Tag Archives: acupuncture

What Is This Qi Stuff, Anyway?

(Written for my colleagues on Acupuncture and Oriental Medicine Day, 10/24/18, and posted on the website of the New Mexico Society for Acupuncture and Asian Medicine.)

The field is the sole governing agency of the particle. — Einstein


There is a school of thought that seems to be gaining currency in our profession lately, which says that the concept of Qi is nothing more than a quaint misunderstanding of what the ancient sages were really writing about, and that our medicine is really all about the nervous system and other purely physical aspects of the body.

This is simply not true.  In an apparent effort to align their work with biomedical science, these authors are actually ignoring a great deal of that same science, not to mention the experiences of myriad practitioners and patients. 

Let me start with typical human perceptions of the energetic field surrounding the body, the manifestation of Qi we think of most often.  While Qi can be complicated to pin down in terms of exactly what types of energy and what frequency ranges are involved, close to the body it’s very simple to perceive and to demonstrate. 

When I am scanning for active points or disturbances in patients’ bodies, the person on the table often says, with surprise, “I can feel exactly where your hand is!”  Of course they can, as this is a normal human ability.  When patients ask me what Qi is, or what is meant by Qi Gong, I have them try a very simple exercise: Hold your palms near each other, about a half inch apart.  Notice what you feel. A kind of pressure, a bit like the feeling of trying to bring two magnets together with the same poles facing?  Warmth?  Tingling?

Nearly everyone can perceive this immediately.  I’ve tried this exercise with hundreds of people when I’ve given presentations to groups, and only a couple have ever said that they didn’t feel anything. 

When I used to teach Reiki, I introduced the concept of the human biofield with another simple exercise.  One person would stand facing a wall, eyes closed.  Another person would walk up to them from the back.  The first person would raise her hand when she felt the presence of the other one.  This would happen consistently when the two were about four feet apart.

But although those effects are consistent and reliable, science likes objective, numerical measurements with instruments.  There are plenty of those to be had as well, and many of them have been done by researchers right here in the US.  That’s been going on for decades.

Earlier this month I had the opportunity to meet the biophysicist Beverly Rubik, who has spent 40 years studying the human biofield, and was part of the group that coined that term.  Her current work is largely in the area of biophotons, the weak but important light emitted from the body in the ultraviolet range.  Among other things, she has studied the changes in biophoton emissions involved with healers and healees, showing that more light is emitted from the hands of healers when they are doing their work.  One instrument she uses to detect biophotons is the Bio-Well gas discharge visualization camera, which is available commercially and has clinical applications that could be useful in an acupuncture office.

She stated at the conference that as a child she could feel energy, but that “it was educated out of her.”  The biofield, she said, is proposed to be “a high-speed wireless communication system, a bridge between the mind and body.”

I had already encountered Dr. Rubik’s work in a 2016 online course, “The Science of Energy Medicine,” given by the Association for Comprehensive Energy Psychology.  Here are some quotes from her presentation there:

‘… I see the biofield as a complex dynamic standing wave within and around the body. Let me tell you more. You’re already familiar with the concept of standing waves from musical instruments, for example a wood instrument, a clarinet. There’s a standing wave when it’s being sounded, or the plucking of a string in a violin or a guitar. Once again, a standing wave is vibrating and rendering sound. Not only sound standing waves are possible. There are also electromagnetic standing waves, too.’

‘There was one main prediction from the biofield hypothesis, and that is that if we can shift the biofield, we can change the physiology and chemistry and move the body, the body mind, to a new steady state….’

Experiments have consistently shown that intention is of great importance in causing measurable energetic effects: ‘I come back to that old principle of Oriental medicine. Where mind goes, chi, or energy, flows, and the blood and flesh follow.  This is the bottom line when it comes to how we can heal ourselves. We must change our minds. Then there are shifts in the biofield, and then the flesh and blood is the slowest to change overall.’

You might wonder why, after four decades of work like this, the science of the biofield is not more familiar, even to those of us who deal with it every day. Dr. Rubik gave some reasons why it is not: ‘We have certain challenges in biofield science. We are dealing with complex dynamical fields that are actually very low-level that become difficult to measure and we have to use a variety of tools. There is no one singular tool that you can grab off the shelf that’s ready-made to look at the biofield, but rather a collection of different tools to understand and probe the biofield through different windows.

‘There’s also very little funding and no concerted effort. Unfortunately, the NIH has dropped the ball and it is not a lead agency. We have no leading organization that’s making a concerted effort to forward biofield science or its understanding in the frontiers of medicine, and I’ve long been an advocate of something I call a Human Energy Project [along the lines of the Human Genome Project].’

Here is an article in which Dr. Rubik gives a lucid overview of methods of measuring the biofield:
https://www.faim.org/measurement-of-the-human-biofield-and-other-energetic-instruments

Another researcher who started measuring the biofield, even earlier, was Valerie Hunt, who began as a scientist with no knowledge of or interest in esoteric or energetic matters.  She eventually developed new instrumentation that could detect immensely higher frequencies than had been measured around the body previously, in the range of hundreds of thousands of cycles per second.

