Health Care in Crisis: Where We Are, How We Got Here, What to Do by Mark Force, DC

Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Health Care in Crisis: Where We Are, How We Got Here, What To Do by Mark Force, DC

Intro “Let's face it we do have a health care cost challenge. We're spending about 16 to 17 percent of our GDP (gross domestic product) on health care and the sad truth is that there isn't universal access to quality care. You'll have a lot of people citing different people to fault for that including our industry for the price of medicine."

The real honest truth is that we don't have a health care system; we have a sick care system. And that's not a play on words, that's a fact, because what's driving costs in our country is that we have now almost half of our country, including every woman, man and child, who has one or more chronic diseases and we don't start spending on you until you get sick. Forty ﬁve percent of Americans are living with one or more chronic diseases and the older we get the higher that percentage goes up. "

"That 45 percent accounts for 75% of the now almost $2.4 trillion we spend on health care and in 2007 terms, that now averages almost $7,200 per person living in the U.S. and that is an astonishing number and that is just what we spend on treatment.”1

~Robert Ingram, Vice Chairman Pharmaceuticals for GlaxoSmithKline2

“The U.S. has the resources that allow people to get fat and lazy. We have the luxury of choosing a bad lifestyle as opposed to having one imposed on us by hard times.”

~Paul Terry, assistant professor epidemiology, Emory University, Atlanta.

1 From “Sound Solutions to Rising Health Care Costs,” an address at the inaugural Distinguished CEO Lecture Series; April 1, 2008, Catawba College, Salisbury, North Carolina.

2 Also Chair for GlaxoSmithKline Foundation Board of Directors, national CEO Roundtable on Cancer, Chairman of the American Cancer Society Foundation, and member of the National Cancer Advisory Board. Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Table of Contents

Healthcare Costs In The US...... 3 Healthcare Outcomes In The US...... 4 Breakdown of Healthcare Costs In The US...... 5 What Is Health?...... 6 What Is Effective Healthcare?...... 7 What Drives Healthcare Costs?...... 7 High Longevity Populations: Clues To Lower Health Care Costs?...... 18 Fundamental Solutions For The Healthcare Crisis...... 20 Functional Medicine: Health Promotion In Healthcare...... 23 Selfcare As Healthcare Reform...... 28 Vital Aging As Healthcare Reform...... 28

2 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Healthcare Costs In The US US healthcare is the most expensive in the world. The U.S. health care system has been rated as the highest in cost and, yet, 72nd in overall level of health when compared to 191 member nations included in a study by The World Health Organization (WHO).3,4

The Committee on the Costs of Medical Care was formed in the 1920s as a result of concerns about the cost of medical care. In 1932, this committee gave the ﬁrst estimate of national health care expenditures at $3.66 billion (4% of gross national income).

In 1971, President Nixon announced a "crisis" in health care costs and said that the system was at risk of collapse from insolvency. In that year, national health care expenditures were $81 billion and represented 7.2% of the gross domestic product (GDP).

We are in trouble. Our federally funded health care programs’ share of the budget has doubled in the last 20 years. It cost $717 billion and represented 26% of total federal spending in 2007.5 Spending on health care by individuals and the government is expected to increase from an average of $7,026 in 2006 to $13,101 in 2017. The total healthcare spending is then projected to reach $4.3 trillion.6

These costs have been considered to put the economic stability of the country at risk.7 We have promised entitlements through the federal government, primarily Medicare and Social Security, that are not funded and may be impossible to meet. “As 78 million baby boomers prepare to retire, the sum of America's unfunded entitlement promises (i.e., Medicare and Social Security) currently exceeds three times the size of the entire U.S. economy, and they are growing by over $2 trillion a year. Entitlement programs must be reformed to reﬂect current economic realities and longer life spans while also making them solvent, sustainable, secure and more savings oriented.8”

3 World Health Organization assessment of the world's health system. Press Release WHO/44 21 June 2000.

4 WHO health system attainment and performance in all member states, estimates for 1997

5 The State of the Union's Finances: A Citizen's Guide available fro download as a PDF from the Peter G. Peterson Foundation (http://www.pgpf.org/)

6 Keehan, S., et al., "Health Spending Projections Through 2017: The Baby-Boom Generation is Coming to Medicare," Health Affairs Web Exclusive, February 26, 2008, W-145. http:// content.healthaffairs.org/cgi/reprint/hlthaff.27.2.w145v1

7 CBO Testimony, Statement of Peter R. Orszag, "Growth in Health Care Costs," before the Committee on the Budget, United States Senate, January 31, 2008, http://www.cbo.gov/ ftpdocs/89xx/doc8948/01-31-HealthTestimony.pdf

8 from the Peter G. Peterson Foundation website (http://www.pgpf.org/)

3 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

In 1980, we were the largest lender nation in the world. Now we are the largest debtor nation in the world. Our current “on the books” debt is $10.8 trillion as of September 30, 2007, but if we include promised future Social Security and Medicare benefits that are unfunded that adds another $41 trillion! And, if you break this figure down, the Social Security benefits add up to $6.7 trillion while the Medicare benefits total $34.1 trillion!

This puts our nation at risk in a scary and long list of ways that is outside of the scope of this paper. I have mentioned these issues because it puts into context the grave and pressing realities of Medicare and health costs. We have to ﬁx these problems for our individual and national health. To understand the entitlements issue and how it relates to our national debt, read “Running On Empty” by Peter G. Peterson.9

We are paying an incredible amount of money for health care in this country through health insurance premiums, tax dollars going to government health care programs, and in direct costs for uncovered services. Yet it looks like we’re not really getting a good return in terms of improved health, longevity, quality of life, and well-being. In fact, increased spending is not correlated with higher quality care.10

Healthcare Outcomes In The US The stats on our health status are pretty dismal. We are 45th in life expectancy (78.06) when compared to other nations.11 If we compare ourselves to Japan, the industrialized nation with the longest life expectancy (82.07), we spend more than twice as much per capita on health care.12

Life expectancies are expected to decline in the future according to current health trends. This reverses a long multigenerational trend in life expectancy increasing with succeeding generations.13

Yet, with all of the money spent and with the intensive use of healthcare in the US, the relationship between doctors and patients is deteriorating.14

9 Also available from the Peter G. Peterson Foundation website (http://www.pgpf.org).

10 Geographic Variation in Health Care Spending, CBO Paper, Peter R. Orszag, February 2008, http://www.cbo.gov/ftpdocs/89xx/doc8972/02-15-GeogHealth.pdf

11 CIA World Factbook (2008 estimates)

12 Snapshots: Health Care Spending in the United States and OECD Countries, Kaiser Family Foundation, http://www.kff.org/insurance/snapshot/chcm010307oth.cfm (USA, $6,711; Japan, $2,249; 2003)

13 A Potential Decline in Life Expectancy in the United States in the 21st Century, Jay Olshansky, Ph.D., et al, NEJM, Volume 352:1138-1145, March 17 , 2005.

