WHERE DO AMERICANS GO FOR HEALTHCARE?

 

Anna Rosenfeld

 

 

            The face of American medicine has changed dramatically in recent decades.  An increasing number of different practitioners now offer a wider-than-ever variety of services to the healthcare consumer while the settings in which these changes are taking place are expanding as well.  And the market is continuing to evolve, with more changes anticipated in the near future.  How are these various services defined?  Where do they take place?  What are they all about?  How many people actually use them?  Do they really work?  How much do they cost and who pays the bills?  Who regulates the facilities and licenses the practitioners, making sure that they are performing an adequate job?  Today the notion of “going to the doctor” no longer means the same thing for everybody, and wise medical consumers are evaluating a broad range of options when deciding what is best for them. 

            The chapter which follows is divided into four sections which describe the most readily available healthcare services in the US today.  The first of these is Conventional Medicine which is subdivided into hospital care including emergency departments and ambulatory care which includes services provided not only by physicians but non-physician healthcare providers as well.  The second is Alternative Medicine, comprised of many eclectic practices and services which often predate “modern medicine” but have only recently begun to regain the widespread popularity and mainstream acceptance which they once enjoyed.  Selected for this section, from the much wider array of services which actually exist, are those schools of thought currently deemed to be the most popular.  These include:  chiropractic, acupuncture, chinese medicine, homeopathy, naturopathy, massage therapy, hypnosis, and biofeedback.  The next domain, Community Medicine, consists of those services provided with increasing frequency in local communities including community clinics, school-based health services, health services in the workplace, and support groups.  The final section focuses on a topic currently receiving a great deal of attention both in the media and the public health arena.  As the aging of the American population becomes a reality, many solutions to the rapidly expanding problem of Elder Care have been proposed.  Nursing homes, home healthcare, continuing care retirement communities, and hospice programs are just a few of the many answers.

 

 

CONVENTIONAL MEDICINE

           

Hospital Care has always been reserved for the sickest of patients.  Today, in the era of cost-cutting managed care, this is more true than ever, and the number of hospitals and hospital beds are thus on the decline.  In 1996, there were 6,201 hospitals in the US (there were 194 hospitals of all types in the state of Ohio in 1999) with a combined total of nearly 1.1 million beds, down from 7,156 hospitals in 1975 accounting for a reduction in approximately 0.3 million beds1,2.  The number of yearly admissions also dropped, from 36,157 in 1975 to 33,307 in 19961.

            Growing costs have driven these reductions.  Today, the average cost of hospital care, not including the price of  surgery, an intensive care unit stay, or expensive diagnostic or therapeutic procedures, well exceeds $1500 per day3.  In fact, nearly $360 billion were spent on hospital care in 1996, compared to only $9.3 billion in 19601.  In 1993, $14.3 billion were spent on hospital care in the state of Ohio alone1.  The government footed 61.5% of the hospital expenditure bill (33% by Medicare and nearly 15% by Medicaid) in 1996, while 31.6% came from private insurers, and 2.6% was paid out-of-pocket1.

            The cost of hospital care is, in part, determined by the type of hospital.  A specialty hospital takes care of a limited number of medical conditions or a specific type of patient3.  Common examples include cancer hospitals, burn centers, children’s hospitals, and women’s hospitals.  General hospitals, on the other hand, are prepared to handle all sorts of patients with a wide variety of medical problems3.  They are frequently composed of many specialty hospitals within one building or several connected buildings, which essentially defines them as a medical center3.  A medical center is generally much larger than a community general hospital — it may have as many as 1000 beds (although the number of hospitals this large is well under 5% of the total) — and is equipped to treat all sorts of rare as well as common conditions1,3.  Large medical centers are also likely to be affiliated with a university and a medical school, thus making it an academic medical center  which serves as a clinical practicum site for residents, medical students, student nurses, and students of other allied health specialties3.

            Small general hospitals are the typical “community hospitals” which make up the vast majority of hospitals in the US.  In 1996, 5,134 , or approximately 83% of all hospitals, were community hospitals, accounting for over 860,000 beds and over 31,000 admissions nationwide1.  Community hospitals average approximately 250 beds (in fact, over 50% of US hospitals have fewer than 200 beds), but can be much smaller or somewhat bigger1,3.  They are usually well equipped, efficiently run, and may provide better service to their patients3.  Historically non-profit organizations, the trend is now towards for-profit ownership3, although in 1996 3,045, or nearly 60% of all community hospitals, were still considered to be operating on a not-for-profit basis1.  There has, in recent years, also been an increasing trend towards affiliation with medical schools, bringing to the community hospital a more academic focus while teaching students about “routine” hospital care3.

            Specialty hospitals and the medical center conglomerates which they form tend to hire doctors who are more knowledgeable about rare diseases as well as cutting-edge researchers who are pioneering new procedures and developing new protocols3.  These facilities usually have the newest equipment and frequently have access to experimental medications3.  Because specialty hospitals focus on narrow categories of diseases, they are assumed to be better at treating those conditions.  Generally boasting large patient volumes, they also tend to be better at performing procedures whose success and complication rates depend on the extent of practice and experience3.  This expertise may, however, bring with it a larger price tag.  Academic institutions also incur greater expenses, up to twice those of the non-teaching hospitals, because of the new technology, top researchers and clinicians, research funds, and the sometimes unnecessary diagnostic tests which are all part of being at a teaching center3.

            Hospitals can also be government owned.  Of the over 6,000 hospitals in the US in 1996 just over 20% were owned by state or local governments accounting for slightly less than 15% of all hospital beds and admissions1.  The federal government owns and operates 173 Veterans Affairs (VA) Hospitals, 401 VA ambulatory care clinics, and 133 VA nursing homes nationwide and in 1996 spent nearly $16.4 billion for health care expenditures at these institutions1,4.  Of this total, 46.3% paid for 807,000 inpatient admissions for 491,000 individuals, 33.6% paid for over 29 million outpatient visits by over 2.8 million patients, and 10.1% was spent on nursing home care1.  Although originally intended to pay only for care stemming from war-related injuries and disabilities, less than two percent of the nations 26.2 million living veterans are actually eligible for services on this basis4.  Therefore, the VA currently provides the majority of its services to that 10% of the US veteran population that lacks insurance and thus access to healthcare anywhere else4.

            All hospitals, regardless of type, are accredited and monitored by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) which conducts periodic checks and reviews of facilities and procedures to ensure that their guidelines and standards are being met3.

 

            In addition to providing inpatient care, hospitals also provide emergency services in an Emergency Department  (ED) designated to treat acute medical problems including severe illnesses, accidents, and injuries at any time of the day or night.  In 1996 Americans made over 90 million ED visits, or 34 per 100 population1.  While emergency departments must be able to provide care for life-threatening conditions which require rapid intervention, they are commonly forced to deal with medical urgencies (those conditions which are not life-threatening but must be addressed in a timely fashion) to a much greater extent than they do with true emergencies.  While up to 80% of the care provided in the emergency department may be urgent rather than emergent in nature, the hospital is required, by law, to provide care to anybody in immediate need regardless of insurance coverage or ability to pay3.

            Emergency departments are assigned a level by JCAHO, based on the degree of care they are able to provide which is determined by the resources, including board-certified emergency physicians, available to them3.  Level I designates an ED which is both comprehensive and sophisticated.  It is staffed by board certified emergency physicians 24 hours a day and physicians from a wide variety of other specialties are available for consultation at all times and can be expected to arrive in no more than 30 minutes3.  Level II departments are fairly comprehensive and must have at least one emergency medicine physician on staff and consulting physicians available3.  Level III EDs provide emergency care 24 hours a day but a physician does not have to be on the premises full-time.  He or she must, however, be able to arrive within 30 minutes when the need arises3.  The main function of these departments is to assess all patients and to stabilize the sickest patient for transfer to a higher level of care facility3.  Level IV departments mostly serve as a first aid station which stabilizes all acute injuries prior to transfer and a triage point for determining which sub-acute patients require admission3.

