individuals, was mostly healthy. Perhaps the additional two visits and the greater number of hospitalizations when care was free were as likely to lead to poor outcomes as to good outcomes in that population. Certainly, the subsequent literature on quality of care and medical error rates has implied that a good deal of inappropriate care was—and is—provided to patients. For example, more than half of the antibiotics prescribed to the experiment’s participants were prescribed for viral conditions. Moreover, about one-quarter of patients who were hospitalized (in all plans) were admitted for procedures that could have


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InternalMed_Harrison. to the experiment’s participants were prescribed for viral conditions. Moreover, about one-quarter of patients who were hospitalized (in all plans) were admitted for procedures that could have been performed equally well outside the hospital, in line with the substantial decrease in hospital use over the last three decades. In short, the additional inappropriate care provided when care was free was not necessarily innocuous; if a mainly healthy person saw a physician, he or she could have been made worse off. The literature on inappropriate care is mostly American in origin, but the finding probably holds elsewhere as well.


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InternalMed_Harrison. Finally, patients’ health habits did not change in response to insurance status. This finding is consistent with the intuition that moral hazard does not much affect incentives to prevent illness.


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InternalMed_Harrison. Recently, another randomized experiment was conducted in Oregon among low-income, childless adults who were uninsured. Many people who gained insurance coverage in 2014 when the United States implemented the Affordable Care Act are from this group. Some of the uninsured childless adults won a lottery that made them eligible for Medicaid; those who did not win became the comparison group. After ~2 years, the results suggested that the use of services by persons on Medicaid had increased by ~25–35%. Medicaid served its purpose of providing protection against large medical bills; there was an 81% reduction in the proportion of families who spent >30% of their income on medical care, and there were large reductions in both medical debt and borrowing to pay for medical care. Turning to health outcomes, there was a 30% reduction in depression among the uninsured who received Medicaid relative to the comparison group as well as an increase in the numbers of diagnosed diabetics and of


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InternalMed_Harrison. health outcomes, there was a 30% reduction in depression among the uninsured who received Medicaid relative to the comparison group as well as an increase in the numbers of diagnosed diabetics and of diabetics taking medication. Although there were no statistically significant changes in measures of blood pressure, lipids, or glycosylated hemoglobin, confidence intervals were sufficiently large that clinically meaningful effects could not be ruled out.


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InternalMed_Harrison. In sum, insurance is certainly desirable to protect families against the financial risk of large medical expenses and in some instances to address underuse of valuable medical services (e.g., by a patient with cardiovascular disease who fails to take medications for financial reasons). Thus, the remedy for moral hazard is not to abolish insurance but instead to strike the right balance between financial protection and incentives to seek care. Moreover, it is probably useful to vary the amounts that patients pay out of pocket, depending on the specific service and the patient’s clinical condition. Health outcomes after myocardial infarction, for example, were better among patients who were randomized to have no copayments for statins, beta blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers than among those who had to pay for these drugs.


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InternalMed_Harrison. Because insurers, whether public or private, cannot pay any price that a physician sets, prices in medical markets with widespread insurance are either set administratively or negotiated. In the simple textbook model of a competitive market, prices approximate the cost of production, but this is not necessarily the case when prices are administered. In the traditional American Medicare program, for example, the government sets a take-it-or-leave-it price. Because of the market share represented by the program, the great majority of physicians choose to take the government’s price rather than leave the program. In some countries (e.g., Canada and Germany), medical societies negotiate fees for all physicians in the nation or in a subnational area. In the United States, commercial insurers negotiate fees with individual physicians or groups of physicians.


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InternalMed_Harrison. The principal problem with administered prices arises because someone must set them and that person has an imperfect knowledge of cost. If the price that is set departs markedly from incremental cost, distortions inevitably result. Because the price-setter typically has little information about incremental cost, the set price could be, and often is, far from the actual cost. If the regulator sets the price below cost, the service may not be available or, if it is, will have to be cross-subsidized from a profitable service. If the price is set above cost, there may well be excess entry and too many services being offered on too small a scale. A beneficent regulator in theory could approximate a competitive price by trial and error if technology did not change, but that condition clearly does not hold in medical care. Not only do new goods and services appear continually, but physicians often become more skilled at delivering a service that is already available or at developing new


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InternalMed_Harrison. does not hold in medical care. Not only do new goods and services appear continually, but physicians often become more skilled at delivering a service that is already available or at developing new tools to deliver that service at a different (and frequently lower) cost. For example, cataract surgery, which took upward of 8 h when first introduced, can now be completed in <30 min.


