Our country is struggling to reduce the cost of healthcare while simultaneously improving its quality and accessibility. I see a partial solution: use Chinese medicine in Western healthcare settings.
There are many ways to do this; in fact, in-hospital acupuncture is used across the United States. To effectively reduce cost and uniquely add quality to care, however, I propose employing traditional Chinese medicine in hospital emergency departments.
First, let's examine emergency rooms (ER) then and now. Twenty years ago, people did not often walk into emergency rooms. You would first call your primary care doctor if something hurt, if you had an infection, or you had chest pains or a fever developed. At that time, you'd be seen quickly. Primary care physicians attended to anything chronic or "sub-acute," and hospitals were only for surgery, trauma, or real emergencies.
Now, the landscape has changed and your primary physician is a referral service for specialists or a gateway to the ER. So, if your shoulder hurts badly, you might be sent to an orthopedist who will prescribe X-rays or MRIs, prescribe you medicine, send you for physical therapy, or even suggest surgery. Enlightened orthopedists might prescribe Chinese medicine (as mine did). Abdominal pain would be referred to a gastroenterologist, and so on. Because specialists make a lot more money when they perform procedures like surgery, they increasingly don't want to see patients who just need a diagnosis and some medicine.
Seeing a specialist means you wait for treatment. It can sometimes be difficult to obtain a diagnosis or treatment during the time you still have pain. Interestingly, this model of care causes many people to seek alternative treatments. In my part of the country, I have encountered many people who, while waiting to see a specialist, found Chinese medicine, resolved the issue and avoided the need for the specialty consultation. Nonetheless, primary care doctors defer to specialists in many cases that they used to treat: local area trauma (you fall down and badly bruise your arm); infection (you have a weird fever); or panic (you have anxiety and some mild chest pain).
Instead of visiting your primary care physician to get a referral for a specialist, you could go to an ER, where a highly trained team will perform triage, administer a battery of tests, quickly make a diagnosis, and either treat you and send you home, or admit you to the hospital if you are too sick to let go. Most people go home. Thus, most ER care is not for emergencies. These departments are being crowded with people who are unwilling to delay treatment by following the referred care model. In addition, ERs are increasingly becoming overrun with people who have no health insurance and nowhere else to go. One healthcare system executive recently told me that her hospital now provides 30 percent more "unreimbursed care" than it did two years ago, before the depth of the recession set in. That means that the hospital provides the care and eats the cost, which isn't good for its viability.
I recently interviewed Dr. Liza Somers, a seasoned ER doctor who practices in two Philadelphia hospitals, the Holy Redeemer Hospital and Nazareth, and who is on staff at Mercy Suburban. She is a graduate of the University of Pennsylvania Perelman School of Medicine and completed her residency at Jefferson University Hospital. When I asked her what were the most common medical problems arriving at ERs, she said; "We see major and minor trauma - ankle sprains, swollen knees, shoulder stiffness. In the winter, coughs and head colds. Often migraine – classic or retro orbital. Nausea and abdominal pain."
Funny, I thought: I routinely see people with all of these problems in my acupuncture practice.
Dr. Somers continued, "There are many people coming to an ER with signs of heart attack – chest pain, shortness of breath. Most don't have a heart attack, but we put them through a battery of tests – EKG, blood tests – and often find nothing. They may even be admitted to the cardiac unit overnight for observation. Most don't have cardiac problems, but they definitely have symptoms."
I remembered that I recently saw two patients who were frightened after complaining of heaviness in the chest, some heat and rapid heartbeat. My diagnosis was Rising Heart Yang. I performed two treatments, gave them some An Shen, and they felt fine. Neither one needed an ER visit. The cost was $240.
"I wholeheartedly think there is a place for acupuncture in the ER," said Dr. Somers. "Patients spend hours waiting [for care] when they are in an ER. Waiting to be put into a patient room from the waiting room, waiting for the nurse to come into the room and see them, then waiting for the doctor to come in, then waiting for the doctor to come back, then waiting for the nurse to come back. It's endless waiting. Often, for the amount of time people have to wait, they don't feel that much better. There is plenty of time for an acupuncture treatment during all this waiting (their families could be treated too)."