 

Ambulatory Care deals with the treatment of individuals on an outpatient basis, and it has been estimated that 95% of all health care can be provided in this setting5.  In 1996, Americans made a total of over 892 million ambulatory care visits or 330 per 100 people1.  Of these visits, approximately 735 million were to physician’s offices, 67 million to hospital outpatient departments, and 90 million to emergency departments1.  In 1996, over $202 billion were spent on physician services1.  Private insurance companies paid slightly more than half of this total, the government paid for nearly a third (21.1% by Medicare and 7.5% by Medicaid), and individuals paid for almost 15% as out-of-pocket expenditures1.  Of the over $171 billion spent on physicians services in the US in 1993, $7.1 billion were spent in the state of Ohio1.

            For many years, outpatient medical care has been delivered in Physician Offices as part of either a group or solo practice setting.  These individuals are graduates of allopathic or osteopathic medical schools which, after four years of professional school training, confer the degree of Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO), respectively.  Both types of physicians have taken national board exams to establish their competency in the practice of medicine as required for state licensure in each of the 50 states.  The National Center for Health Statistics estimates that in 2000 a total of 16,112 individuals will graduate from the 125 allopathic medical schools and 1,934 individuals will graduate from the 17 osteopathic medical schools in the US1.

            While most people are familiar with the role of allopathic physicians in assessing patients and diagnosing and treating illnesses, people tend to be less knowledgeable about osteopathic medicine.  Founded by Dr. Andrew Taylor Still in 1874 on the Missouri frontier, today there are more than 40,000 DOs in the United States who account for a total of roughly 100 million patient visits per year3,6.  The medical school curricula are almost identical for the two types of physicians, and graduates of both programs can specialize in various medical fields.  The osteopathic curriculum, however, puts particular emphasis on holistic medicine, regarding the human body as a unified whole and emphasizing the important role of the musculoskeletal system in achieving good health3.  Osteopathic physicians also receive some additional training in nutrition, exercise, and osteopathic manipulation of the spine as well as other parts of the body3.  Those osteopathic physicians who have received extensive training in spinal manipulation may be of particular service to patients with musculoskeletal disease (by helping to improve posture, bone and joint function, and mobility), headaches, arthritis, back pain, neck pain, and sports injuries3,6.

            Although the traditional image of a physician is that of a primary care doctor working in a solo private practice, this pattern of practice has changed dramatically over the last several decades, with many physicians choosing to leave their solo practices to join larger groups which are frequently part of a Health Maintenance Organization (HMO).  They frequently cite the financial difficulties of solo practice such as a lack of economies of scale, large overhead costs, and continuously increasing difficulties in obtaining decreasing reimbursements from Medicare and private insurers as the primary reason for the change7,8,9.  But they also list the increasing amount of paperwork needed to comply with government regulations and a diminishing number of solo-practice colleagues available to share call and cover for time off7,8,9.  In group practice they note income stability, office space with on-site ancillary services (such as radiology, laboratory, and billing), and the company of colleagues who can provide advice as important advantages7,8,9.  Some practitioners have overcome the financial limitations of solo practice, however, by joining an independent practice association or an alternative agreement with other solo practitioners to centralize purchasing, billing, and contracting with insurance companies for patients and service referrals7,8,9.  They point to the autonomy in clinical decision making, the independence of structuring their practice in the way that they want, and the lack of bureaucracy associated with a large group practice as the primary reasons for staying despite the long hours and increasing economic hardships7,8,9.

            An even newer variation of the group practice collaboration is a working partnership between physicians and non-physician clinicians (NPCs) such as physician assistants (PAs) and nurse practitioners (NPs).  Each of these disciplines has been in existence in the US for about 30 years and has made large strides in gaining broad public acceptance in recent years due to the belief that they provide readily accessible, cost-effective healthcare10,11.  As a result, there is an increasing integration of these practitioners into HMOs and private practices. 

            The roles of these two types of NPCs are frequently similar.  Both PAs and NPs are trained to perform physical examinations, order and interpret laboratory tests, diagnose illnesses, establish and implement treatment plans, suture wounds, and provide preventive health services10.  While state laws governing their practice prerogatives vary markedly, there is a  growing trend towards increasing rights and privileges, particularly with regards to the right to prescribe medications10,11.  So far, the increase in practice prerogatives has correlated positively with the growth in the number of practitioners, a trend that is expected to continue into the future.  For example, in 1994 there were a total of 223,500 NPCs (85 per 100,000 people), a number equivalent to 40% of the number of physicians in the US at that time11.  This number is expected to nearly double to 443,000 (143 per 100,000 people) by 2010 at which point it will, most likely, equal 60% of the total number of US physicians11.

            Physician assistants complete a two year training program either for an associate’s degree, as part of the curriculum for a bachelor’s degree, or at the master’s degree level11.  In 1994, there were fewer than 30,000 physician assistants, graduates of one of 64 programs nation-wide, practicing in the US12.  By 1996, the number of training programs had risen to 78 with 40 more awaiting accreditation12, and the number of PAs is now expected to exceed 75,000 by 201011.  PAs are currently recognized by licensing boards in all but one state, can prescribe medications in 39 states, and become licensed by passing the Physician Assistant National Certifying Examination12.  Approximately 92% of practicing PAs have passed this exam, 72% have a bachelor’s degree or beyond, and 13% have a master’s-level education12.  By definition, physician assistants aid physicians, but their specific duties, responsibilities, and amount of supervision can vary widely between states and within individual practices10,11,12.  Although trained primarily in primary care, approximately half currently practice in specialty fields11.

            Nurse practitioners are registered nurses who have completed one or more years of graduate-level course-work and clinical rotations, most commonly in a program which provides them with a background in primary care11,13.  The current trend is for NPs to have completed at least a 2-year master’s program and then receive certification by the American Nurses Association, and it is believed that nurse practitioners can be reasonably expected to deliver 80% of services that primary care physicians provide at a comparable level of quality and a decreased cost11,13.   State licensure requirements and privileges vary widely, however, making it difficult to estimate the actual number of practicing NPs and to clearly define their roles.  It has been estimated that there were approximately 40,000 NPs in 1994, a number which is expected to exceed 100,000 by 201011.  At least 50-75% of these providers are in a primary care field, with 75% of the 1995 graduates from 206 different universities having selected a primary care field of practice10,11,13.  Currently, 20 states allow for completely autonomous practice while the other 30 require NPs to collaborate with physicians13.  And 48 states grant some prescribing privileges (although these are limited in all but 11 states) 13.  Medicaid tends to reimburse NPs at a rate of 50-100% of the physician rate, and many states require private insurers to reimburse NPs as well11.

            Another recent trend in ambulatory care is the Ambulatory Care Center of which there were over 4,600 by 1993 3.  These relatively new innovations, frequently called urgent care centers, are a hybrid of a sub-acute emergency department and a private office, providing care for minor injuries and less serious illnesses 3.  These centers provide quick, convenient access via walk-in appointments at extended or even around-the-clock hours 6 or 7 days out of the week 3.  They are definitely less costly than a visit to the ED but may cost no less (and sometimes even more) than a visit to the patient’s primary care physician 3.  Furthermore, concerns have been raised about the quality of the care they provide 3.

 

 

Alternative MEDICINE

 

            While traditionally defined as interventions which are not taught widely in medical schools and generally unavailable in US hospitals14, the definition of alternative medicine is changing along with the face of medical practice.  Alternative medicine practices and techniques are growing in popularity; they are also gaining increased attention from the media, mainstream medicine, and the federal government which recently established the National Center for Alternative and Complementary Medicine at the National Institutes of Health.  Furthermore, since the mid-1990s, an expanding number of insurance providers and HMOs have offered at least some alternative medicine benefits as part of their regular or extended-coverage packages11,15, and the majority of US medical schools now offer some education on alternative medicine topics14.  The widespread acceptance of some of these practices raises the question as to whether they are still truly “alternative”.