14 Well: Doctor and Patient, Now at Odds, Tare Parker-Pople, The New York Times, July 29, 2008.

4 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Breakdown of Healthcare Costs In The US Some of the factors that have been cited to drive up healthcare costs are inappropriate use or over-utilization of medical care, regional variation in recommended services and their costs, wasteful or inefﬁcient administration, uninsured populations, a lack of preventive services, an aging population, a lack of free market price controls because of patient’s often indirect relationship to fees, “defensive” testing and referrals due to the prevalence of malpractice claims, marketing of sophisticated and expensive tests, treatments, and drugs, and poor lifestyle choices leading to chronic degenerative diseases.

Approximately 1% of the population with the highest spending accounted for 27% of aggregate health care spending. The top ﬁve percent of costliest Medicare beneﬁciaries account for nearly half of Medicare spending.15

Advanced diagnostic and therapeutic technologies have been proposed to account for as much as half of the health care costs in the last few decades.16

Those without healthcare insurance are less likely to get regular and preventive health care and to seek immediate care when necessary. The decreased and delayed use of ongoing health maintenance care results in more crisis care which is signiﬁcantly more expensive than regular and ongoing treatment for chronic degenerative conditions (i.e. diabetes, heart disease, obesity, high blood pressure, etc.).17 This strategy commonly used by the uninsured increases costs and decreases the efﬁciency of ER facilities for those in actual need of emergency care.18

The fairly recent trend of using of hospitalists rather than coordinating with the primary physician when patients are hospitalized may actually decrease quality of care and increase costs.19,20

15 Reducing the Growth of Medicare Spending: Geographic Versus Patient-Based Strategies, Lieberman, S.J., et al., Health Affairs Web Exclusive, December 10, 2003. W3-605.

16 Technological Change and the Growth of Health Care Spending, U.S. Congressional Budget Ofﬁce, January 2008.

17 Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition,” Hadley, Jack, JAMA, March 14, 2007; 297: 1073 - 1084.

18 Ambulatory Medical Care Utilization Estimates for 2005, Catharine W. Burt,Ed.D.; Linda F. McCaig,M.P.H.; Elizabeth A. Rechtsteiner,M.S., Advance Data From Vital and Health Statistics, No 388, June 29, 2007.

19 Hospitalists and the family physician, Bruce Bagley, M.D.; American Family Physician

20 Hospitalist concept: another dangerous trend, Robert G. Brown, M.D.; American Family Physician

5 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Disparities in the health of minorities, such as Hispanics, African Americans, and Native American populations in the US, is a known public health problem.21

What Is Health? We need to have some measure of what it is we are trying to accomplish with healthcare. Often the metric, or method of measurement, for determining whether we’re actually meeting our goals is missing. Often in the healthcare arena, the immediate aims are clear, but the overall goals are not, and because of this actions taken in the present don’t include those necessary to create long-term outcomes.

For instance, with an acute infection an antibiotic may be a necessary and appropriate therapy. But, is the patient then treated and given direction to restore their immune response and normal resistance?

What is the overall robustness of their genetic constitution? What emotional, social, socio-economic, dietary, and environmental factors might need to be addressed to help that person be less prone to infection (or disease, in general) in the future? What educational process would give them the knowledge and resources to be more self- determined about their health?

Symptom-focused treatments may address immediate and essential needs for a patients and help manage symptoms, but they often don’t lead to health as measured by improved body functions and may even cause secondary (iatrogenic) health problems.

So what is health?

“Health is a state of complete physical, mental, and social well being, and not merely the absence of disease or inﬁrmity.”

World Health Organization (1998)

Health has no inherent value. The value associated with health comes from the utility of possessing good health. It is arguable that health is most usefully viewed as a resource required for everyday life. It is the most fundamental resource to draw from for any pursuit and experience.

21 Understanding Health Disparities, Goldberg, J., Hayes, W., and Huntley, J. Health Policy Institute of Ohio (November 2004), page 3.

6 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

The above deﬁnition for health certainly presents some standard and is arguably a good model, but it doesn’t give us the metric for measuring the presence or absence of health. If we use a method that can be used for objectively measuring the outcomes that we want to achieve, we will be better able to reﬁne the methods based on the feedback from implementation of different variables into the healthcare model.

What Is Effective Healthcare? For healthcare to be effective, its’ application has to result in measurable outcomes that optimize body functions and minimize disabilities and illnesses and maintain functions at a level that allows independent living until end of life.

These outcomes decrease healthcare costs by minimizing chronic utilization of medication, surgeries, and the need for direct home care. Ideally, these outcomes are achieved mainly through education programs that emphasize the need for selfcare and provide the tools and resources needed for implementation.

Effective Healthcare Optimizes function and minimizes disability Maintains function and independence until end of life

What Drives Healthcare Costs? Multiple factors drive healthcare costs. Here are key global factors that contribute to the high costs of healthcare in the US:

Chronic degenerative illnesses Heroic end of life care Compromised newborns Compromised environment Compromised food supply Poverty Emphasis on treatment rather than prevention Emphasis on high-tech diagnostics & therapies De-emphasis on primary care Symptom-focused healthcare Pharmaceutical industry inﬂuence Underutilization of information technologies Insurance management of clinical practice Short-term outcome focus Malpractice law Complicated Administration

7 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Chronic Degenerative Illness Primary causes of death in 1900 were pneumonia, tuberculosis, diarrhea, enteritis, and injury.22

Now, most people die from a chronic degenerative illness and, ultimately, chronic diseases account for $3 of every $4 spent on healthcare. That’s nearly $7,900 per year for every American with a chronic disease.23

Disease Numbers (CDC) Diseases of choice*

Heart Disease 710,760 675,222 (95%)

Cancer 553,091 497,782 (90%)

Stroke 167,661 159,278 (95%)

Lung Disease 122,009 115,908 (95%)

Trauma 97,900 78,320 (80%)

Diabetes 69,301 65,836 (95%)

Infections 65,313 58,782 (90%)

Alzheimer’s 49,558 47,080 (95%)

Kidney Disease 37,251 35,388 (95%)

Septicemia 31,224 28,101 (90%)

*The ﬁgures are based on my opinion as to what percentage are outcomes of lifestyle choices.