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InternalMed_Harrison. The distortions between price and cost when prices are administered have consequences for the way medical care is produced. There may well be too much capacity in “profitable” areas of medicine, such as cardiac services and sports medicine, and too little in less profitable areas, such as primary care. A fee above incremental cost for a procedure encourages more procedures.


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InternalMed_Harrison. Conversely, payment methods that attempt to cover many services with one fixed payment, such as capitation and a per-admission payment, pay nothing for doing more and therefore may result in too few services and in choices by providers to reduce the number of unprofitable patients under their care, much as a hospital may shutter an emergency room if it becomes a magnet for the uninsured. These phenomena also reflect the asymmetry of information between patients and physicians and, in the case of fee-for-service payment, the incentive for insured patients to go along with a recommendation for additional services (“I am pretty sure I know what the problem is, but 15e-3 let’s just carry out this additional test to be sure”).


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InternalMed_Harrison. There is good evidence that physicians respond to prices that are set. For example, if there is a general reduction in fees that, other things being equal, would lower practice income, some physicians order more services, whereas the opposite pertains if all fees increase. This behavior is sufficiently well established empirically that the U.S. Medicare program’s actuaries account for it in their estimates of what various changes in fees will cost or save. The outcome is different if the fee for one procedure or service changes and that procedure accounts for a modest proportion of income. In that case, another service can be substituted. For example, if the fee for a mastectomy increases relative to that for breast-conserving surgery, there will be a higher proportion of mastectomies. A particularly striking example of this type of behavior occurred when Medicare sharply reduced the fees it paid oncologists for chemotherapy in 2005. The proportion of lung cancer patients who received


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InternalMed_Harrison. striking example of this type of behavior occurred when Medicare sharply reduced the fees it paid oncologists for chemotherapy in 2005. The proportion of lung cancer patients who received chemotherapy rose by 10%. Margins for some chemotherapeutic agents, however, were cut more than those for other agents, and thereafter oncologists made less use of the agents whose margins had fallen more.


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InternalMed_Harrison. Negotiated prices may get closer to cost than administered prices that are set, but they are not a panacea. First, negotiated prices may well exceed cost when there is no effective competition among similar physicians in a particular market. Because medical care markets are typically local, there may only be one group or a few groups in any particular specialty in a smaller market, in which case physicians will have considerable market power to obtain more favorable reimbursement. Further increasing physicians’ market power is the fact that many, and probably most, patients are reluctant to change physicians because their current physician knows their medical history, because they are uncertain whether a new physician would be an improvement, and because insurance may shield them from most of the cost differences among physicians. Finally, in the United States, commercial insurers often negotiate fees as a multiple of the Medicare fee schedule; thus, any distortion in administratively


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InternalMed_Harrison. of the cost differences among physicians. Finally, in the United States, commercial insurers often negotiate fees as a multiple of the Medicare fee schedule; thus, any distortion in administratively determined relative fees is carried over into negotiated fees. For example, in the Medicare fee schedule, procedures generally are more profitable than cognitive services known as “evaluation and management,” and this difference probably plays a role in the numerical insufficiency of primary care physicians in the United States.


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InternalMed_Harrison. One branch of economics—positive economics—seeks to explain actual phenomena without making a judgment about the desirability of those phenomena. Another branch—normative economics—seeks to prescribe what should happen and, in particular, what public policy should be developed to ensure that it happens. The main result of the application of normative economics is that, under certain very special assumptions, competitive markets result in a system in which no one can be made better off without another person’s being made worse off. These assumptions do not hold in medical care, in part because of selection and moral hazard; economists term the result a market failure. By contrast, as the discussion of administered prices in this chapter indicates, even a beneficent regulator will introduce distortions from lack of sufficient information; moreover, there is no guarantee that a regulator will be beneficent, as periodic corruption scandals show. Economists term this phenomenon regulatory


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InternalMed_Harrison. distortions from lack of sufficient information; moreover, there is no guarantee that a regulator will be beneficent, as periodic corruption scandals show. Economists term this phenomenon regulatory or government failure. Economists see decisions about the proper form and amount of public intervention and regulation in medical care as a matter of finding the right balance between various types of market failures and various types of regulatory failures—a balance that different societies may choose to strike differently.