‘My academic background is as a neurophysiologist, and I was also a registered physical therapist. I was working in electromyography and electrocardiography, and I was interested in the patterns of electromyographic energy in the body that were related to emotions. Eventually, I established a pattern of emotions connected with neurological energy. In the process, I was the first researcher to have a telemetry, electromyography instrument. This was when the first astronauts went into space. They had to have monitors of their basic health — the heart rate, the blood pressure, and the galvanic skin response — sent from space. They did this using telemetry, which is a radio frequency instrument system. It would send a signal on an FM frequency down to the earth, where NASA would record the FM frequencies and know what was happening to the astronauts.

‘When I heard about this, I got in touch with NASA and the young scientist who had first made that telemetry instrumentation, and I had him build for me the first telemetry electromyography instrument. This meant I could test a person using an FM frequency, a radio frequency, process the data through my instrumentation and record it. And when I did this I found the electromagnetic energy field.

‘This was in early 60’s, and I thought, “Oh my God, what have I got here?” So I brought in researchers from the university’s chemistry, physics, and engineering departments. I said, “What have I got, an artifact?” And they kept saying I didn’t, that my equipment was working fine. They tested everything, and finally I realized I was dealing with a new kind of energy in the body.’

https://healthontheedge.wordpress.com/2012/01/28/the-human-energy-field-an-interview-with-valerie-v-hunt-ph-d/

Dr. Hunt famously worked with the healer Rosalyn Bruyere, and was able to correlate her perceptions of the human aura with the readings made by her instruments.  In addition to making measurements of the biofield, she was able to create practical applications for healing.  She was still going strong on a number of projects when she died in 2014.

All of these electromagnetic emanations from the body are relatively weak.  How do we explain the much more extreme effects that can be produced by well-trained Qi Gong masters and some others?  That’s not at all clear, but the effects are incontrovertibly there.  For example, a fascinating series of trials by Mikio Yamamoto in Japan was reported by Lynne McTaggart in her seminal book The Intention Experiment, involving a master doing tohate, in which the master could push another person back several yards through sheer force of will and Qi, while the other was trying to resist.  The master was isolated in an electromagnetically shielded room on the fourth floor of a building, while his student was placed in a similar room on the first floor.  Neither the distance nor the shielding prevented the effect; in nearly a third of 49 trials, the master was able to push the student back.  (p. 53)

A nonexistent energy could not visibly, objectively move a body. 

Probably quite a few of us have felt a more mundane version of this kind of effect, being pushed back from the treatment table when a blockage in a patient suddenly released, maybe even feeling that we were “knocked across the room” by a considerable force.  How can the biofield, which seems so feeble when measured, create a force like that?  I don’t know of anyone who has answered that question in terms of biophysics, and it is urgently begging for an answer.  There has to be something more to Qi than the types of electromagnetism we have detected in and around the body so far.

At the conference where I met Dr. Rubik, I had an unusually dramatic experience of being strongly tapped between the eyes by someone who was not physically present.  It didn’t hurt, but it knocked me back a little, and everyone in the room saw that.  Some years ago, such a person pushed my whole body a few inches sideways on my chair.  You can’t help but be impressed when an invisible force moves you against (or at least without) your will.

The other issue with explaining Qi solely as a matter of electromagnetic fields is that electromagnetic effects rapidly diminish with distance, but Qi has no trouble at all being transmitted across any given amount of space.  The tohate experiments are a particularly vivid example of that, but many of us do remote treatments that are effective in a quieter way.  What, precisely, is being transmitted?  Or is that the wrong question?

Here, from the ACEP course, is Gary Schwartz attempting to deal with this issue:
‘Now, how do we explain effects that are taking place across 3000 miles or in London, which is what, 6000 miles from Tucson [where he is based]? Or Sydney, Australia, which is even further. Electromagnetic field effects are insufficient to explain that kind of data because the intensity of electromagnetic fields decreases with the square of the distance, and they are modified by all kinds of objects in the environment. That’s one reason why you need to consider higher level or more sophisticated theories of physics to be able to explain this.’

‘To say that a quantum field is involved in distance, which it may very well be, for example, does not mean that the electromagnetics are not involved in proximal things. You can have multiple layers of mechanism being operative at the same time. That’s why I use a staircase for the explanations so people can see this. The problem with skeptics and probably most of us is that we don’t look at the whole picture.’

So at this point, we are very clear about many aspects of the human biofield— which we can call a manifestation of Qi— but there are large and crucial holes in our understanding.

To be continued….

 

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All Healing Is Self-Healing, Part I

A few weeks ago I ranted about one aspect of our dysfunctional medical system, prohibitively high copays. Since then I went to see my chiropractor*, and he mentioned that his patients have been telling him that they would be coming in more often if not for their recently inflated copays. He added that in the past, by this time of year, patients would virtually all have met their deductibles, but now deductibles are so high that 80% of them have not.

What amazes me most is that we are all putting up with this. But then, we’ve learned that we have no power within this system. Many of us have also learned that we don’t have much power over our own health. More than anything, that is what is going to have to change if we are to have any hope of getting health care on a viable and sustainable course.

Last time I gave you a link to a post by my friend James Rolwing, which he began with this crucial statement: “All healing is self-healing.” Please think about that for a moment. Does it sound true to you? Does it have exceptions? Does it feel liberating, or does it make you a little uneasy?

All any of us in health care can do, for any amount of money, is to aid the body’s and the mind’s own natural healing processes. Even in the case of the most drastic interventions, such as a joint replacement or organ transplant, the body must take what has been added and make it work, while repairing the tissue around the new portions. Surgery can remove damaged tissue or stitch it together, sometimes in truly ingenious and astonishing ways, but there is no force on this earth that can heal surgical incisions except the body’s own innate ability. We do what we can, and then we must wait.