Diseases of choice are caused by lifestyle habits that include diet, exercise, stress management and environment environmental stress (pollution, pesticides, etc.) which, barring the limitations of marked poverty and genetic, are under each individual’s control.

22 http://www.cdc.gov/nchs/data/dvs/lead1900_98.pdf

23 Centers for Disease Control and Prevention. Chronic Disease Overview: Costs of Chronic Disease. Atlanta: CDC, 2005. Available at http://www.cdc.gov/nccdphp/overview.htm.

8 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Diseases of choice are costly and they ultimately cause immeasurable disability and suffering. But, by the measure of healthcare costs, someone who has one or more chronic conditions is 5 times more costly to the healthcare system than someone without any chronic conditions.24

People who make the lifestyle choices that result in chronic illness are a ﬁnancial and emotional burden to their friends and families, a ﬁnancial burden to society, and represent diminished contribution and available resources for themselves, their friends and family, and society, in my opinion.

Obesity alone signiﬁcantly increases health care costs to almost twice that of normal weight individuals.25 Diabetes is strongly linked to premature births and cardiovascular disease for the child later in life.26 And, 1 in 3 babies born today is projected to develop diabetes in their lifetime.27

Minority groups suffer more chronic degenerative diseases. When compared to Whites, African Americans and Hispanics have about twice the risk of developing diabetes. Minorities also have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality.28 These diseases are most likely driven by a higher prevalence of poverty in these groups and insufﬁcient public health policies aimed at education, prevention, and ongoing management for chronic degenerative illness.

Compromised Newborns For infants, 5% of infants accounted for 76% of total infant hospital costs. Low birth weight (LBW) and very low birth weight (VLBW) infants had signiﬁcantly longer hospital stays and accounted for a signiﬁcantly higher proportion of total hospital costs.

24 Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, September 2004 Update. Baltimore: Johns Hopkins University, 2004. Available at http://www.partnershipforsolutions.org/DMS/ﬁles/

25 Growth in Health Care Costs, CBO Testimony, Statement of Peter R. Orszag, before the Committee on the Budget, United States Senate, January 31, 2008.

26 Low birth weight, a risk factor for cardiovascular diseases in later life, is already associated with elevated fetal glycosylated hemoglobin at birth, T. Pfab, et al. Circulation 114:1687–1692, 2006.

27 American Diabetes Association. The Dangerous Toll of Diabetes. Alexandria: ADA, 2005. Available at http://diabetes.org/diabetes-statistics/dangerous-toll.jsp.

28 Eliminating Health Disparities: Toolkit, American Public Health Association (APHA), 2004.

9 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Maternal health has been shown to increase the risk for premature births. Some speciﬁc factors that increase premature birth risk that are in most cases controllable through lifestyle are high blood pressure, pre-eclampsia, diabetes, periodontal (gum) disease, and pregnancies before 18 or after 35 years of age.29

Poor nutrition (most commonly seen in poor, inner city populations), smoking, excessive alcohol, drug use , and teen pregnancies (especially younger than 15) are all well known risk factors for low weight births. Simple public health practices to encourage improved lifestyle factors (i.e. improved diet, avoidance of smoking and alcohol) signiﬁcantly decrease the risk of premature and low birth weight infants.30 Low birth weight has also been related to environmental stress.31

Low birth weight increases the risks for infants developing autism and psychiatric disorders.32,33 It is alarming to note that the incidence of bipolar disorder in those under 20 years of age has risen dramatically (25 cases per 100,000 in 1994-5 versus 1,003 per 100,000 in 2002-3) in recent years.34

Low birth weight children are signiﬁcantly more prone to a number of chronic health problems and disabilities that include cerebral palsy, asthma, impaired vision, IQ of less than 85, poor academic performance, and poor motor skills.35

Low birth weight newborns represent lost potential and an increased burden on society that is easily preventable through decreased poverty and public health programs, in my opinion.

29 http://en.wikipedia.org/wiki/Premature_birth

30 Reducing Low Birthweight by Resolving Risks: Results from Colorado’s Prenatal Plus Program; Sue Austin Ricketts, PhD, Erin K. Murray, MSPH, RD and Renee Schwalberg, MPH; American Journal of Public Health November 2005, Vol 95, No. 11 | 1952-1957.

31 Ambient Air Pollution and Low Birth Weight in Connecticut and Massachusetts, Michelle L. Bell,Keita Ebisu, Kathleen Belanger; Environmental Health Perspectives Volume 115, Number 7, July 2007.

32 Stability of Psychiatric Outcomes of Low Birth Weight: A Longitudinal Investigation, Bohnert et al. Archives of General Psychiatry, 2008; 65 (9).

33 Birth Weight and Gestational Age Characteristics of Children With Autism, Including a Comparison With Other Developmental Disabilities,” Diana Schendel, and Tanya Karapurkar Bhasin. Pediatrics, Vol 121, No 6, pp 1155-1164, June 2008.

34 National Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in Youth, Carmen Moreno, MD, et al, Arch Gen Psychiatry. 2007;64(9):1032-1039.

35 Chronic Conditions, Functional Limitations, and Special Health Care Needs of School-aged Children Born With Extremely Low-Birth-Weight in the 1990s, Maureen Hack,et al, JAMA. 2005;294:318-325.

10 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Children must have all environmental conditions optimally met to fully express their genetics. These conditions are compromised by the presence of pollution and other environmental stresses, lack of a full complement of required nutrients from food, too little or too much physical activity, inadequate emotional or intellectual nurturing. Children experiencing compromised developmental environment become adults who experience more disease.36

Heroic End Of Life Care The typical end of life scenario around 1900 was a brief period of disability before death at home while being cared for by family. Now, most Americans live out the last days of their lives in hospitals, rest homes, nursing facilities, hospice, or professional home care.