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InternalMed_Harrison. CHAPTER 15e The Economics of Medical Care Racial and Ethnic Disparities in Health Care Joseph R. Betancourt, Alexander R. Green Over the course of its history, the United States has experienced dramatic improvements in overall health and life expectancy, largely 16e


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InternalMed_Harrison. Native American, Alaskan Native 329.8 300 293.7 258.0 228.3 222.3 192.4 179.6 173.2 168.2 155.2 152.7 147.6 141.1 133.0 129.1 115.9 105.9 102.0 94.5 91.9 28.2 12.0 4.0 7.5 3.6 1.5 0 1.9 1.0 0.8 as a result of initiatives in public health, health promotion, disease prevention, and chronic care management. Our ability to prevent, detect, and treat diseases in their early stages has allowed us to target and reduce rates of morbidity and mortality. Despite interventions that have improved the overall health of the majority of Americans, racial and ethnic minorities (blacks, Hispanics/Latinos, Native Americans/ Alaskan Natives, Asian/Pacific Islanders) have benefited less from these advances than whites and have suffered poorer health outcomes from many major diseases, including cardiovascular disease, cancer, and diabetes. Research has revealed that minorities may receive less care and lower-quality care than whites, even when confounders such as stage of presentation, comorbidities, and


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InternalMed_Harrison. disease, cancer, and diabetes. Research has revealed that minorities may receive less care and lower-quality care than whites, even when confounders such as stage of presentation, comorbidities, and health insurance are controlled. These differences in quality are called racial and ethnic disparities in health care. Addressing these disparities has taken on greater importance with the significant transformation of the U.S. health care system and the implementation of health care reform and value-based purchasing. The shift toward creating financial incentives and disincentives to achieve quality goals makes focusing on those who receive lower-quality care more important than ever before. This chapter will provide an overview of racial and ethnic disparities in health and health care, identify root causes, and provide key recommendations to address these disparities at both the clinical and health system levels.


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InternalMed_Harrison. Minority Americans have poorer health outcomes than whites from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer, and HIV/AIDS (Fig. 16e-1). Multiple factors contribute to these racial and ethnic disparities in health. First and foremost, social determinants—such as lower socioeconomic status (SES; e.g., lower income, less wealth, and lower educational attainment), inadequate and unsafe housing, and racism—are strongly linked to poor health outcomes. These factors disproportionately impact minority populations. In fact, SES has consistently been found to be one of the strongest predictors of health outcomes. While the mechanisms are complex (i.e., does poverty cause poor health, or does poor health cause poverty?), it is clear that low-SES populations expe-16e-1 rience disparities in health and that low SES is a major factor in racial/ ethnic disparities.


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InternalMed_Harrison. Racial/ethnic disparities are documented globally, although their assessment has centered more on the comparison of individuals by SES in other countries than in the United States. Similar to the U.S. pattern, low-SES residents of other nations tend to have poorer health outcomes. It is noteworthy that results are mixed when the health status of nations is compared by SES. High-SES nations such as the United States do not necessarily have health outcomes that correlate with their high expenditures for health care. For example, as of 2011, the United States ranks 34th in the world—just behind Cuba—on basic public health measures�such as infant mortality. This ranking may be due in part to the correlation between wealth distribution and SES rather than just absolute SES. This area of active research is outside the scope of this chapter.


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InternalMed_Harrison. Racism has more recently been shown to predict poorer health outcomes. The physiologic impact of the stress imposed by racism (and poverty), including increased cortisol levels, can lead to chronic adverse effects on health. Lack of access to care also takes a significant toll. Uninsured individuals are less likely to have a regular source of care and are more likely to delay seeking care and to go without needed care; this limited access results in avoidable hospitalizations, emergency hospital care, and adverse health outcomes.


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InternalMed_Harrison. In addition to racial and ethnic disparities in health, there are racial and ethnic disparities in the quality of care for persons with access to the health care system. For instance, disparities have been found in the treatment of pneumonia (Fig. 16e-2) and congestive heart failure, with blacks receiving less optimal care than whites when hospitalized for these conditions. Moreover, blacks with end-stage renal disease are referred less often to the transplant list than are their white counterparts (Fig. 16e-3). Disparities have been found, for example, in the use of cardiac diagnostic and therapeutic procedures (with blacks being referred less often than whites for cardiac catheterization and bypass grafting), prescription of analgesia for pain control (with blacks and Latinos receiving less pain medication than whites for long-bone fractures and cancer), and surgical treatment of lung cancer (with blacks receiving less curative surgery than whites for non-small-cell lung cancer).