            The best data on the prevalence of alternative medicine use in this country comes from two studies conducted by Eisenberg, et al.  In a 1990 large-sample telephone survey, they found that approximately 34% of Americans used one of 16 defined alternative medicine therapies14. Their 1997 follow-up study found that this number had increased to 42% and was widely distributed across all demographic groups14.  In that year, the estimated number of visits to all alternative medicine practitioners exceeded the number of visits to all primary care physicians by approximately 243 million with well over half of those visits intended, at least in part, to “prevent future illness from occurring or to maintain health and vitality”14.  Of those individuals surveyed in 1997 who reported seeing a medical doctor for one or more specific conditions, nearly one-third also used an alternative therapy (with nearly 14% going to an alternative medicine practitioner) for the same condition14.

            Users of alternative medicine therapies saw definite improvements in third party reimbursements over the course of those 7 years14.   In 1990, it is estimated that between $14.6 and $22.6 billion were spent on alternative health care with $7.2 to $11 billion paid out-of-pocket14.  By 1997, these numbers had risen to $21.2-32.7 billion and $12.2-19.6 billion, respectively14.  And while in 1990 only 36% of individuals reported at least partial insurance reimbursement of alternative health care services, nearly 42% did so in 199714.

            The general consensus is that alternative medicine therapies, if used with common sense, are safe and may be very effective in attaining a clearly defined set of objectives.  It is important to keep in mind, however, that these therapies should remain complementary (and are frequently referred to as such), in the sense that they should never keep people from seeking professional services from conventional medical practitioners when they are seriously ill or injured or if their condition persists despite alternative treatment6,15.  Although alternative therapies can, at times, be used to enhance the effectiveness or ameliorate the side-effects of conventional treatments6, they should never be used in their place when doing so will jeopardize a person’s chance for a successful recovery and should be avoided when there is a possibility that they will diminish the effectiveness of the conventional therapy15.  Another important point to keep in mind with respect to alternative therapies is that there is a great deal of overlap between practitioners’ domains.  While it may be advantageous to select a practitioner whose interests lie in more than one field, it is important to make sure that person is adequately trained in the particular type(s) of therapy desired and has a state license and malpractice insurance, when applicable15.

 

Chiropractic is regarded as the leading form of alternative medicine and the third leading healthcare profession in the US with approximately 50,000 practicing chiropractors in 1998, a number which is expected to double by 20106,16.  In fact, many do not consider the 2,950 students who are expected to graduate this year with the degree of Doctor of Chiropractic (DC)  from a total of 17 schools1 accredited by the Council of Chiropractic Education16 to be “alternative”  practitioners at all. 

            Chiropractic was the first alternative medicine specialty to gain mainstream recognition, with all 50 states as well as the District of Columbia having established licensure requirements for DCs by 197416.  These services have been reimbursed by Medicare since 1972 and are also currently paid by Medicaid, Worker’s Compensation programs, and most major insurance companies16, with 41 states requiring private insurers to cover at least some of the costs of treatment11.  Eisenberg found that 11% of the population saw a chiropractor in 1997, averaging about 10 visits each or an estimated 191,886,000 total visits in the US in 1997 alone14.  Insurers provided complete coverage for 18%, partial coverage for 38%, and no coverage for 44% of these individuals14.

            The practice of chiropractic, Greek for “hand work”, specializes in manual manipulation of the spine16.  Begun in 1895 by Daniel David Palmer, the specialty took advantage of popular health reform to combine three schools of contemporary thought:  bonesetting, magnetic healing, and orthodox science16.  Originally dealing only with bones, the scope of practice was gradually expanded to include joints, muscles, and nerves16.  Chiropractic practice today focuses on mobility, posture, blood flow, muscle tone, and the condition of nerves and

use conventional physical therapy techniques such as exercises, ice packs, braces, bed rest, moist heat, and massage16.  Less frequently, chiropractors may also use ultrasound, electrical stimulation, herbal preparations, homeopathy, vitamins, nutritional counseling, and acupuncture as part of the treatment plan6.

            Although still regarded by traditional academic medicine as being on the fringe, many physicians do acknowledge the important role that chiropractors often play in the treatment of low back pain, the primary complaint of 65% of all chiropractic patients16.  Conventional medicine has, overall, not done a very good job of treating chronic pain, particularly back pain.  Most conventional physicians, for example, regard typical low back pain as a self-limited, non-threatening condition for which the best treatment is time.  Chiropractors, on the other hand, take a very different approach to back pain, one which improves patient satisfaction16.  They tend to empathize with their patients while proposing a plausible and easy to understand theory of why they are experiencing pain16.  By seeing the patient within 24 hours, validating their experience by assigning a physical cause to the pain, and providing an expectation of improvement and thus a feeling of empowerment, the profession has led many people to prefer DC over MD treatment for their conditions which, in addition to back pain, include such things as:  neck problems, headaches, sprains/strains, arthritis, chronic pain, and even digestive problems14, 16, 17.

            The results of randomized clinic trials range from showing no difference between conventional treatment, chiropractic care, and sham manipulation to a clear benefit in those patients assigned to receive chiropractic services16.  While all of these trials had methodological limitations, no trials have found chiropractic to be worse for back pain than any other existing treatment, although it is not yet clear whether the benefits attained are expected to bring long term or only acute relief16.  It is, however, safe to deduce from these trials that chiropractic therapy may offer clear benefits to some patients at a very acceptable level of risk.  Minor complications of spinal manipulation include soreness or muscle spasms6 while major complications (such as fractures or embolic stroke) occur on the magnitude of 1/million(s)16.  Chiropractic treatment is, however, contraindicated in patients with cancers affecting bone, fractures, extreme osteoporosis and severe degenerative disease, inflammatory conditions, and infection6,16.  Most uncomplicated problems for which chiropractic care is sought can be treated in about 6-8 weeks, with some improvement seen within the first month of treatment (and usually sooner) 6.  A more complicated situation, such as an acute injury superimposed on pre-existing disease, may, however, take twice as long to improve or resolve6.

 

Acupuncture was used by 1.0% of the people surveyed by Eisenberg’s study group in 1997, the vast majority of whom consulted a practitioner, accounting for an estimated 5,377,000 total visits to practitioners nationally that year14.  Another one of the less “alternative” forms of alternative medicine, acupuncture has been a part of mainstream medicine in China for nearly 3,000 years6 and gained significant popularity in the US following President Nixon’s 1972 visit to China18.  The practice of acupuncture involves inserting very thin solid needles into strategic points in the body (over 300 such acupuncture points exist along channels called meridians) 6,18.  Approximately 10 needles are used in a typical session which can last from several seconds to an hour6.  The idea behind this somewhat spiritual form of medicine is that everything in the human body is interconnected, with the needles, which may be left in place or manipulated throughout the session, facilitating the body’s free flow of qi (“vital energy” or “life force”) 6,18. As is often the case with alternative medicine therapies, acupuncture draws heavily from other practices, most notably traditional Chinese Medicine6.

            There are several different schools of thought in acupuncture.  The most common are:  Classical which is based on Chinese theory, Japanese which uses thinner needles and massage techniques, auricular which focuses on acupuncture points in the ears, and French/Helms-style or “medical acupuncture”6.  This last form is the one most commonly used by the American MDs and DOs who have trained in acupuncture and is the only kind that is legal in 23 US states6.  Needle-free alternatives and other variations on the acupuncture theme also exist.  The most common of these is acupressure, a technique older than acupuncture, in which pressure is used to stimulate acupuncture points6.  Japanese shiatsu is the most popular type of acupressure although other schools do exist6.