But what about drugs, you say. Drugs make direct changes in body functions. Yes, but the body must metabolize and make use of the drugs, and individual bodies do that in individual ways.

When I do acupuncture I am acutely aware of the fact that all I can do with needles is to give signals to the body about what it needs to do to get back into balance. I can use needles to talk to the body through obviously physical means, engendering tiny electrical currents and stimulating the release of substances such as neurotransmitters and hormones, as well as the subtler energetic signaling that medicine understands less clearly. I can ask for increased circulation or for excess fluids to dissipate. I can ask for whatever I care to, but then the body will do exactly what it wants to do and is able to do, no more and no less.

This is not so much a limitation as a gift, though it can be frustrating to find the optimal way to get the body to respond. Most of the effort and cost in American health care goes to dealing with chronic and often very confusing conditions, and there is contention and controversy about how to treat them. If we say that we want people to have access to health care, what exactly do we want them to be able to access? What is our underlying belief system about how to deal with diabetes or fibromyalgia or cardiovascular disease or even simple aging? I think you have a pretty good idea of how things stand in the medical world at present. We do a lot of fixing but not a tremendous amount of healing, lots of sick care but not so much health care.

How do we find a path to health for ourselves as individuals and as a society? How do we take responsibility for our health in concrete ways? We know about fundamentals like nutrition and exercise (though even those are fraught with controversy), which in themselves could transform our lives if we would do what we know we should. There is far more that we can do, at least if we are fortunate enough to have access to the information we need and the openness to make use of it.

Here James outlines two possible ways of thinking about our bodily discomforts:

“Essentially, we have two choices of dealing with a symptom. We can drive it back below the threshold of our awareness (a suppressive approach) or we can participate with it (an expressive approach). With suppression a door is closed, and with expression a whole world opens up.

“Most of what is typically described as healing occurs as the result of suppressive mechanisms. Painkillers and antidepressants are obvious examples, but any type of therapy can employ a suppressive approach. It is often a fear-based strategy, as we unconsciously fear to examine what is underneath the symptom.

“Expressive healing describes the mechanism of self-healing, and views a symptom as an indication that something within us is asking for acknowledgement, most often trapped or repressed feelings and emotions. Relief or resolution occurs as the result of recognizing and giving expression to these underlying sources, because the symptom was only there to point us toward the deeper cause in the first place.”

http://rolwingjames.wordpress.com/2014/04/13/the-intervention-fallacy-part-i-how-it-starts/

While I was working on this post, my right arm and hand were giving me a lot of grief, impossible to ignore, just in time to help me think about how to apply what I was writing about. That was what sent me to the chiropractor. You might wonder why I needed to/chose to do that, since one’s physical structure ought to be able to right itself naturally. In fact, that’s an essential concept in chiropractic, the body’s innate wisdom and healing capacity. Well, I had been doing everything I could come up with on my own, and it wasn’t enough. I was still having disabling pain and dysfunction, and I needed this kind of assistance. (It’s OK to acknowledge that we can’t do everything alone; that’s not abdicating responsibility for oneself.) Getting my bones pushed back into place helped the acute situation quite a bit, though that also brought other aspects of the pattern to light, which I then needed to deal with. I still had to work with the emotional issues that had been stored in that area of my body; that is, I had to do expressive healing. It was very clear that I had to do that, and that the pain would not resolve otherwise. In the midst of it I went for an Alexander Technique session** to get some guidance in releasing the habitual tensions that were feeding into the problem and to help move the stuck emotional content. It all took a lot of time and effort, especially considering that most of it was a matter of simply letting go! I’m doing a great deal better now. Maybe I even know a bit more about how to avoid this in the future.
Here’s a case for you to contemplate:

A patient of mine who is disabled and on Medicare hit the “donut hole” recently.  A drug which has helped immensely with his diabetes will now cost him $295 per month. That will be the case for four months, one third of this year, even though he is insured— all the way till next year. (This would not happen in the same way with private insurance or with Medicaid, only with Medicare.) His family makes $1000 per year too much to get any kind of extra subsidy. He’ll never get out of the donut hole, because he won’t be able to pay out of pocket up to the amount where coverage would kick in again. They might as well ask him for $2950 per month— he simply can’t afford that $295. He’s already tried the other available medications, some of which are cheaper, and this one worked tremendously better. I could see a marked difference in his condition with it, and I’m sure his PCP was delighted to see what it was doing. So much for that.

If complications from his diabetes put him in the hospital for even one day, that will cost us all more than we would pay to cover his medication for the rest of the year. Our country is being financially stupid as well as cruel to this man. And our vaunted medical breakthroughs are meaningless if our doctors can’t get them to the patients.

This gentleman is a superb energy healer himself, and he does everything as naturally as he can to take care of himself. He has had some success in the past with herbs to control his troublesome symptoms, and he is exploring herbal options again. After a period of being enraged with the system, he decided that the present situation might be an opportunity to find a better way to deal with his blood sugar. At least, he pointed out, he won’t have to worry about the potential side effects of the drug. He already does all the obvious things with diet and exercise, you understand, and with his mental attitude. We’ll see what else he and I can come up with.