Most Americans live an average of two years prior to death with disability due to chronic illness signiﬁcant enough to require help from others to meet their needs.37

Mean medical costs for people aged 65 or older in their last year of life was $37,581 from 1992 to 1996.38 This extends to accounting for an average of around 28% of all Medicare expenses for a given year.39 Using hospital intensive care units for end of life care for the elderly rather than hospice accounts for approximately 1 of every 4 days of ICU use and ICU care accounts for about 30-40% of all hospital spending.40

Yet, providing more intense health care in the last two years of life to patients with severe chronic illnesses (more tests and procedures along with longer hospital stays) is not associated with better patient outcomes.41

36 Chronic Conditions, Functional Limitations, and Special Health Care Needs of School-aged Children Born With Extremely Low-Birth-Weight in the 1990s, Maureen Hack,et al, JAMA. 2005;294:318-325.

37 Adapting Health Care To Serious Chronic Illness In Old Age, Joanne Lynn, David M. Anderson, Rand Health White Paper, WP-137 (2003).

38 Medical Expenditures during the Last Year of Life: Findings from the 1992-1996 Medicare Current Beneﬁciary Survey, Hoover, Donald R., et al; Health Services Research. 37(6):1625-1642, December 2002.

39 ibid

40 Adult Intensive Care Unit Use at the End of Life: A Population-Based Study. E Seferian, B Afessa, Mayo Clin Proc. 2006;81:896-901.

41 Tracking the Care of Patients with Severe Chronic Illness, The Dartmouth Atlas of Health Care, 2008.

11 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Based on the costs of “heroic” and desperate measures not producing better outcomes, is it reasonable to use intensive and invasive care in an attempt to brieﬂy prolong the life of someone who is inevitably dying? Is the quality of life for the person dying actually improved by this approach or is it diminished? What are the ﬁnancial, physical, and emotional costs to the person dying and to their family and society? Do we demean rather than honor the person who is dying through intensive end of life care that attempts to keep them alive for a rather brief time isolated from their friends and family?

Compromised Environment Environmental pollutants (auto and industrial exhaust, heavy metals, pesticides, fungicides, herbicides, plastics, etc.) have been extensively linked to disease, diminished lifespan, and decreased quality of life.42,43,44

Compromised Food Supply The soil depletion associated with industrial farming results in foods that are less nutrient dense. Use of pesticides, antibiotics, and plastics associated with most commercial farming and food industry have been associated with many diseases.

Commercially grown foods have been shown to have lower nutrient concentration than foods grown organically. Food refining, generally, results in removal of nutrients and foods that are less nutrient dense or lacking in essential nutrients. Food additives, such as artificial flavors and colors, sweeteners, and preservatives decrease nutrient density, and appear to be toxic. 45,46 Genetically modified (GMO) foods have been associated with toxicity, abnormal immune responses, and decreased fertility.47,48

42 An Association between Air Pollution and Mortality in Six U.S. Cities. Douglas W. Dockery, et al; Volume 329:, 1753-1759, December 9, 1993.

43 Air Pollution and Cardiovascular Disease. Robert D. Brook, MD, et al; Circulation. 2004;109:2655-2671.

44 http://www.who.int/water_sanitation_health/diseases/lead/en/

45 Human Health, the Nutritional Quality of Harvested Food and Sustainable Farming Systems. John B. Marler and Jeanne R. Wallin, Nutrition Security Institute.

46 Assessing food additive toxicity using a cell model. Stefanidou M, et al, Vet Hum Toxicol. 2003 Mar; 45(2):103-5.

47 Séralini GE, Cellier D and de Vendomois JS (2007) New analysis of a rat feeding study with a genetically modiﬁed maize reveals signs of hepatorenal toxicity. Arch Environ Contam Toxicol 52, 596-602.

48 Bøhn T, Primicerio R, Hessen DO and Traavik T (2008) Reduced ﬁtness of Daphnia magna fed a Bt-transgenic maize variety. Arch Environ Contam Toxicol 55, 584-592.

12 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Poverty Underlying much of the public costs of healthcare in this country is poverty and all of it’s repercussions. Those in poverty tend to live in polluted inner-city and industrial area at a greater percentage than those with ﬁnancial stability. Poverty also undermines diet, both in having sufﬁcient caloric intake and in nutrient density.49

Without health insurance, people experiencing poverty will tend to delay or forego health care for minor health problems, regular physical exams, and maintenance or preventive healthcare. Because of these factors the impoverished tend to use hospital emergency rooms for primary care once they have developed complications for illness or injury.50

Emphasis On Treatment Rather Than Prevention “An ounce of prevention is worth a pound of cure.” ~Benjamin Franklin

Treatment for existing disease is not as efﬁcient physically or ﬁnancially as prevention of disease.51 While there is some emphasis appearing on prevention in healthcare, the process of preventative healthcare is in most forms general and tends to rely on medication, a form of treatment. An example here would be medications to improve bone density as opposed to educating a patient to use weight bearing exercise (the weight of evidence supports the use of exercise over using medication). This is often the case even when research indicates that the selfcare-based approach is more effective than treatment.52,53,54

49 http://en.wikipedia.org/wiki/Diseases_of_poverty

50 Emergency department usage by uninsured patients in Galveston County, Texas. Jacques Baillargeon, PhD, et al, Proc (Bayl Univ Med Cent). 2008 July; 21(3): 236–242.

51 http://www.who.int/mediacentre/factsheets/fs172/en/index.html

52 Exercise and bone mineral density, Chilibeck PD, Sale DG, Webber CE., Sports Med, 1995 Feb; 19(2):103-22.

53 Bone mass and bone turnover in power athletes, endurance athletes, and controls: a 12-month longitudinal study, Bennell KL, Malcolm SA, Khan KM, Thomas SA, Reid SJ, Brukner PD, Ebeling PR, Wark JD, Bone, 1997 May;20(5):477-84.

54 Can a disease self-management program reduce health care costs? The case of older women with heart disease., Wheeler JR, Janz NK, Dodge JA, Med Care, 2003 Jun; 41(6):706-15.