            A growing body of scientific evidence from credible, peer-reviewed publications has shown that acupuncture works6, although the vast majority of evidence has come from less convincing studies including case reports and case series or intervention studies with inadequate power18.  Furthermore, the mechanism of action is not clear, but it is hypothesized that the insertion of needles either stimulates the release of pain-mediating hormones and/or opioid peptides or regulates the nerves in the muscle at the acupuncture points to modulate pain input to other parts of the body6,18.  Acupuncture may also alter the regulation of blood flow, activate the hypothalamus and pituitary glands, and affect immune function18.  Another limitation of existing studies is that sham acupuncture has also been shown to work6.  Despite these limitations, however, the US Food and Drug Administration recently removed acupuncture from its list of “experimental” therapies and devices, and the National Institutes of Health released a statement in 1998 calling acupuncture “remarkably safe, with fewer side effects than many well-established therapies,” purporting that it may work as well as many accepted Western therapies for pain following dental surgery, and the nausea and vomiting associated with surgery, chemotherapy or pregnancy6,18.  Other potential uses for acupuncture include:  headaches, facial pain, neck pain, low back pain, carpal tunnel syndrome, arthritis, epicondylitis (tennis elbow), fibromyalgia, kidney pain, and menstrual cramps, the management of asthma and bronchitis, and for improving recovery from a variety of illnesses including addiction, sports injuries, and stroke6,18.  In China, acupuncture is used to treat a wide variety of conditions, including depression and is used in 40% of all surgeries to boost the effect of the anesthetic agents6.  The World Health Organization has cited over 40 conditions in which it believes that acupuncture may serve a purpose18.

            In some states only MDs and DOs can be licensed for the practice of acupuncture, usually after completing at least 200 hours of training (although many physicians have attended courses three times as long) 6.  These physicians then become members of the American Academy of Medical Acupuncture15.  Thirty-six US states, however, allow non-physicians with an amount of training deemed to be appropriate to be certified6.  This usually involves completing a two-year course in an approved program and then passing a National Certification Commission for Acupuncture and Oriental Medicine exam6.

            Many insurance companies will only pay for acupuncture services performed by MD and DO practitioners and Medicare does not pay for acupuncture at all6.  Eisenberg’s 1997 study found that no private insurance plans provided full coverage of acupuncture while insurers provided partial coverage in 40.7% of cases and no coverage in the remaining 59.3%14.  Six states now do require private insurers to pay for acupuncture, at least in part11. 

            Without insurance, at a cost of $35-80 per one-hour session, acupuncture can get quite costly, especially considering that most uncomplicated conditions will require one or two treatments a week for six to eight weeks6.  However, the number of treatments needed and the specific acupuncture points used vary considerably for each person18.  Older patients, those with more extensive illness or injury, and those who have been sicker longer will usually require a prolonged treatment course but should get a sense within several weeks as to whether the therapy is likely to work for them6.  A minority of individuals (although a larger percentage than previously believed) will not respond to acupuncture at all18.

 

Closely related to acupuncture in many ways is the field of Chinese Medicine which dates back over 5,000 years emphasizing wellness and disease prevention, the interaction between patient and healer, and the concepts of holistic medicine which through physical, emotional, and psychological healing attempt to maintain or restore overall health rather than cure or ameliorate a particular symptom or disease6.  The group of philosophies embodied by this practice are, more accurately, referred to as “Oriental Medicine” with roots in China, Japan, Korea, and other parts of Southeast Asia6.  Traditional Chinese Medicine is, however, the largest branch, especially in the US.  Built on five pillars of practice which parallel the Chinese theory of the five elements of nature (earth, fire, water, metal, and wood), this 2,300 year-old tradition works to bring balance to the body through acupuncture; massage; herbal preparations; diet and nutrition; and lifestyle changes such as exercise (martial arts), stress reduction and relaxation, mind-body medicine, and meditation6.  Other types of Chinese or Oriental Medicine bring in many eclectic techniques from a variety of different schools of thought6.

            Chinese Medicine has been used for the treatment of low back pain, muscle pain and cramps, osteoarthritis, tooth pain, facial pain, fibromyalgia, headaches, asthma, chronic fatigue syndrome, chronic bronchitis, emphysema, Crohn’s disease and ulcerative colitis, nausea and vomiting associated with surgery, pregnancy, or chemotherapy, withdrawal symptoms experienced in recovering from addictions, and paralysis (from strokes, head and spinal cord injuries, multiple sclerosis, and Bell’s palsy)6.  However, many of the theories and claims are very difficult, if not impossible, to substantiate scientifically, although it is hoped that the recent increase in research in the field will bring somewhat more definitive results6.  For those trying to decide whether or not to seek the services of an Oriental Medicine practitioner, it is important to keep in mind that the real dangers of these forms of treatment lie in the medications and not the techniques6.  There are numerous case reports in the literature of Chinese patent remedies that have been adulterated with heavy metals, steroids, and prescription medications, and the herbal preparations, some of which have significant toxicities, must be mixed professionally and appropriately in order to assure that they are safe6,15.

            Appropriate training can be obtained at one of 35 US schools with 3- or 4-year graduate programs which confer the degree of Doctor of Oriental Medicine (OMD)6.  These non-physician graduates can obtain licensure in 25 US states11, although the requirements for licensure and registration vary widely6.  In general, it is easier to find qualified Oriental Medicine practitioners on the West Coast with California, Colorado, Florida, New Mexico, New York, Oregon, and Washington boasting the largest numbers of these healers6.

            The cost of services frequently depends on the extent of the practitioner’s training, with MDs who have additional training in Oriental Medicine typically charging the most6.  In general, the price of an initial visit ranges from $60 to $110 and follow-up visits cost between $30 and $806.  The herbal medications, which are a necessary part of many treatment plans typically run another $25 to 50 per month6.  Currently, few insurance plans pay for Oriental Medicine services, although visits to an MD who also practices Oriental Medicine are more likely to be reimbursed6.

 

Homeopathy was used by 3.4% of the population surveyed by Eisenberg, et al., but only 16.5% of these individuals saw a homeopathic practitioner14.  It has been estimated that in total Americans made 1,777,000 visits to homeopaths in 199714 and spend over $200 million annually on homeopathic medications, a figure which grows by approximately 12% annually6.  World-wide an estimated $1-5 billion is spent annually on homeopathic services and medications6.

            The philosophy behind homeopathy is very unique, claiming that highly diluted concentrations of natural substances can be used to cure each individual’s illness in its own way6.  Homeopaths believe that these highly diluted solutions work via the “law of similars” such that a substance, which in large amounts would produce the same symptom that the patient is experiencing (and may even be toxic), in minuscule quantities incites the body to mount its “life force” or “vital energy” against the foreign substance, initially resulting in an intensification of the undesired symptom but ultimately bringing about its successful resolution6.  The more dilute a solution, the more potent, and it is not unusual to find only one drop of substance diluted by one million drops of water6.

            This unique practice was founded approximately 200 years ago, in the late 1700s, by Samuel Hahnemann and picked up a great deal of momentum during the 19th century when the practices of blood-letting, purging, and patent medicines routinely used by conventional physicians of the day were considered by many to be undesirable if not outright dangerous6.  When the widespread popularity of homeopathy began to seriously threaten the livelihood  of allopathic physicians, allopaths throughout the country joined together to the form the American Medical Association (AMA) in an attempt to limit the ability of homeopaths to practice their alternative medicine6.  Their efforts failed, however, and by 1900, with approximately 15% of all US physicians having graduated from one of the homeopathic medical schools then located in almost every major city, the AMA granted recognition to the homeopathic movement6.  But the victory for homeopathy was short-lived6.  With the discovery of antibiotics and vaccines, more barbaric medical practices fell out of favor and mainstream medicine became much more palatable to the public6.  As a result, homeopathy all but died out, with fewer than 100 homeopathic physicians practicing in the US in 19706.

            Although homeopathy has been used to treat such diverse conditions and symptoms as allergic asthma, hay fever, migraines, childhood diarrhea, rheumatoid arthritis, and fibromyalgia and to decrease the duration of labor and the time required to recover from trauma, studies on the perceived benefits are difficult to conduct6.  Meta-analyses, published in well-respected journals such as The Lancet and the British Medical Journal, however, have shown some benefits over placebo6.