Update!!!  My patient has been able to get his meds through a free sample program at Presbyterian.  It took quite a while before this happened, and when he first (and second and third) inquired he wasn’t told this was possible, but the system did come through for him.  He was already developing preventable problems while waiting, however.

 

*Terence Timm, DC. I’d refer you to him except that (waaahhh!) he is retiring very soon.
** with Karen DeWig. http://alexanderabq.wordpress.com/

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Killer Copays

Most of us seem to enjoy complaining about our so-called health care so-called system, but not a lot of clear paths for improvement have been put forth. I have come to think that above all, we have a failure of imagination. We cannot envision another way of doing things, or at least a way out of the present situation, and so we continue to put up with a reality that is increasingly insupportable. We tinker around the edges, but nothing more. As Dr. Dean Ornish put it, “We spend so much time in medicine mopping up the floor around the sink that’s overflowing without ever turning off the faucet.”

Much of what I’m writing today will focus on a small aspect of the system, copays, and will not offer grand visions for the future, but I would like to drop this idea into your head so you can let it grow in the background: We created the present situation. We can create something else. What we have now is not ordained by God or nature. It hasn’t even existed for a very long time, only a few decades.

After you’ve read this post, please look up the 2012 film Escape Fire, which outlines just how completely screwed we are and what we can do about it. You can find it here:  http://www.escapefiremovie.com/  It’s also available through Netflix.

Escape Fire is based on a book by Donald Berwick, MD, the former head of Medicare and Medicaid. He wrote it early in the 2000s, and you’d think that a decade later we would have figured a few of these matters out, but as far as I know we haven’t made a single one of the changes he recommended. The idea of an “escape fire” is that if one is about to be overtaken by a forest fire, one can burn an area on purpose to provide a path to escape. The film recounts the story of a group of firefighters who were in this type of situation. Their leader dropped a match on the ground and burned a circle around their position, using up the fuels that would have fed the fire. He told the others to stay in the circle with him, but they took off, insisting that they could get out safely. Guess who survived. Dr. Berwick’s point is that we have obvious paths to escape right in front of us, but we refuse to take them, or even to see them.

Dr. Berwick pointed out that people within the health care industry do exactly what makes sense to them where they find themselves. It’s just that the system contains such incredibly perverse incentives that they often do things that have ill effects for the country as a whole.

Recently one of my elderly patients canceled her appointment for the next day. The reason was that she had to see her eye doctor, and the copay for that is $45, meaning that she wouldn’t have the money to pay even the extremely reduced price I would have charged her as a low-income senior who doesn’t have insurance that covers my services. This lady lives in a subsidized retirement apartment complex. Some of the people who live there have income of less than $1000 per month, and few have much more than that. A copay of $45 is huge for them, possibly even requiring saving up over a couple of months. These folks have Medicare and often other coverage, but strangely, it’s still quite possible to face daunting copay amounts.

A few weeks ago, an insurance company representative told me that high copays do not prevent access to care. Clearly, they do. Copays and deductibles* are both going through the roof. I wrote to her company, one of the major insurers in our area, one which pays only 2/3 of usual and customary fees for acupuncture, as follows:

“Copays keep increasing in general. I understand that at least in part this is caused by attempts to limit increases in premiums. What is troubling is that in many cases copays are equal to or greater than the amount insurers actually reimburse for a given service. As copays continue to go up, this situation is likely to keep getting worse.

“Within the ____ system, the most extreme case I’ve seen involves City of Albuquerque employees. They have a $55 copay for acupuncture, but ___ only pays $43.73 for acupuncture. [Your representative] said that she thought in this case the member would only be expected to pay the $43.73, but that is not how it works. EOBs show clearly that the full $55 copay is expected. And providers are not allowed to discount copays and can get into trouble for doing so.

“It is more typical these days to see a $40 copay for ____ members, and has been for a couple of years now. That means that much of the time ____ is paying a princely $3.73 for acupuncture, and the patient is paying nearly the entire charge. When you include the fact that ____ limits members to 20 treatments per year, the total paid for the year can be as little as $74.60, less than the price of a single appointment for most medical services.

“In both of these types of cases, the member and the employer (often through the taxes we all pay) are paying for coverage for acupuncture, but they don’t get anything that can really be called coverage, and in the case of the highest copays, they have a kind of negative coverage. It’s an advantage to me as a provider to have the patient pay a larger copay, but it’s still painful to see them treated so unfairly.

“I imagine that when the HR department or whoever set up these copays were in discussions about how their plans would work, the amounts sounded quite reasonable to them. Perhaps someone said, ‘I don’t know, what does acupuncture usually cost?’ and someone replied, ‘Well, my acupuncturist charges $70.’ It might not have occurred to them that $55 would be higher than the reimbursement amount.

“(After all, usual and customary insurance payments for acupuncture alone are in the range of $62-65, not counting any amounts for E & M codes or other services. ____ is unusual in paying only about 2/3 of that— an amount that has not changed for a number of years even as patients pay more and more. This exacerbates the issues with copays.)

“I don’t know about how other types of providers are affected. I do know that chiropractors have some similar issues.