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InternalMed_Harrison. less pain medication than whites for long-bone fractures and cancer), and surgical treatment of lung cancer (with blacks receiving less curative surgery than whites for non-small-cell lung cancer). Again, many of these disparities have occurred even when variations in factors such as insurance status, income, age, comorbid conditions, and symptom expression are taken into account. However, one additional factor—disparities in the quality of care provided at the sites where minorities tend to receive care—has been shown to be an important contributor to overall disparities.


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InternalMed_Harrison. FIgURE 16e-1 Age-adjusted death rates for selected causes by race and Hispanic origin, 2005. (From the U.S. Census Bureau, 2009.) 81.5 80 76.9 76.8 75.8 74.2 73.3 69.5 74.6 68.7 66.2 FIgURE 16e-2 Recommended hospital care received by Medicare patients with pneumonia, by race/ethnicity, 2006. The reference population consisted of Medicare beneficiaries with pneumonia who were hospitalized. The composite was calculated by averaging the percentage of the population that received each of the five incorporated components of care. (Adapted from Agency for Healthcare Research and Quality: The 2008 National Health Care Disparities Report.)


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InternalMed_Harrison. Little progress has been made in addressing racial/ethnic disparities in cardiovascular procedures and other advanced surgical procedures, whereas some progress has been made in eliminating disparities in primary-care process measures. Data from the National Registry of Myocardial Infarction found evidence of continued disparities in guideline-based admission, procedural, and discharge therapy use from 1994 to 2006. Black patients were less likely than white patients to receive percutaneous coronary intervention/coronary artery bypass grafting (PCI/CABG), a disparity that has improved little since 1994. Further, compared with whites, black patients were less likely to receive lipid-lowering medications at discharge, with a gap that has widened since 1998 (Fig. 16e-4). A 2009 study showed that blacks had worse post–myocardial infarction outcomes than whites but that the difference could be explained by site of care and patient factors (such as socioeconomic status and comorbid


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InternalMed_Harrison. showed that blacks had worse post–myocardial infarction outcomes than whites but that the difference could be explained by site of care and patient factors (such as socioeconomic status and comorbid conditions).


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InternalMed_Harrison. The Centers for Disease Control and Prevention (CDC) analyzed national and state rates of total knee replacement (TKR) for Medicare enrollees for the period 2000–2006, with patients stratified by sex, age, and black or white race. TKR rates overall in the United States 82.2 80.3 68.9 67.9 59.6 57.9 40.6 40 40.3 FIgURE 16e-3 Referral for evaluation at a transplantation center or placement on a waiting list/receipt of a renal transplant within 18 months after the start of dialysis among patients who wanted a transplant, according to race and sex. The reference population consisted of 239 black women, 280 white women, 271 black men, and 271 white men. Racial differences were statistically significant among both the women and the men (p<.0001 for each comparison). (From JZ Ayanian et al: N Engl J Med 341:1661, 1999.)


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InternalMed_Harrison. Percentage of patients increased 58%, with similar increases among whites (61%) and blacks (56%). However, the TKR rate for blacks was 37% lower than the rate for whites in 2000 and 39% lower in 2006; i.e., the disparity not only did not improve but even worsened slightly (Fig. 16e-5). More recent data (up to 2010) show no apparent change in these figures. Data for enrollees in Medicare managed-care plans provides evidence for a narrowing in racial disparities between 1997 and 2003 in several “report card” preventive care measures, such as mammography and glucose and cholesterol testing. However, racial disparities in more complex measures, such as glucose control in diabetic patients and cholesterol levels in patients after a heart attack, actually worsened during that interval.


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InternalMed_Harrison. The 2012 National Healthcare Disparities Report, released by the Agency for Healthcare Research and Quality, found little improvement in disparities for core measures of quality over the previous decade. In fact, for blacks, Asians, Native Americans/Alaskan Natives, Hispanics, and poor people, the vast majority of core quality measures (87–92%) stayed the same, and a small proportion (2–8%) got worse, including measures of effectiveness, patient safety, and timeliness of care. While a small number of these measures improved, disparities were eliminated in no measured area. This annual report is particularly important, given that most studies of disparities have not been repeated with the same methodology used to document possible trends. Some studies have tracked disparities using specific disease and treatment registries. For example, by 2008, the use of acute and discharge medications for myocardial infarction had largely been equalized among racial and ethnic groups; however,