            The FDA regulates the manufacturing and marketing of the over 2,000 different homeopathic medications available for sale in the US6 .  Approval of these medications, however, tends to be a formality, since manufacturers are rarely required to provide evidence of safety and efficacy and most of these preparations can be purchased without a prescription6.  Furthermore, only four states provide licensure15 whereas the standards by which homeopathic providers are regulated in the reamining 46 states are quite variable.  The Council of Homeopathic Education has, however, stated that five universities — three on the West Coast, one in Canada, and one in Europe — meet their standards for providing adequate training in homeopathic medicine6.

            An initial visit to a homeopath averages $137 with follow-up visits costing around $55 each6.  Medications, however, are significantly less expensive at $3-7 a bottle, and refills are rarely required6.  Although insurance reimbursement may be available when individuals consult mainstream practitioners who also practice homeopathy6, Eisenberg’s study found that no insurance coverage whatsoever was provided to those individuals who sought homeopathic services14.

 

Naturopathy is the branch of alternative medicine dealing with “anything ‘natural’” including herbal medications, dietary supplements, acupuncture, dietary and/or lifestyle modification, stress management, and detoxification6.  From the diversity of the components involved, it is evident that naturopathy is more a philosophy than a given set of techniques; a philosophy which draws heavily from the other conventional and alternative medicine practices, including Asian, Indian, and Greek medicine, which believe in the healing power of nature and the body’s ability to heal itself6.  Also inherent to this philosophy of “natural medicine” are the previously discussed concepts of the holistic individual, the active role of the patient in attaining spiritual and physical health, the role of the physician as teacher, and the importance of preventive measures6.  Another important component of naturopathy is an attempt to find and change the cause of disease which it believes lies in the environment — either internal or external6.

            The profession of naturopathy was brought to the US in 1895 by a German immigrant named Benedict Lust who founded the New York City’s American School of Naturopathy in 1902 and the American Naturopathic Association in 19196.  It has been used to treat such diverse conditions as allergies, asthma, arthritis, gastrointestinal illnesses, depression, insomnia, nausea, high blood pressure, labor pains, gynecologic problems, stress, and chronic pain6.  Naturopathy emphasizes the prevention of  illness and, like many alternative therapies, may work best in situations where conventional treatments have failed6.

            In many ways, training for the degree of Doctor of Naturopathic Medicine (ND) parallels the training of allopathic and osteopathic physicians6.  Four years of college precede four years of naturopathic medical school where much of the curriculum overlaps with allopathic medicine but includes training in acupuncture, physical manipulation, and massage therapy6.  There are currently four such colleges in North American, three on the West Coast of the US (in Seattle, Portland, and Scottsdale) and one in Toronto, Canada6.  Although licensure is currently granted to NDs in 12 states throughout the US as well as the District of Columbia15, the West Coast, particularly the Pacific Northwest, is the best with regard to regulation, licensure, and reimbursement, and in the state of Washington naturopaths are considered primary care providers6.  In general, naturopaths’ fees run about half the cost of an allopathic visit6.

 

Massage Therapy was used by 11.1% of the population in Eisenberg’s study, with the majority going to a therapist for an average of 8.4 visits per year14.   This translates into 113,723,000 total visits in the US in 199714.  Massage therapy, however, is a frequent component of other types of alternative medicine practices and schools of thought and many different kinds of alternative medicine practitioners are taught massage techniques as part of their training. 

            Massage therapy involves the “systematic manipulation of the soft tissues of the body” via nearly 100 different techniques (and combinations of techniques) such as rubbing, kneading, slapping, tapping, rolling, pressing, and many others6.  The two most popular types in the US are the Swedish and contemporary Western forms6.  Swedish massage was developed in the early 1800s and brought to the US in the 1850s where it is currently the most popular6.  It falls into the broader category of traditional European massage with a goal of improving blood flow in the muscles, relaxing the muscles by mimicking both active and passive exercise, improving circulation throughout the body, and increasing the body’s range of motion6.  Also popular is contemporary Western massage which takes a holistic approach to the therapy with the hope of improving the function of the body and mind, thus bringing about a greater sense of well-being6.

Other common forms include:  deep tissue massage, manual lymph drainage massage, myofascial release,  neuromuscular massage, trigger point massage, myotherapy, and sports massage6.

            Massage therapy has been used to treat high blood pressure, asthma, burns, chronic pain (back and neck pain, arthritis, migraines), rashes and other skin conditions, labor pains, addiction, depression, anxiety, attention deficit hyperactivity disorder, eating disorders, symptoms of premenstrual syndrome, chronic fatigue syndrome, sore muscles, and muscle sprains and strains6,14,17.  It has also been used to reduce swelling, enhance relaxation, boost immune function, improve diabetic control, and improve general well-being6,14,17.  Regulation and licensure of practitioners varies by location, although the Commission on Massage Therapy Accreditation recommends a minimum of 500 hours of education and the National Certification Board for Therapeutic Massage and Bodyworks administers a national certifying exam6.

            A one-hour massage therapy session costs between $30 and $60 (although more specialized techniques will cost more) with most sessions lasting 30-90 minutes6.  Insurers tend not to cover the cost of massage therapy, but a referral from a physician may increase the likelihood of reimbursement6.  In Eisenberg’s study, insurance plans provided complete coverage for 11.8% of the individuals who saw a massage therapist, partial coverage for 16.7%, and no coverage for 71.5%14.

 

Hypnosis places an individual in a trance-like state during which time he or she is barely aware of the surroundings and is susceptible to the power of suggestion 6.  It was used by 1.2% of the respondents polled by Eisenberg’s, et al14.  With the majority of these individuals going to a practitioner an average of about 3 times per year, it is estimated that, nation-wide, Americans made 4,171,000 visits to hypnotists that year14.

            The practice of hypnosis was begun in France in the late 1700s by Franz Mesmer6.  Originally a fraudulent practice more often than not (Mesmer was later expelled from France for medical fraud), hypnosis has been accepted as a genuine medical therapy in the US since 19586.  Many medical practitioners from a wide variety of backgrounds have since attained adequate training and experience in the techniques of hypnosis6.  However, obstacles to its widespread acceptance remain.  The mechanism(s) through which hypnosis works are unknown, and the techniques are only effective in a selected population of individuals6.  While hypnosis can only work for those people who believe in it and have clear goals for their therapy in mind, even among the highly motivated individuals 25-30% remain minimally susceptible to the techniques while 60-80% are moderately susceptible and 5-10% are highly susceptible6.

            For those individuals in whom hypnosis works, it seems to be a reasonable approach to take in attempting to get rid of bad habits, irrational or overwhelming fears, pain, and addiction to drugs or cigarettes6.   Hypnosis has also been found effective in weight loss programs and for the treatment and management of skin conditions, asthma, nausea, irritable bowel syndrome, fibromyalgia, cerebral palsy, and migraine headaches6,19.

            No licensure requirements currently exist for the practice of hypnosis.  However, the American Board of Hypnosis and the American Council of Hypnotist Examiners issue guidelines to assure minimal competency among practitioners6.  And while the cost of a hypnosis session may, theoretically, be covered if performed by a healthcare provider licensed in a conventional medical field, Eisenberg found that complete coverage was only available to 5.1% while a lack of any partial coverage left 94.9% of those surveyed to pay the entire bill out-of-pocket14.

 

Biofeedback links the mind with the body in a way that allows the mind to control certain bodily functions.  In this alternative medicine technique used by 1.0% of the population in Eisenberg’s survey14, an individual is hooked up to a monitoring device which provides an indication of how a specific part or system of the body is functioning6.  Examples of these devices include machines which monitor brain waves, breathing patterns, muscle stimulation and response, sweat gland function, pulse, skin temperature, and blood pressure6.  The output from the machine is continuous and nearly instantaneous.  Thus, as the patient focuses on the physiologic response output and attempts to change it through mind-body exercises such as relaxation, the machine provides the feedback which guides future attempts at modification6.  While significant changes may take a number of sessions (the individuals who reported using biofeedback in Eisenberg’s study scheduled an average of 10 visits a year) as well as a great deal of practice between sessions, this therapy has been shown to be effective6, 14.  Biofeedback is now widely accepted throughout the healthcare field for the treatment of such conditions as anxiety, asthma, tension headaches, chronic pain, high blood pressure, stress, and Raynaud’s disease6.  Additional investigations are now underway to determine if it may have an adjunct role in the treatment of diabetes and epilepsy and rehabilitation following a stroke6.