“Copays are charged for us DOMs at the ‘specialist’ rate, but since we are not reimbursed at anything like the amounts cardiologists, etc. get, the copays are a much larger percentage of the price. I understand that PCP visit copays are kept lower because insurers want members to see their PCPs to try to catch problems early, but often the PCP can’t do anything and simply makes a referral anyway, meaning that the PCP visit is a waste. Visits to DOMs, DCs and PTs are relatively discouraged by the higher copays, even though we are saving insurers money by helping patients avoid more expensive interventions such as surgeries— not to mention helping the patients relieve their suffering and improve their overall health, which ultimately reduces costs as well as being worth doing in itself.

“[Your representative] said that members have far wider benefits than just acupuncture, which obviously is true, and a member who has a major health problem may end up with much more value paid in benefits than they pay in premiums in a given year. However, this does not change the fact that members with high copays for acupuncture are being sold a benefit that they don’t truly receive. It’s rather like going into a store to buy a shirt, and being told that although the shirt normally costs $45 and most people pay that or less, you have to pay $55 for it.”

So costs to consumers and the country at large keep going up and up and up. In what aspects of the system are those costs increasing so persistently? Let me tell you, payments to doctors are not the problem. We’ve been seeing flat or even decreasing rates of reimbursement. Medicare and Medicaid in particular squeeze providers, and as shown in a heartrending segment of Escape Fire, often the only way a clinic can stay in business is to pack in more and more patients. Again, providers are doing what appears to make sense from their perspective in their corner of the system. But not only is this compression of appointments terrible for patients, especially those with more complex needs, it can actually raise costs. Primary care doctors who don’t have enough time to figure out what’s going on with a patient are likely to refer that patient to a specialist, costing dramatically more, whereas with more time to think, the PCP might well have solved the problem and come up with a treatment plan without making a referral.* So reducing payments for primary care to absurdly low levels is classically penny-wise and pound-foolish. “There is no more wasteful entity in medicine than a rushed doctor.”
http://www.nytimes.com/2014/07/21/opinion/busy-doctors-wasteful-spending.html?contentCollection=opinion&action=click&module=NextInCollection&region=Footer&pgtype=article&_r=3

I would like to propose a simple rule that copays may not be more than 50% of the amount reimbursed for a given service. Period. I truly believe that there is more than enough wasted money, far more than enough, to make this happen. I would also like to propose that resources be redirected into primary care and especially accessible clinics for the most vulnerable portions of the population, like the ones being seen by the frustrated PCP in Escape Fire. Continuing to cut already-thin payments to practices like that makes no sense.

These of course would only be stopgap measures. Next time, I’ll take up some thoughts about self-care and our responsibilities toward our own health. Meanwhile, I offer you one more pithy post to chew on: 
http://rolwingjames.wordpress.com/2014/04/13/the-intervention-fallacy-part-i-how-it-starts/

*https://elenedom.wordpress.com/2014/02/04/health-care-access-and-why-pcps/

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Health Care Access, and Why PCPs?

Grant's rainbow 2.2.14A friend posted this picture of a rainbow that appeared two days ago in our area, a most welcome sight since we had had no moisture at all for over 40 days.  The rainbow showed up just after her neighbor died after a long illness, giving its benediction to the family.  Last night we had a fair amount of rain and snow, and it feels like we will not dry up and blow away just yet.

I am trying to keep up some hope for our health care system as the conflicts over so-called “Obamacare” continue and costs keep spiraling upward.  There does seem to be some lucid thinking going on in at least scattered spots among those in the medical field and those making policy, and I want to encourage that.  There’s also a lot of the same old thinking that got us where we are today.  Here is my current take on some aspects of the situation, which I sent to the Albuquerque Journal today:

The Journal has published some useful articles lately on problems with access to health care, and I’d like to add my perspective as a provider out in the field.  There are three main issues with access to care for New Mexicans: distance, cost, and scarcity of providers.

I don’t have to tell you that for many of our residents, most everything is far away.  Even in our smaller cities, there are not a lot of services.  In Grants, where I see patients once a week, medical specialists come in from Albuquerque or elsewhere, as I do.  People who need VA services must go to Albuquerque, no matter how elderly or disabled they are.  It’s bad enough in a small city like Grants, but people who live in more rural areas, as some of my patients do, may be completely out of luck if they lack transportation.

Getting more New Mexicans insured is necessary and commendable.  However, this does not remotely solve all the problems with the direct cost of medical care to consumers.  As those who are shopping on the state exchange have no doubt noticed, many plans have deductibles in the thousands of dollars.  Also, with some plans patients pay as much as 90% of the cost of the service themselves, even after their deductible is met, because their copays are so high; they are paying for coverage that they don’t get. The ACA was intended to bring deductibles and copays into the realm of reason, if I understand correctly, but as it is, cost limits access even for those who are insured.

For those on Medicaid, at least, copays are low or nonexistent.  However, very basic and critically necessary care may not be covered.  For example, one of my elderly patients needs drops for an unusual and painful eye condition caused by her recent case of shingles.  The cost is low compared to most of her care, but Medicaid is not covering this medication, and on her extremely limited Social Security income, this lady can’t afford enough of it to last through the month.  For all the millions we spend as a state, we still can’t get people simple things that they need badly.  And while the myriad costs add up to so many millions, Medicaid and Medicare payments to providers are so unsustainably low as to keep providers out of the programs, exacerbating the access problems all the more.