13 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Emphasis On High-Tech Diagnostics And Therapies It is common practice to use new and sophisticated (and high cost!) technologies when simpler and more established technologies or exams would be sufﬁcient for a given clinical problem. This strategy is driven by fear of malpractice, lack of time with patients, and a tendency to believe that newer and more sophisticated technologies are inherently better technologies. This is an essential factor driving healthcare costs in this country, yet increased costs associated with more sophisticated testing may not improve the outcomes.55

There has, also, been great hope and investment in personalized genetic medicine in the last decade. The hope is that treatments and drugs can be developed to control the expression of or even repair genetic “faults.” Conceptually, this sounds like a noble idea, but the driving factors behind research in this area probably comes from the huge return expected from this developing branch of medicine.

Yet, modiﬁcation of environmental factors such as diet, exercise, stress management, exposure to environmental pollutants, etc. has been proven in numerous studies to limit the expression of genetic predispositions to heart disease, diabetes, cancers, osteoporosis, and digestive and hormonal diseases. Adherence to a Mediterranean diet alone has been shown dramatically improve lifespan and decrease incidence of degenerative diseases.56 Long-term exercise has profound effects on modifying metabolic and physiological changes normally associated with aging.57

Coverage For Lifestyle-Caused Illnesses The greatest costs for healthcare are for chronic degenerative diseases, such as heart disease, diabetes, etc., that are caused primarily by lifestyle choices.58 Insurance coverage for diseases that are the direct outcomes of personal choices decrease the motivation for personal responsibility and increase the likelihood that healthcare will be put off until more intensive and expensive secondary care is necessary.

55 High-Cost Medical Advances Need to Prove Value, Mark Moran, Psychiatric News, Volume 38 Number 24, December 19, 2003.

56 Mitrou PN, Kipnis V, Thiébaut AC, Reedy J, Subar AF, Wirfält E, Flood A, Mouw T, Hollenbeck AR, et al. (2007) Mediterranean dietary pattern and prediction of all-cause mortality in a US population: results from the NIH-AARP Diet and Health Study. Arch Intern Med 167, 2461-2468.

57 Brooks N, Layne JE, Gordon PL, Roubenoff R, Nelson ME and Castaneda-Sceppa C (2007) Strength training improves muscle quality and insulin sensitivity in Hispanic older adults with type 2 diabetes. Int J Med Sci 4, 19-27.

58 http://www.cdc.gov/NCCdphp/overview.htm; chronic diseases cost ~ 75% of the nation’s $2 trillion medical costs; diabetes ~ $174B/yr; smoking ~$193B/yr; heart disease & stroke ~$448B/ yr; obesity ~$117B/yr.

14 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

De-emphasis On Public Health Services Public health services have played a huge role in improving the public health and preventing the disease epidemics through improving sanitation, air and water quality, food quality (except with regard to the issue of food processing and additives), decreasing exposure to toxic and infectious agents, and educating the public to the importance and methods of hygiene.

Public health services have not developed public education programs to effectively convey the effects of diet, exercise, stress management, and other selfcare strategies on an individuals’ health, healthcare costs, and quality of life, yet the cost effectiveness of selfcare education programs in speciﬁc settings.59

De-emphasis On Primary Care Increased access to primary physicians has been associated with decreasing overall healthcare costs.60

Yet the high costs of medical/osteopathic school education means that most new doctors to have huge debt loads upon graduation and this burden drives physicians into specialties since they are compensated signiﬁcantly greater than general and family practitioners (GP/FPs).61

As a result of high education-related debt and compensation discrepancy that favors specialists, there is a higher number of specialists in this country relative to GP/FPs when compared to other countries. This deﬁciency of GP/FPs in the US has been well recognized.62

Low compensation for GP/FPs ofﬁce visits has forced them to schedule very short ofﬁce visits for a given clinical problem which may result in a higher incidence of misdiagnosis or mismanagement. Time constraints forced by low compensation may lead to expensive high-tech tests being ordered when a more time intensive and complete direct history and exam by the primary physician could result in improved management and outcomes for a given health problem at less cost.63

59 ibid

60 Slowing the Growth of Health Care Costs - Learning from International Experience; Karen Davis, Ph.D.; n engl j med 359;17, october 23, 2008.

61 Doctors urge: Rescue primary care or work force shortage will mount. Kevin B. O'Reilly, Brian Hedger (staff), AMNews. Dec. 8, 2008.

62 Bolster primary care: Avert a physician shortage, editorial, Am Med News, Jan 12, 2009.

63 2007 Medical Group Compensation and Financial Survey. Alexandria, VA: American Medical Group Association, 2007.

15 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Around 1996, concierge medicine emerged, where enhanced care and services are provided by primary care physicians for a retainer fee. This level of care is, however, outside of insurance coverage and is prohibitively expensive for most consumers.64,65

Symptom-focused Healthcare A common pattern that develops from a heavy dependence on referral to specialists, especially for chronic and complex illnesses, is multiple specialists arriving at multiple diagnoses and treatments for what is in actuality a systemic illness. The patient then experiences a scenario analogous to a group of blind men all trying to understand an elephant from touching different parts of it.66 This approach often ends up being ineffective, overly expensive, and can in many cases even complicate the patients illness.

Pharmaceutical Company Influence There has been a trend for pharmaceutical companies (Big Pharma) to manipulate research, journals, and books to favorably influence utilization of medications. Educational programs sponsored and materials developed and disseminated by Big Pharma often mislead and misinform physicians. Big Pharma often markets newer and more profitable drugs that they control patent for even though older, generic drugs may be as, or more effective, less costly, and cause less side effects.67

Underutilization of Information Technologies (Medical Informatics) Poor communication between doctors working with a given patient often results in ineffective integration of test findings and reproduction of testing. Doctors often find it difficult, inefficient, and even, essentially, impossible to gather, sort, integrate, and optimally use the data associated with patients’ file to arrive at the accurate and comprehensive diagnosis required for a patient’s care that produces a positive outcome.

64 http://en.wikipedia.org/wiki/Concierge_medicine

65 Linz AJ, Haas PF, Fallon LF and Metz RJ (2005) Impact of concierge care on healthcare and clinical practice. J Am Osteopath Assoc 105, 515-520.

66 http://en.wikipedia.org/wiki/Blind_Men_and_an_Elephant

67 see The Truth About the Drug Companies: How They Deceive Us and What to Do About It. by Marcia Angell, MD. Once editor-in-chief for the New England Journal of Medicine, she resigned over issues of the pharmaceutical industry manipulating peer-review based credibility of the journal.