            The majority of individuals who use biofeedback see a trained practitioner, accounting for an estimated 3,871,000 visits in 199714.  Although no licensure is available for these practitioners, who are usually traditional healthcare providers as well, the Biofeedback Certification Institute of America does provide certification for those individuals who meet their minimal standards of training and competency6. 

            Often approaching $150 per session6 and typically requiring many sessions before the desired effect is achieved, biofeedback tends to be quite costly as far as alternative therapies go.  The good news, however, is that this therapy is frequently covered by insurance plans for a cause which is “mainstream” or upon the recommendation of a physician6.  Eisenberg, for example, found that insurers provided complete coverage for 30.5%, partial coverage for 43.7%, and no coverage for 26.0% of individuals14.

 

 

Community MEDICINE

 

Community Clinics were designed to provide free or low cost medical care and preventive health services to those individuals without insurance who are unable to pay high out-of-pocket fees.  Begun in the 1960s, they have, for the most part, grown out of grass-roots efforts to provide healthcare for the working-poor, thus enabling them to stay off welfare5.  Depending heavily on community support and the effort of hundreds, if not thousands, of local volunteers, these clinics have become well-respected facilities in the many communities which they serve fostering pride, encouraging voluntarism, and building a strong sense of community5.  In 1990, there were over 1500 community clinics in the US, over 200 of which were considered to be “free clinics”, including the Free Medical Clinic of Greater Cleveland; and the states of Virginia and North Carolina both had laws freeing clinic volunteers of liability for services donated5.

            Despite receiving no financial support from the federal government, these facilities have found the means to provide rather costly services such as laboratory tests, x-rays, and prescription medications to their patients5.  Although some community clinics rely on limited funding from their local government, all have found alternative means of financing their budgets while keeping their overhead expenses low5.  These mostly volunteer-run organizations have very few, if any, salaries to pay and they often utilize donated space and products5.  Their funding and supplies come from such diverse sources as:  local hospitals, pharmaceutical and medical/dental equipment companies, health departments, private community organizations, individual donors, interest from endowments, the United Way, and local businesses5.  In addition, many community clinics, even those which are “free”, charge their patients at least a nominal fee, not only as a means of generating revenue, but, more importantly, to encourage these individuals to invest in their well-being and to become active participants in their healthcare5.

            Because they have remained flexible throughout the years, community clinics have been able to identify creative, locally-based solutions to not only meet their financial needs but to solve the healthcare problems unique to their communities5.  Their strength in providing much needed healthcare lies in their ability to eliminate many of the barriers which make it difficult for the working poor to seek medical care anywhere else5.  These include not only large costs but also transportation and inaccessible hours5.  Community clinics are usually located in the heart of the community, eliminating transportation problems for those at greatest need5.  In addition, this closeness-to-home provides a sense of familiarity, intended to encourage increased use5.  Many community clinics have also altered their hours of operation, opening only in the evenings or on weekends when more of their patients, and volunteers, are likely to be off from work5.  And by becoming intimately familiar with the communities they serve, these clinics have been able to identify and address specific healthcare concerns which they feel are being overlooked5.  Many community clinics have educational programs addressing hygiene, nutrition, prenatal care, and safe sexual practices and provide their patients with lists of social services and other valuable community resources5.

 

Healthcare is also provided to the community through School-Based Health Services which range from a nurse in the school to a school-based clinic or health center.  All of these varying services are designed with the notion that school children of all ages, and adolescents in particular, have unique physical, mental, and social health needs which are not being met by the conventional healthcare system which they underutilize20.  This may stem from the fact that one out of every seven US adolescents lacks health insurance while many others have only limited coverage which prevents them from accessing frequently-needed services such as preventive health, mental health, and drug and alcohol treatment20.  Because of these and other concerns, many state and local governments nationwide are trying to improve the health programs in their schools21.

            School nursing, “a specialty branch of professional nursing [which] seeks to identify or prevent student health problems, and intervenes to remedy or modify these problems” 21 has been in existence in the US for over 100 years21.  It began in the late 1800s with attempts to prevent the spread of communicable diseases but serves today to “bridge the gap between health and education”, combining the objectives of providing health education, performing direct services, and improving the school environment21,22.  Specific tasks of the school nurse include triaging students who are ill or injured, conducting screening and early intervention programs, educating and counseling students, providing mental health services, fostering healthful behaviors geared towards health promotion and disease prevention, and providing public health services to the greater community21,22.  From this extensive list, it is evident that many of the services are provided on a group level via classroom education and intervention programs22.

            In an attempt to provide comprehensive healthcare to students on an individual basis, school-based clinics and health centers have recently been developed.  First started in secondary schools, these programs are now being expanded into the elementary schools of many communities as well20,22.  With only two such programs in the US in 1970, the number had exploded to over 700 in 41 different states by 199520 and was approaching the 1000-school mark by 1998 with many more under development22.

            With a multidisciplinary professional staff consisting of NPs, PAs, part-time physicians, and social workers these clinics offer a wide variety of services including those which address the preventive, mental, and sexual health of their young patients20,22.  Specific services include:  physical exams, immunizations, diagnosis and treatment of minor injuries and sexually transmitted diseases, laboratory tests, management of chronic illnesses, prescriptions and supplies, gynecologic services including family planning, prenatal education, developmental assessment, and counseling on a wide range of topics such as nutrition, drugs and alcohol, and HIV/AIDS20,22.  When they are unable to provide services directly, as is often the case with prenatal, specialist, and dental care, school-based clinics offer referrals and help in ensuring that the barriers to obtaining these services are overcome20,22.  Like the school nurse has always done, these clinics are also beginning to integrate education into their long list of services, with projects ranging from individual classroom presentations to the development of comprehensive health education curricula20,21,22.  As a result, many school nurses, who once saw the school health education domain as exclusively theirs, are now partnering with these health centers to achieve mutual goals while sharing from the same limited resource pool22.

            The funding for these clinics, which were initially born out of grass-roots efforts, now comes from public as well as private sources20.  Sponsors of these projects include county and city health departments, community clinics, local hospitals, and even HMOs20.  Additional finances come from reimbursements by Medicaid and some private insurers, although HMOs and other managed care plans which require in-network utilization have been reluctant to pay20.

            Short-term evaluations of these clinics and health centers have shown some success in improving the overall health of the students including reductions in risk-taking behaviors, decreases in school drop-out rates, increases in the rate of promotion to the next grade, and improvements in the consistent use of contraception during sexual intercourse20.  More importantly, these studies indicate that students will utilize these services if they are readily available20.   In order to use the services offered by school-based clinics and health centers, students must first enroll, a process which requires parental consent20.  Typically, 60-70% of all students in a school with an existing program will in fact enroll, and 50-70% of these will utilize the services during the course of the school year20.  In one study, 31% of those who used the school-based clinic went for acute care, 26% for preventive services, 20% for mental health counseling or treatment, 18.5% for reproductive services and sexual health needs, and 8.5% for the management of one or more chronic illnesses20.  Parents have the right to limit the extent of services their child is to receive, although this rarely happens in practice20.