Our state’s lack of health care providers has multiple causes, but it also has the potential for multiple solutions.  Making better use of mid-level practitioners, as many have suggested, is certainly necessary, and any efforts which will attract more health care workers are worth trying.  However, there are other available health care forces which are only partly being tapped.  One of your editorials did refer to “traditional community health workers,” by which I assume you mean people like curanderas/os and Native healers.  Encouraging greater use of their abilities would be a definite help– but how is that going to be funded?  For the most part our insurance system has ignored the existence of these valuable resources, as it has ignored herbalists, homeopaths, and those who do energy healing such as Reiki.  Most federal dollars will also bypass all those practitioners and the people who rely on them.

New Mexico has a formidable and growing health workforce in the members of my profession, Doctors of Oriental Medicine.  We too are being used far less efficiently than we could be, even though most commercial insurance in the state does cover our services.  Decision makers don’t seem to realize how much primary care we do– and we have not yet managed to get the word out to them sufficiently.  We are lumped in with “rehabilitative medicine” by insurers, but that is only one aspect of our medicine.  Patients walk in to acupuncturists’ offices with everything from flu to IBS to sciatica, and we treat them effectively.  We are well placed to help take the strain off of primary care MDs, and we are ready and willing to serve.  However, provider groups organizing “patient-centered medical homes” have generally not included us in their planning.

Medicare does not cover acupuncture, and under most circumstances Medicaid also does not, largely because the federal dollars are not available to make that happen.  Attempts to fix this in the state and federal legislatures have failed thus far.  So immediately a huge proportion of our population is left out of a major form of effective and cost-effective medicine.  And while our NM-based insurers do offer coverage, as I mentioned before, in many cases reimbursement is slim and patients are left to pay as much as 90% of the charges, so that this “coverage” is not very meaningful.  (Fortunately, there are also many plans with much better coverage, I must add.)  Yet, many patients do use us as their front-line care providers, and that could be expanded.

There are still other possible providers as well.  In some situations a chiropractor may be the best choice to see first, and access can be a bit easier than that for DOMs, with so many chiropractors available and a good number of them accepting Medicare.  For at least some conditions these practitioners could also help to ease the burden on primary care MDs.  Physical therapy is usually given limited coverage, and patients tend to be referred to PT only after they have failed to get better for a long period of time.  That is inefficient and leads to unnecessary suffering.  We could use PTs more as the first choice, go-to practitioners for injuries, back pain, and the like.

There is one access problem that would be very easy to solve, IF those who are in charge were willing.  That is the system of HMO and PPO networks.  It was unconscionable when Lovelace ended its relationship with ABQ Health Partners and tore hundreds of thousands of New Mexicans (including my family) away from the doctors they knew and trusted.  Now Presbyterian has stopped coverage to the UNM providers, again leaving patients in the lurch.  We could stop this kind of abuse, I expect, legislatively or perhaps through actions of the state insurance department.  I am not holding my breath, but as the provider crunch gets more and more serious, I hope access will be broadened across insurance networks.  There is no good reason for things to be this way; we all pay and we all deserve to have the best providers for our needs.  HMOs were supposed to reduce costs and improve health outcomes.  Neither has happened.  Time for a different approach.

And we do have a different approach waiting in the wings: the home-grown, NM-specific Health Security Act is still here and has been gathering more and more support over the years, though so far it hasn’t made it past all the Powers That Be.  In the next few years we will have the opportunity to improve upon the current health insurance exchange and enact this more efficient plan.  We can choose to do it– it’s just a matter of willingness.

 

OK, that’s what I sent off to the newspaper a moment ago.  Continuing:

Let’s say that a patient has jumped through all the hoops of distance and cost and gotten the coveted access to care, and is now sitting in the doctor’s office.  Now the main barrier is time.  The patient may have waited months for this appointment, but she is going to be very lucky to get more than 10 minutes of the doctor’s time.  And maybe even that pittance may soon be a luxury.  An editorial written by two local executives with Presbyterian Health care and published a few days ago stated that because of the pressures on PCPs, we have to find some alternative to the standard 15-minute appointment with the physician, such as group appointments for people with common conditions like diabetes.  Wait just a MRSA-contaminated minute here!  We pay more and more and more for our supposed health care every year, we are totally breaking the bank, we are stressing the whole country out trying to fix all this, and we can’t even get a measly 15 minutes with the Minor Deity?  Seriously?  (Meanwhile, the Deity is struggling to stay afloat in a world of shrinking reimbursements and greater pressures on his or her business.)

I must say that on the fairly rare occasions when I’ve gone to an MD, as for my yearly OB-GYN checkup, I’ve had more like a 25-minute appointment.  I hear that this is not usual, but it has been the norm for me thus far, perhaps precisely because I’m not there all the time– I’m having more than just brief followup appointments.  So I have a little bit of hope, but again, as the provider crunch gets worse, that hope is likely to evaporate.

(Appointments with me as the doctor, in contrast, are still normally scheduled for an hour or more.  My patients who have gone to community acupuncture or to other colleagues who see multiple patients in an hour tell me that they appreciate the difference.  I find trying to treat more than one person at a time very stressful, in addition to feeling that I can’t be as effective, and I have no intention of doing that on a regular basis, but the squeeze on insurance reimbursement may force me to change my ways eventually.  I hope not.)