16 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

The management, maintenance, storage, and transport of paper ﬁles is expensive and prone to mistakes that can compromise the accuracy, completeness, and privacy of a patients’ records.68

Insurance Management of Clinical Practice Insurance adjustors are often charged with managing patient care to minimize costs. Because the aim of this management is typically to decrease the immediate healthcare costs, this can compromise the clinical decisions of doctors and nurses for treating patients based on their own best judgment. This can compromise primary care for a patient and, ultimately, result in the patients’ condition continuing, worsening, and requiring more complicated and costly secondary care.

Short-Term Outcome Focus Emphasis on the short-term goals of eliminating symptoms and minimizing costs often leaves a patients’ underlying condition untreated and allows their health to deteriorate.

As a result, many illnesses that could be addressed early and at less cost are able to fully develop. These unaddressed illnesses which could be reversed in their early stages through patient education and health care coaching often progress from being functional and reversible to being pathological and irreversible.

Malpractice Law The current practices concerning tort law drives the implementation of defensive medicine and over-utilization of exotic, expensive and clinically unnecessary testing. 69

Complicated Administration It is estimated that administration costs account for thirty-one cents of every health care dollar.70 Other countries utilizing simpler health insurance systems have considerably lower administration costs.

68 A Proposal for Electronic Medical Records in U.S. Primary Care. David W. Bates, MD, MSc, Mark Ebell, MD, MS, Edward Gotlieb, MD, FAAP, FSAM, John Zapp, MD and H.C. Mullins, MDJ Am Med Inform Assoc. 2003;10:1-10.

69 Why Does U.S. Health Care Cost So Much? (Part I). Uwe Reinhardt, New York Times, Nov 14, 2008

70 Costs of Health Care Administration in the United States and Canada. S Woolhandler, T Campbell, D Himmelstein, NEJM, Volume 349:768-775, August 21, 2003, Number 8.

17 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

High Longevity Populations: Clues To Lower Health Care Costs? Though Japan is the nation with the longest lifespan among industrialized nations, it is only third among nations, overall. It is interesting that the two nations with the longest lived populations are extremely small countries that could almost be argued to be city states rather than nation states because of their diminutive stature.

Macau has the longest life expectancy in the world (84.33 years). This formerly Portuguese colony of 11 square miles is now “administered” by China in the same way as Hong Kong, which lies across the bay. Interestingly, mainland China ranks 103rd of nations for life expectancy at 72.88 years. Evaluating for all the factors that account for this would make for a long and difﬁcult study, but it is interesting to note some standout aspects of their healthcare system which might account for some of the inﬂuence on longevity.

Macau has numerous health centers that provide free basic medical care and traditional Chinese medicine to residents. The Macau Health Bureau coordinates public health policies and activities between public and private organizations and promotes programs that support disease prevention and health promotion through the Centre for Disease Control and Prevention (established 2001). In the second part of this paper I will connect the fundamentals of their healthcare and public health policies and programs to a model for effective and frugal healthcare in this country.

Andorra is an independent state (181 square miles; sixth smallest country in Europe) located in the Pyrenees Mountains between Spain and France. Andorrans citizens live in the country with the second longest life expectancy (82.67 years). Their main industries are tourism, cattle raising, timber, and banking. There is some agriculture comprised of growing rye, wheat, barley, oats, and vegetables and raising sheep.

Being a mountain people living in a region where the average elevation is 6,500 feet, Andorrans ﬁt the common pattern of the long-lived Vilcabamba of Peru, Hunza of Pakistan, and Georgians of Abkhazia who all live in mountainous regions. Claims that marked longevity (>100 years) in these populations is common and that extreme longevity occurs have been essentially discounted, but robust longevity is the norm.71

71 http://en.wikipedia.org/wiki/Longevity_myths

18 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

These groups are, however, known for their older members being able to live independently and without significant disability until advanced age and shortly before death.72 Based on long-lived groups that have been well-researched, such as those in Okinawa, it is reasonable to assume that a figure for natural lifespan for people for who have not been significantly compromised from prenatal or developmental stress, injury, or infection and incorporate a reasonable regimen of diet, exercise, stress-management and avoidance of environmental stress is around 90 years, plus or minus 10 years depending on genetic constitution.73,74

Andorran culture is primarily Catalan (northern Spanish) and their diet meets the model of the Mediterranean Diet. There has been extensive research that establishes the beneﬁts of the Mediterranean diet and recently it has been found to correlate with a signiﬁcant increase in longevity and decrease in degenerative diseases typically associated with aging.75,76,77,78,79

Per capita health care costs are markedly lower in populations in Macau and Andorra when compared to the US, yet these populations enjoy longer life spans, lower infant mortality, and have less disability prior to death.80 We may be able to ﬁnd clues to the crisis in health care cost and quality in the US by looking at the elements in these cultures that lead to such impressive quality of life measures.

72 Ancient Futures: Learning From Ladakh, Helena Norberg-Hodge, Sierra Club Books, 1992

73 Okinawan Centenarian Study, http://www.okicent.org/study.html

74 First Autopsy Study of an Okinawan Centenarian: Absence of Many Age-Related Diseases, Adam M. Bernstein, The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 59:1195-1199 (2004).

75 Adherence to Mediterranean diet and health status: meta-analysis, Soﬁ F, Cesari F, Abbate R, Gensini GF, Casini A BMJ (Clinical research ed.) 337: a1344. (2008).

76 Traditional Mediterranean diet and longevity in the elderly: a review, Antonia Trichopoulou, Public Health Nutrition (2004), 7 : 943-947.

77 Adherence to a Mediterranean-type diet and reduced prevalence of clustered cardiovascular risk factors in a cohort of 3204 high-risk patients, Sanchez-Tainta A, Estruch R, et al, Eur J Cardiovasc Prev Rehabil, 2008; 15(5): 589-593.

78 Association between adherence to the Mediterranean diet and oxidative stress, Dai J, Jones DP, et al, Am J Clin Nutr, 2008; 88(5): 1364-70.

79 Mediterranean diet and plasma concentration of inﬂammatory markers in old and very old subjects in the ZINCAGE population study, Dedoussis GV, Kanoni S, et al, Clin Chem Lab Med, 2008 May 21; [Epub ahead of print].

80 https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html; andorra (3.23 infant deaths/1,000 live births); Macau (3.68/1,000); USA (6.3/1,000).