            Perhaps these clinics are so popular among both students and community leaders because of the many advantages they offer.  They are convenient to students because they are readily accessible and easy to use, freeing them from reliance on adults when it comes to seeking much-needed care20.  Located on school grounds, they eliminate the transportation barrier to access, and with their nearly-universal policy of providing care without regard to insurance status, they are available to all students regardless of ability to pay20.  Furthermore, these clinics and health centers have been designed to be user-friendly for their young patients, stressing confidentiality, educating them about the services offered, and making care easy to obtain20.  With appointments scheduled around school hours, loss of classroom time is dramatically reduced20.  And for the many adolescents who are spontaneous in seeking medical care, large blocks of time set aside for walk-in appointments make it easy to “drop by” 20.  With the implementation of such programs, many communities have realized reductions in the number of ED visits, which translate into decreased costs20.  Cost savings also occur when sexually transmitted diseases and teen pregnancies are prevented, screening and immunization programs are implemented in a timely manner, and better follow-up for chronic disease management occurs20.  Furthermore, these clinics and health centers have been shown to provide cost-effective primary care by centralizing utilization thus eliminating the duplication of services between multiple providers in the community20.  Perhaps most important, however, is the benefit to the entire community when the health of its children improves.  They are then more likely to become better learners, remain in school longer, and become productive members of adult society20.

 

A more loosely defined community is the workplace, where innovations in healthcare are also taking place.  Traditionally limited only to the treatment of work-related injury and illness, Healthcare in the Workplace is now expanding in a limited number of corporations to include primary care and preventive health services as part of “24-hour coverage”23,24.  A study published in 1995, looking at four such pilot programs in California, showed that these plans are effective in reducing healthcare costs24.  Savings stem from the fact that the additional services use pre-existing on-site facilities and support and administrative staff23.  Furthermore, when the worker-patient is being evaluated by one well-coordinated healthcare team, duplications of expensive services such as diagnostic tests and referrals can be minimized23.  And since it is not always clear which conditions stem from work-related injuries and exposures and which do not, having access to both primary care and occupational medicine providers in one facility helps ensure that a wider variety of diagnoses can be made more rapidly and accurately23.  An additional advantage to both worker and corporation is the convenience of having more medical services on-site, resulting in less time away from the job when seeking care as well as an increased use of preventive services23.  When these result in the improved overall health of employees, job-performance and productivity increase while absenteeism decreases23.

            However, the consequences of merging work-related healthcare with other medical services are not all positive.  Health records which track illnesses not related to the workplace can interfere with workers’ privacy rights and could potentially lead to discrimination23.  And healthcare providers who are paid by the company but serve its employees may find themselves in the uncomfortable position of trying to determine to whom they are accountable and whose best interests they are trying to serve23.  Additional problems stem from the fact that the physicians staffing the employee health clinics are trained in occupational medicine, with a background focusing on preventing, recognizing, and treating work-related injuries and illnesses23.  They are not trained in primary care and are thus not adequately qualified to provide such services to patients23.  This means that a company wishing to expand its employee health clinic to provide primary care would need to hire additional physicians who have the appropriate expertise23,24.  This would not only take funding and other resources away from the occupational health services which may be more essential to the corporation but would require multiple physicians to work closely together to maintain the continuity of care which such programs are striving to achieve23.  The financial burden will be particularly great for those companies which did not, in the past, pay for the primary care insurance of some or all of their employees but which now wish to expand their clinics to provide comprehensive healthcare benefits to all workers23.

 

Forming a very different category of community healthcare organization are Support Groups.  Defined as “self-governing groups whose members share a common health concern and give each other emotional support and material aid, charge either no fee or only a small fee for membership, and place high value on experiential knowledge in the belief that it provides special understanding of a situation” 25, the number of these organizations, also known as self-help groups, has increased dramatically since their inception in the 1960s25,26.  Over 500,000 such groups were in existence across the US at the end of the 1980s, and it is estimated that 10 million people attend an average of almost 20 sessions annually while at least 25 million individuals have tried support groups at some point in their lifetime14,25,26.  Focusing on a variety of diverse topics, a group exists for virtually every type of morbidity and mortality, and just about every aspect of medicine and public health is addressed26.  Some well-known examples include:  Alcoholics Anonymous, Mothers Against Drunk Driving, the Association for Retarded Citizens, the National Black Women’s Health Project, the National Alliance for the Mentally Ill, Take Off Pounds Sensibly, and Overeaters Anonymous25,26.  Other support groups exist for those recovering from addictions, parents of premature infants, widows and widowers, and those with illnesses such as post-traumatic stress disorder, chronic fatigue syndrome, multiple sclerosis, and a variety of cancers, to name just a few17,25,26.

            Perhaps self-help groups are so popular throughout the country because they work25.  By allowing people with similar problems to come together, these groups provide individuals an opportunity to learn from each other by sharing experiences and ideas25,26.  Often people find not only support and companionship in the midst of these groups but also role models who have overcome their adversity and teach and encourage others to do the same25,26.  These factors combine to give many support group members a regained sense of control over their lives and a feeling of empowerment25,26.  They are also able to serve as a political venue for voicing concerns and advocating for change at both the local and national levels25,26.  And they themselves maintain the ability to evolve and adapt to meet the ever-changing needs of a dynamic local community26.  Amazingly enough, all of this happens at little or no financial cost and without a reliance on healthcare professionals, making the services accessible to all while taking a significant burden off a community’s formal health care system25,26.

 

 

Elder Care

 

The number of  Americans over the age of 65 is climbing, with the most rapid growth occurring in that category of elderly — over age 85 — who are known as the “oldest old” 27.  As the volume of senior citizens continues to expand, so does the demand for services to assist and take care of these individuals27.  Often-times, when family support systems prove no longer adequate and the burden of care to the community becomes too great, Nursing Homes are called upon to provide the needed care. 

            In 1996, nearly 1.5 million Americans over the age of 65 resided in 17,208 nursing homes across the country (1020 of which were in the state of Ohio), occupying 83% of the nearly 1.9 million beds available nationwide1.  At an average monthly cost of $3,135 per resident, nursing home expenditures totaled over $78.5 billion in 1995, compared to only $0.8 billion spent in 19601.  Government funds paid for nearly two-thirds of all nursing home residents that year, while roughly one-third were supported by their savings or their family’s income, and private insurers contributed only 5% to the total pool of funds1.  In looking ahead, it has been estimated that 40% of all individuals who had turned 65 by 1990, can expect to reside in a nursing home for at least some portion of their life, with nearly 1 out of 4 spending one year or longer in such a facility and 1 out of 11 living there for over 5 years27.  Based on these figures, the demand for nursing home beds is expected to approach 5 million by 2025, at an annual cost of $700 billion27.

            In increasing numbers, nursing home residents are older and more functionally dependent, unable to care for themselves27.  Currently, about half of all nursing home residents are over 85 years old1.  And a large majority, nearly two-thirds, are cognitively impaired, suffering from dementia, delirium, and other mental illnesses27.  Many are also immobile, confined to a bed or a wheelchair, with multiple medical problems requiring many medications27.  In 1995, it was reported that 79.0% of all nursing home residents required assistance with mobility, 63.8% were incontinent, 44.9% needed help eating, while 36.5% fell into all three categories1. However, as the push to decrease the duration of hospital stays continues, nursing homes are, with increasing frequency, being asked to deal with more acute and subacute medical issues by providing services to younger patients who need extra help recovering from a major illness, surgery, or accident3.  Thus, the duration of a nursing home stay does not have to be long-term, with approximately 25% of the residents returning home after less than 6 months of rehabilitation3,27.  However, nearly 50% of residents do spend 6 months or longer in a nursing home while 25% receive fewer than 6 months of end-of-life care27.

            Obviously the sicker, older residents require the highest level of care.  With around-the-clock nursing care and physicians available to manage many active medical issues on-site, skilled nursing facilities are called upon to provide a full range of medical, personal, and residential care services to their highly-needy residents3.  Medications are administered, rooms are cleaned, meals are prepared, and clothes are laundered3.  Social activities and physical and occupational therapy sessions are provided as is assistance with eating, dressing, bathing, and ambulating3.  This is the only level of nursing home, when mandated by a patient’s medical condition, that is covered by Medicare3.  The needs of less disabled individuals, however, may be met by the lower-level of services offered at an intermediate-care facility3.  These less costly alternatives are more likely to be used by those seeking short-term rehabilitation3.  The final type of nursing home, frequently referred to as “assisted living”, provides only a very limited number of personal care and homemaking services in a “sheltered” or “custodial” setting that does not offer any medical care3.