Now let’s think about what actually happens during that 10, 15, or possibly 25 minutes.  What are primary care physicians for, and do they fulfill that purpose?  One of the main things they do is to prescribe and authorize refills of medications.  In the case of chronic illnesses, they should be able to help the patient maintain well and deal with any changes in their condition that come up.  Well, last week one of my patients, who has been taking Synthroid for decades since she had thyroid surgery, went to see her new PCP, who had been forced upon her by the issue I mentioned above, Presbyterian ending its relationship with the UNM system.  Her last PCP had reduced her dosage, and she had done extremely poorly until she figured out the problem– herself– and started taking the higher dose again.  She explained all this to the new guy, but he flat-out refused to consider prescribing the dose she needs.  Total failure both at paying attention to the patient and at delivering the treatment.  Especially at paying attention!  I wish I could say this was unusual, but it’s what I hear from patients over and over and over, and it seems most common with regard to thyroid issues.*  In this case, there was an out– I sent the patient to a colleague of mine who specializes in endocrinology and can prescribe natural thyroid extract.  Not everyone has such an alternative, and many patients go without effective treatment.

The other main thing a PCP is “for” is to be on the lookout for problems and do something about them before they get worse.  Often they really shine in that role.  A few weeks ago we got my mother’s PCP appointment moved up because she was getting markedly weaker and often short of breath.  The PCP (Ann Jones, MD, about whom I have few complaints) didn’t like the way my mom looked either, and sent her for extensive testing at the ER space across the parking lot.  They didn’t find much, but my mom came home– after an exhausting 9 hours– with a clear diagnosis and a prescription that has been noticeably helpful.  That’s more or less how things should work.**

On the other hand, a patient who has recently entered the Medicare age group went for her first ACA-mandated Medicare yearly wellness checkup around the same time.  This lady has had a chronic cough and severe fatigue for months, following a period of extreme stress, and although she’s improving, no clear cause has been found and the problem has been hard to treat.  The idea of these yearly exams for Medicare is supposed to be to give the patient a thorough going-over so that any problems will be found and dealt with appropriately, keeping them from getting worse and causing more cost and suffering.  My patient reported that the appointment lasted less than 10 minutes, she barely had the opportunity to ask any questions, her main complaint was not really addressed, and no treatment was suggested.  And this is a very assertive and articulate patient.  So it didn’t seem like the purpose of the exercise was fulfilled at all.

The PCP is often the most accessible and cost-effective person for performing minor, in-office surgeries.  And of course the PCP can order tests, which will either show that there’s no problem or perhaps guide the path to more specialized care.  When I had that health scare back in August, I ended up with Bob’s PCP, Oswaldo Pereira, MD, who had no more idea what was going on than I did, but could send me for further testing.  We ruled out a number of possibilities, and that was helpful and quite necessary; I needed to know that I didn’t have a cardiac issue, for example.  However, Dr. Pereira never came up with either a diagnosis or a treatment.  Since we couldn’t find anything dire, and since I was gradually getting better, we both dropped the matter.

I had the most significant improvement with a structural approach, under the care of my friend Christine Dombroski, PT.  Dr. Pereira, thoughtful and knowledgeable as he is, would never have thought to send me there, and didn’t really understand why this helped.  It’s just not part of the way MDs are usually trained.

I love the PCPs of the world and feel sympathetic toward them, but the more I consider all this, the more I think our typical use of them is a bit misguided.  I’d like to end with some fairly obvious statements about when to head for your PCP’s office, and how to use that system appropriately.  First, please do not see the PCP when you have a cold!  You will accomplish nothing except to waste time and money, tire yourself out when you need to rest, and spread viruses around the office.  Even a run-of-the mill case of flu is not a good reason to go to the PCP, unless you have an underlying condition that makes it more dangerous; all they can do is give you Tamiflu, which works poorly if at all, and tell you to rest and drink fluids, which you already know.  (Do feel free to see me or my colleagues, as we can actually treat you!)

Do head for urgent care or the ER if you have severe unexplained pain, trouble breathing, or other scary symptoms that are not resolving in a reasonable way at home.  And of course if you are having any signs of a possible heart attack or stroke (I should write another post on those), you should call 911 as soon as you can reach the phone.

 

*It doesn’t have to be that way.  Both my last PCP and my OB-GYN tend to dose thyroid replacement on the basis of symptoms rather than strictly by blood test results.  They are not unique, fortunately, just not the rule. 

**Update, later in the day:  This morning my mother saw Dr. Jones again, and she is leaving most medication issues up to the specialists.  So I ask again, what is the PCP for?  It’s not easy for 89-year-olds to get to appointment after appointment, nor for their families to get them there.

 

As I was writing this, I came across a great Medscape article by a doctor who has a vision of what a true health care system could be like.  You may have to sign up with Medscape to read it, but if you have any interest in medical matters, it’s well worth it.
http://www.medscape.com/viewarticle/819947?nlid=46863_1521&src=wnl_edit_medp_wir&uac=167278MR&spon=17

Here the author imagines an idealized school health teacher:
‘”She sat down with all of the physical-education, biology, and health-education teachers in her system, and together they outlined a plan to change the curriculum such that health education starts in kindergarten. In their system, by the time children reach the 12th grade, they know which side hurts when their appendix is about to rupture. They know the warning signs of a heart attack. They know when to start screening for colon cancer, and they know when it’s appropriate to access the doctor’s office, the urgent-care clinic, or the ER. They understand the basic dangers and positives of over-the-counter medications. In other words, by the time someone puts a high school diploma in their hands, they are as well equipped to take care of their bodies as they are to find their favorite iPhone app.