19 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Fundamental Solutions For The Healthcare Crisis Institute Universal Primary Healthcare The US is the only industrialized nation in the world that does not have universal healthcare. Free and accessible healthcare increases the likelihood of utilization of care for illness in the early stages when simpler and less expensive care and selfcare education is likely to be sufﬁcient. Evidence indicates that implementation of universal primary healthcare is not associated with increased costs.81

Focus Healthcare On Health Promotion Healthcare that is focused on health promotion tends to be more effective overall and is automatically aimed at long-term outcomes. Health promotion will usually produce better resolution of illness than symptom-based care, get rid of symptoms better, and improve quality of life at the same time.82

Restore Primary Practice To restore primary care to it’s key role GP/FPs must be given the authority to work-up, diagnose, and treat patients directly and be compensated sufﬁciently to draw talent to primary practice. Promotion and respect for primary care encourages primary physicians to treat more directly, simply, and cost-effectively.

It is solidly arguable that primary practice is the most challenging practice of all; the breadth and depth of knowledge necessary and the range of possible diagnoses and therapies that a primary physician must study, keep up-to-date on, and have a reasonable mastery of is far greater overall than a specialty.

To restore primary practice, we must show the position more respect, give physicians the authority to practice their craft, and be compensated commensurate with the demands of the position. Most illnesses and injuries can be treated directly, effectively, and less expensively by primary physicians.83

81 Lu JF and Hsiao WC (2003) Does universal health insurance make health care unaffordable? Lessons from Taiwan. Health Aff (Millwood) 22, 77-88.

82 Aldana, PhD SG (2001) Financial Impact of Health Promotion Programs: A Comprehensive Review of the Literature. American Journal of Health Promotion: Vol. 15, No. 5 pp. 296–320

83 Cost-effective primary care providers: an important component of health care reform, Prescott PA, International journal of technology assessment in health care, 1994, vol. 10, no 2 (37 ref.), pp. 249-257.

20 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Because of the deﬁciency of primary physicians and poor reimbursement for primary care, patient’s healthcare is often being managed by specialists when it could be managed under primary care at less cost.84,85

Expand Primary Practice Naturopathic and chiropractic physicians are both trained to provide primary care.86,87

Additionally, chiropractic and naturopathic physicians typically have had more education in nutrition, exercise, stress management, and disease prevention as a standard part of their standard curriculum than allopathic and osteopathic physicians. This makes these natural healthcare physicians an effective choice for primary care that includes direction and reﬁnement of selfcare.

This is not to imply that allopathic and osteopathic physicians are less capable of practicing natural and functional healthcare and teaching selfcare. Many allopaths and osteopaths have done post-graduate study in nutrition, exercise, stress management, and disease prevention and practice natural and functional healthcare and teach selfcare in their practices. Indeed, many of the diagnostic and treatment approaches used in natural healthcare were developed by allopathic and osteopathic physicians.88

Family nurse practitioners and physician assistants also provide high quality primary care with associated high patient satisfaction levels and at less cost.89,90,91

84 Changes in health care utilization and costs associated with managed care Medicaid among children and adolescents. Dick AW, Holl JL, Herbert TM, Klein JD, Schaffer SJ, Shone LP, Szilagyi PG; Association for Health Services Research. Meeting. http://gateway.nlm.nih.gov/ MeetingAbstracts/ma?f=102194921.html

85 Primary Care, Health, and Equity is an excellent powerpoint presentation on the issue from the University of Pittsburgh.

86 Chiropractic Education: A Curriculum Comparison

87 Fleming SA and Gutknecht NC (2010) Naturopathy and the primary care practice. Prim Care 37, 119-136.

88 Textbook of Functional Medicine by Sidney MacDonald Baker, Peter Bennett, Jeffrey S. Bland, and Leo Galland (2005)

89 Horrocks S, Anderson E and Salisbury C (2002) Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 324, 819-823.

90 Dierick-van Daele AT, Metsemakers JF, Derckx EW, Spreeuwenberg C and Vrijhoef HJ (2009) Nurse practitioners substituting for general practitioners: randomized controlled trial. J Adv Nurs 65, 391-401.

91Hooker RS and Freeborn DK (1991) Use of physician assistants in a managed health care system. Public Health Rep 106, 90-94.

21 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Use Reasonable Standards For Implementing Or Limiting Care Heroic end of life care rarely increases length of life signiﬁcantly or improves quality of life. It is, however, incredibly expensive and usually decreases quality of life. We need to be more emotionally authentic as a society and honestly recognize people being in the process of dying.

Most cases of fatal illness in the later stages are better managed with hospice or home care. This approach is usually healthier emotionally for the person dying and their friends and family.

Restore Personal Responsibility For Healthcare Costs It is appropriate, in my opinion, that people who have chronic degenerative diseases that are deﬁnitively linked by the research to conscious lifestyle habits (smoking, excessive drinking, excessive eating, no exercise, etc.) to pay for a portion of their secondary care. The alternative is that others pay for healthcare costs that are the outcome of an individuals’ personal and conscious choices.

Making people responsible, or even partially responsible, for secondary care directly attributable to their lifestyle choices and developing effective public health educational programs that make the relationships between personal actions and disease solid provides ﬁnancial motivation for practicing self-responsibility and selfcare and the knowledge for how to do so.

Allowing people who exercise the discipline to practice selfcare regularly and effectively to benefit financially and making people who cause their diseases through their actions take financial responsibility for their health outcomes provides both benefits and penalties that encourage personal responsibility and likely result in lower tax, insurance, and societal costs.

Tax-free health savings accounts along with high-deductible health insurance also promote and reward self-responsibility.92 Money in the accounts can be used to pay for current medical expenses or saved to cover future medical expenses.

Overall, people tend to be more responsible when they have a ﬁnancial interest in the outcome.

Utilize Information Technology Computerizing all the paper in healthcare decreases the direct costs of the paper, its’ movement between doctors, and its’ storage. Database management of the information increases likelihood of an accurate diagnosis, prevents duplication of testing, and improves coordination of care between physicians working with a given patient.

92 http://en.wikipedia.org/wiki/Health_savings_account

22 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Along with better management of a patient data, computerizing can allow treatment protocols to be evaluated for effectiveness, decrease administration costs, and increase transparency for the public regarding quality and costs of care.