            In addition to level-of-care categories, nursing homes can also be divided on the basis of ownership.  Proprietary facilities are owned by an individual or a corporation3.  Driven by competitive market forces, these establishments may provide better services at a lower cost3.  In 1995, 63.6% of all nursing home residents were paying an average of $3,047 per month to live in one of these facilities1.  The other 36.4% of residents were living in non-profit facilities operated by community organizations, religious groups, or the government at an average monthly cost of $3,2881.

            All nursing homes are highly regulated, licensed by state governments and certified for Medicare/Medicaid payments by federal authorities3,27.  They are held accountable for the care they provide and are required to conduct periodic, comprehensive assessments of all residents, enforce standards for employees, attempt reductions in the use of physical and pharmacologic restraints, and review quality assessment measures on a regular basis3,27.

 

But while nursing home care may be the only viable solution for some, a large number of elderly individuals with significant healthcare concerns turn to other options, and it has been estimated that “for every elderly person living in a nursing home, at least two persons living in the community have the same disease and disability burdens” 27.  One such option, gaining increasing popularity, is that of Home Care.  In 1992 over 1.2 million patients nationwide were receiving home healthcare services1.  By 1996, this number had nearly doubled1.  And while cheaper than hospitalization, this sector of the healthcare market consumes a significant portion of the federal Medicare budget.  In 1992 alone, Medicare spent $8.2 billion (or 6% of its budget) on home care, a number estimated to be increasing by 10% annually3.  Medicaid and many private insurers will also cover the cost of home care when medically indicated, prescribed by a physician, and delivered by a certified home care provider3.  In 1993, 6,497 home health agencies were on Medicare’s certified provider list and an additional 5,714 agencies offered services3. 

            Although categorized here as an “elder care” service, home healthcare is not reserved solely for the elderly.  Home care can be provided to a qualified younger individual who is either chronically ill or recovering from an acute hospitalization3.  In fact, while in 1992 nearly 76% of all individuals receiving home care were 65 and older, by 1996 this number fell slightly to 72.5%1.  The main diagnosis leading individuals to seek home care are (in descending order):  heart disease, arthritis and other musculoskeletal diseases, diabetes, stroke, lung disease, cancer, and fractures1.  Services provided by home care nurses, doctors, health department workers, and lay employees include:  nursing care, health assessment, hospice care (see section below), social services, respiratory therapy, physical therapy, occupational therapy, speech therapy, and intravenous antibiotics3.  Help with cooking, cleaning, shopping, and household chores, although not covered by Medicare funds, are also frequently considered to be home care services3.  These are usually offered by local community volunteer organizations, social service agencies, and church groups through popular programs such as Passport and Meals-on-Wheels3.

 

Including both nursing home facilities and home care as part of their multi-level elder care model are Continuing Care Retirement Communities (CCRC).  Sometimes referred to as “lifecare communities”, approximately 1000 such facilities currently exist in the US, serving an estimated 250,000 individuals between the age of 70 and 9028.  Ranging in size from 200 to 2500 beds, they offer housing in an apartment, assisted living, and nursing home setting to meet an individual resident’s changing level of need28.  Medical and self-care services provided include home healthcare, skilled nursing facilities, and, often, subacute short-term facilities to care for those recently discharged from the hospital28.  Many CCRCs also hire full- or part-time primary care providers (physicians as well as NPCs) while others provide transportation to nearby facilities28.  And most contract with one or more local hospitals to facilitate and control costs for resident admissions as well as dealing with the insurance paperwork and medical bills on the residents’ behalf28.

            To enter such a community, an individual (77% of all CCRC residents are single) must sign a lifecare agreement and pay a rather steep entrance fee which entitles them to life-long care28.  Monthly service fees are assessed to cover the cost of apartment maintenance, common area upkeep, social activities, security, local transportation, and one or more meals per day28.  The entry fee serves as insurance for the increased costs which would be incurred if an individual were to require a higher level of care and is highest in those communities classified as Type A by the American Association of Homes and Services for the Aging (AAHSA).  CCRCs of this category are all inclusive, providing skilled nursing and home care, as needed, at no extra charge28.  Type B communities offer the full range of services as well, but limit their amount so that residents needing care beyond the extent specified will incur an additional fee28.  Type C communities operate on a fee-for-service basis, charging the smallest entry fee but requiring residents to pay out-of-pocket for any care in excess of the amount covered by their monthly assessment28.  Communities of the A and B type are also more likely to pay the medical or pharmaceutical bills not covered by the resident’s Medicare and Medigap insurance, although they usually require the residents to use their preferred providers in order for such coverage to apply28.  But because they are all inclusive in the services they offer, they not only charge more but set rather stringent entrance requirements, limiting admission to higher-functioning residents predicted to be less likely to require extensive care in the future28.  Attempts are currently underway to make these communities, originally founded by nonprofit charities but now marketed to only the wealthiest 10% of the elderly by for-profit development groups, more affordable and accessible to the middle-class28.

 

Another type of service available to qualified individuals of any age but utilized primarily by the elderly is Hospice.  Established by Dame Cecily Saunders in London, England in 1967 to provide end-of-life care for the terminally ill, the first US hospice program was started by Florence S. Wald in 1977 providing home-based care for those with a predicted life expectancy of under six months3,29.  Hospice programs currently provide care through in-patient facilities, in the home, and at free-standing clinics to nearly 60,000 individuals each year1,3.

            The mission of hospices nationwide is to ensure death with dignity by optimizing pain control and minimizing suffering3.  The services provided extend not only to the patient but the family as well.  Aiming to allow individuals to remain at home surrounded by their family and friends rather than extensive hospital equipment, hospice workers and volunteers provide education to help the patient and family prepare for death and ultimately lend support to the survivors3.  Although 58% of hospice patients have cancer, heart and lung disease also accounts for a large proportion of individuals receiving care, 78% of whom are at least 65 years old1.

            As of 1982, Medicare (as well as many private insurers) covers the cost of hospice care if the patient is Medicare eligible, has a terminal illness with an expected survival of less than six months, has given informed consent, and seeks care from a certified agency29.  In 1993, 1,223 hospice programs nationwide were certified by Medicare and an additional 477 programs were in existence3.  In the state of Ohio, 51 different hospice programs were available in 19992. 

 

 

For the Healthcare Manager, the question “where do Americans go for health care?” is an important one to consider.  The answers are numerous and diverse.  Although this discussion has attempted to provide a comprehensive overview of the types of services which exist, both traditional and alternative, in the community and for the elderly, it has only begun to scratch the surface of a rapidly evolving marketplace.

            The important lesson for the manager to keep in mind is that the array of services is broad and the settings in which they are found are also varied.  Thus, the role of a manager can vary considerably, often involving a wide variety of different tasks.  This may range from no involvement in a solo office practice to the gargantuan task of ensuring that the wide variety of services and large number of employees comprising a large medical center or an extensive Continuing Care Retirement Community are smoothly and efficiently integrated.  Somewhere along this continuum of management complexity lie the many other practice environments and styles described.  Today, many complementary medicine practitioners from a variety of different schools of thought are joining together to provide their patients with multiple options in alternative care within the confines of a single office.  This parallels the recent evolution in the traditional group practice model.  It is not uncommon to find, in a large group practice today, a number of allopathic and osteopathic physicians, trained in several different fields of medicine, working side by side with non-physician clinicians to provide higher-quality and more efficient care to their patient-consumers.

            From this discussion, it should be apparent that the key to surviving in this changing healthcare system is to be open to change.  Will the new services and structures which continue to develop blend in smoothly with the existing models of care?  Or will they be better served by finding a more innovative method of bringing care to the community?  Only time will tell.

 

 

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