“They understand the difference between a carbohydrate and a fat and which foods fuel their systems to fight cancer, heart attack, and stroke. They are not going to be obese because they know to exercise at least 150 minutes per week. Mrs J’s students are going to cost us less and live longer. They will live better with more money in their pockets, because they won’t have to buy a laundry list of prescription medications every year until they die prematurely from a preventable illness.’

And here’s her imaginary doctor who figured out a fix for electronic health records:  ‘Then, there’s Dr P [for practical]. Although we acknowledge the necessity of electronic health records [EHR], our earliest efforts have failed the patient. A doctor’s daily work has ground down to a snail’s pace. Patients complain about the basic lack of eye contact during an office visit because the doctor is focused on a screen. Dr P revolted against that practice. He designed a system where there are shorter updates at each visit and there is a symptom-limited entry into each subsequent visit. You don’t have to go through 900 reviews of systems that have nothing to do with why this particular patient has come to see you. He does only a positive review of systems. He took the time away from his EHR and gave it back to his patients, and his patients are more satisfied and better taken care of because of it.’

All this could happen.  There’s no reason why it couldn’t.

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The Wealth of Health: Oriental Medicine as a New Mexico Resource

The following is an updated version of an article I wrote for the April issue of Santa Fe’s Green Fire Times.

 

Although New Mexico is considered a poor state, we have a wealth of options for healthcare that many other parts of the country can hardly imagine. How can we turn this wealth into not only better health outcomes but also a brighter economic future?

There is broad agreement at every level of society that maintaining wellness is better and cheaper than trying to fix things that have already gone wrong. However, the market forces that we allow to rule, more often than not, work against this ideal. For example, if people use at-home methods of preventing influenza, huge profits can’t be reaped from selling millions of flu shots. That’s horribly backwards because healthcare costs are eating our country alive.  There is very little that is healthy about our “healthcare” system, financially or otherwise.

In Oriental medicine we think in terms of keeping patients well through educating them about diet, emotional balance and the like. A famous proverb says that the mediocre physician cures illness, the good physician prevents illness, and the superior physician teaches people how to live so that they stay well. We’re also told that in ancient times doctors were paid when people stayed healthy, not when they got sick– the original HMO plan! Unfortunately, things have changed quite a bit, and despite efforts in that direction, so far our modern system hasn’t figured out how to pay healthcare providers for having patients who don’t need treatment.  But if we can somehow manage this kind of emphasis on wellness instead of sickness, our healthcare costs will surely drop. Many of our most financially draining patients are those with largely preventable chronic diseases like Type 2 diabetes. We know we have to get such “lifestyle” illnesses under control. Oriental medicine is an excellent framework for doing that.

To a large extent health insurance has ignored wellness-based care, and our Health “Maintenance” Organizations even specify in their plans that they don’t cover treatment intended for maintenance. We do have a relatively good situation in our state, in which acupuncture and some other aspects of Oriental medicine are covered, albeit sometimes poorly, by insurers based in NM. However, there is no Medicare coverage at all, and Medicaid is limited to a few special circumstances. This means that many of the people who could benefit most are left out.

And then there is the geographic problem. Medical care of all types is scarce and often of poor quality in the less-populated parts of the state, and non-mainstream care is even harder to get.  (I am the only provider of acupuncture in a large swath of western NM, and I’m only there once a week.) This is exacerbated by the fact that those areas tend to have a higher proportion of low-income people.

Could financial incentives help with getting more providers into rural areas? So far, that hasn’t seemed to be enough. MDs are already paid much more in some underserved areas, yet it’s hard to get them to go and live there. Doctors and nurses can get their student loans forgiven if they practice in such places for a certain period of time. While that’s a good idea, it doesn’t encourage practitioners to put down roots in a community. And Doctors of Oriental Medicine aren’t eligible for this help with their loans. Still, there are a great many DOMs, and we do a lot of primary care. In a state that is short on MDs, there must be a way to use us to fill some of the gaps.

The Affordable Care Act mandates that states must have health insurance exchanges in place by 2014 to make coverage available to most of the population. In New Mexico, it looks like acupuncture will be included as an essential health benefit. This should make a real difference in access for our citizens– when it happens, which may not be the date originally prescribed.  At the 11th hour of the 2013 session, our state legislature finally came up with a plan for an exchange.  However, the plan that emerged was a compromise that left out consumer protections that many legislators wanted.

The health insurance exchange plan, alas, will leave the insurance companies in charge no matter what the details are. It will also contribute to high costs by adding even more plans to the mix– the cost of dealing with a multitude of plans is a huge reason why American medicine is so expensive. Analyses done so far say that this approach is unaffordable for our relatively small population. New Mexico does have another option, one that’s homegrown and tailored for us, one that enjoys wide support around the state. The Health Security Act, which was submitted yet again in this year’s legislature, provides a framework that could cover most of us and have a real shot at controlling costs. The exchange could morph into a more efficient model like this if we ever muster the will to do it. This year the HSA did very well early in the legislative process, and looked as if it would at last come to the floor for a vote.  However, political infighting involving some of Health Security’s formerly loyal “friends” (Reps. Stewart and Garcia, you know who you are) prevented the bill from reaching the House floor.

If we in New Mexico and elsewhere continue to destroy our chances to build a workable health care system on the basis of greed or because of petty, short-term concerns, then we deserve what we get.  We can do so much better.

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