Dr. Somers and I talked about which types of patients could safely receive acupuncture treatment prior to the triage process. Front-desk staff at ERs are given a set of criteria that distinguish potentially life-threatening signs and symptoms from those that are not. The most acute patients are more quickly moved from the waiting room to the triage room in the back, leaving less critical people waiting longer. Dr. Somers and I agreed that these less acute patients would be prime candidates for acupuncture.
We then talked about what clinical value acupuncture could add to the care of these patients. "Over the years, I have seen many patients with a problem that doesn't show up on any of our tests," said Dr. Somers. "Quite frequently, people present with some physical complaint for which I cannot give a precise diagnosis. I can reassure them that they will get better and that their ailment is not an acute, life-threatening process. Often times, this is all the patient wants to hear; some reassurance that whatever they are feeling is not life threatening. Sometimes, however, these individuals are frustrated that (A) I can't identify the problem, and (B) I can't make them feel significantly better, unless they want to be drugged with narcotics or some other pharmaceutical. In these situations, I usually remind them that I am an ER doc, and my job is to rule out an emergency. For all of these in-between-the-lines patients, however, I think acupuncture would be perfect, as I often say to myself when I encounter these cases."
As we know, practitioners of Chinese medicine often can diagnose and treat people who feel poorly, but whose symptoms do not show up on Western diagnostic tests. Any seasoned acupuncturist has treated hosts of patients with all manner of complaints that couldn't be detected on blood work or an MRI.
Why waste the (often very expensive) diagnostic Western medical resources when seasoned ER doctors can probably predict when they are unnecessary? Why not use Chinese medicine first for the sub-acute patients who arrive in distress? The partnership between emergency medicine and Chinese medicine is a natural one. Acupuncturists could easily be the "front room" provider in an ER setting, providing treatment to those sub-acute patients and potentially preventing the need for expensive ER procedures. We need collaboration between acupuncturists and ER personnel in order to test the benefits of this idea. Dr. Somers and I are game to set up a trial, and we encourage other practitioners of Chinese medicine to do the same. If you wish to make your case to your local ER, the following information may help you understand the circumstances that healthcare leaders face.
Get Your Foot in The Door
I work in three healthcare systems in different parts of the U.S. One is in Texas, one near Seattle, and the third is in my home city, Philadelphia. My clients are multi-hospital, complex healthcare systems where care is provided in many settings: hospitals, primary care offices, urgent care centers, day surgery centers, emergency departments, and rehabilitation facilities. Increasingly, care is also provided in the patient's home, online, and even at the local Rite Aid, where healthcare system employees (nurse practitioners) deliver simple primary care.
These institutions are moving away from the old hospital-centric model of (very expensive) care and are trying to adapt to the new frugal times by diversifying their approach to care delivery so that people spend less time in hospitals. For some healthcare systems, this change was voluntary, stemming from data showing that it isn't so safe to stay in a hospital for an extended period of time. For others, the reimbursement model drove the change. Insurers (government and otherwise) and are looking to cut costs these days and just won't pay as much reimbursement. Regardless, progressive healthcare systems are shifting the point of care and education from the hospital to the community, and even the home.
The Obama administration hired Dr. Don Berwick, the founder of the Institute of Health Improvement (IHI), to promote the notion that outcomes should drive the decision-making process about how to treat a patient. Berwick is quoted as saying that "20%-30% of health spending is waste, with no benefit to patients, because of overtreatment, failure to coordinate care, administrative complexity, and fraud."
In other words, it's no longer OK for each physician to make a decision about a patient's care without acknowledging what procedure gets the best results and with whom they must communicate. If physicians don't follow a treatment protocol that is shown to work, the insurer will not pay the bill. It's that simple. Western medical systems call this "accountable care," and they use the catchphrase, "The right care for the right patient at the right time." What they actually mean when they say this is: "In the old days, when most people had good health insurance, we used to encourage everyone who needed care to come to the hospital, where we could be absolutely thorough and where we could bill for many procedures, tests, and consultative fees. Now, we follow guidelines and get people home as soon as possible, avoiding the expense and possible complications caused by longer stays."
Healthcare systems have embraced this notion of outcomes determining treatments and are adjusting how they work. It is a prime time to introduce Chinese medicine to the conventional healthcare landscape. The use of Chinese Medicine within the Western medical settings can drive down the cost of care, improve clinical results, and increase patient satisfaction, particularly for patients who would have otherwise fallen between the diagnostic cracks of Western medicine. If we are truly motivated by outcomes, this partnership should be natural.
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