Institute Malpractice Reform There are risks associated with any healthcare procedure. Complications can arise even when care is administered correctly. There are certainly cases when a malpractice case is appropriate and the settlements justified. There is, too, a culture in our country of settlements that go far beyond compensation to retribution. This culture could be changed to benefit our society, financially and civilly.

Improve Our Physical and Social Environments Improved health of the environment, quality of our food supply, and support for our impoverished to improves health of members of our society as a whole. Greater health equates to greater production and quality of life and less disease and associated healthcare costs.

Functional Medicine: Health Promotion In Healthcare For healthcare to lower healthcare costs, it is essential that it incorporate health promotion. The strategies of health promotion are screening exams to evaluate for predisposition and risk for developing certain diseases, counseling to incorporate effective healthcare that offsets predisposition and risk for disease, and re-exams to measure the outcomes of physician directives and patient selfcare.

The Continuum of Health Conventional healthcare tends to look at health and disease as an either/ or phenomenon - you’re either healthy or you’re not. But, the reality is more nuanced than that and what often happens is that most illnesses are somewhere between health and pathological illness.

This is especially true for the group of illnesses that many people have still after seeing many doctors and having many kinds of treatment and still suffer. Often people having these illnesses are told “everything seems OK”, “we don’t know what to do for you,” or “you’ll just have to live with it.” Most people experiencing this kind of frustration in ﬁnding answers and getting well have a form of functional illness, where they aren’t well, but don’t have a pathological illness either.

23 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Commonly people who have functional illnesses get dropped through the cracks when trying to get answers through conventional medicine; not because conventional medicine is wrong, but because it’s not the right tool for the job.

Conventional healthcare is the right tool for treating pathological illnesses. Examples here are antibiotics for pneumonia, surgical repair of a knee injured in an accident, replacement of a heart valve weakened from an infection, and insulin injections for someone with type I diabetes.

Functional medicine/healthcare is the right tool for treating functional illnesses and for maintaining and protecting your health over time. Examples here are allergies, most digestive problems, many hormonal imbalances, most menstrual problems, inﬂammatory illnesses that lead to pain, most types of hypertension, anxiety, depression, hypoglycemia, type II diabetes, and fatigue.

The gray zone is that condition of illness where the body may or may not still have the capacity to heal. Here a trial of functional care is often justiﬁed or a combination conventional and functional healthcare together. This is also a situation where concurrent care, utilizing both conventional and natural therapies together may be the most effective approach to restore a patient’s health.

So what is functional healthcare? It is a synergistic combination of natural therapies, such as acupuncture, chiropractic, clinical nutrition, craniosacral therapy, herbal medicine, homeopathy, osteopathy, lifestyle counseling and modiﬁcation (diet, exercise, stress management), and conventional diagnostics such as physical, orthopedic, and neurological exams, x-rays, MRI, CAT scans, and laboratory testing.

24 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Comparing Healthcare Types

Conventional Natural Functional

Philosophy & Foundational Theory

Mechanistic Vitalistic Mechanism & Vitalism

Aims

Eliminating symptoms/ Healing through Restoration illness natural means of function

Strengths

Uses exams & lab tests Exams & lab testing Natural therapies and natural therapies

Weaknesses

Complex & difficult; Drugs used to manage Underutilizes exams integration of extensive functional diseases & lab testing data may lost

Functional healthcare is an approach that utilizes the strengths of both conventional and natural healthcare synergistically in a way that contributes to effective care. This is a healthcare approach that can be incorporated into the practice of all physicians, nurse practitioners, and physician assistants as it uses the same fundamental tools of diagnostics common to the practice of healthcare and adds to this common background the more focused use of natural methods as a ﬁrst choice tools for most illnesses.93

Functional healthcare outcomes are measured through follow-up exams and lab tests to determine results from care. This is the same gold standard used in conventional healthcare and the same fundamental tools are used. This approach ensures that functional healthcare is producing tangible, measurable, and reliable results. Using this standard shows that functional healthcare produces results that are real and cost effective.94

93 For example, all healthcare practitioners have the same basic background in anatomy,physiology, biochemistry, neurology, and diagnostics; we use the same textbooks for our basic knowledge. We all use stethoscopes, reﬂex hammers, and otoscopes in the same way; we all order the same basic lab tests (I.e. a blood count is a blood count); we do abdominal exams essentially the same; we agree on the fundamentals and have the same fundamental tools.

94 Maxion-Bergemann S, Wolf M, Bornhöft G, Matthiessen PF and Wolf U (2006) Complementary and alternative medicine costs - a systematic literature review. Forsch Komplementmed 13 Suppl 2, 42-45.

25 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Functional Healthcare for Decreasing Healthcare Costs: An Example There is a tendency to regard natural and functional healthcare as being useful for simple illnesses, but not really being effective for severe, complex, or chronic illnesses. This is especially true by the conventional medical community even though research scientists are generally more open to the evidence that natural and functional healthcare methods are therapeutically effective for a wide range of illnesses.

Dewayne S. ﬁrst came to my ofﬁce in May of 2005. He had contracted viral endocarditis and his heart had been damaged to the extent that he had congestive heart failure and was on a heart transplant list. The consensus among the physicians he had worked with up to that point was that the heart transplant was inevitable.

Dewayne had recently been released from the intensive care unit of a local hospital. He was barely able to walk from the parking lot to my ofﬁce and coughed throughout our consultation due to his lungs being nearly full of ﬂuid because of the weakness of his heart.

Exams revealed that his condition was possibly still within the “gray zone” of illness and that he was a candidate for a trial of care. I explained what would be required of Dewayne if he was to heal and that a trial of care was not a guarantee that he would be able to respond and heal.95

Dewayne opted for care and worked diligently with me for many months. He saw improvement within a few weeks, but the amount of healing that his heart and body needed required time as well as our efforts. Healthcare included chiropractic care, craniosacral therapy, acupuncture, herbal medicine, and clinical nutrition. Selfcare included yoga, meditation, visualization, diet, fasting, and exercise.

By September of 2006, his heart was retested at UCLA Medical Center and his ejection fraction, a critical measure of heart function, was found to be better than would be expected from a heart transplant.

Now, four years after our ﬁrst meeting, Dewayne is able to run, hike mountain trails, exercise vigorously, and he feels energetic and well. He continues to practice selfcare and gets periodic functional selfcare. He is able to work again full-time and play tirelessly with his kids.

He does take a couple of medications to decrease stress on the heart and this is a good example of concurrent care - the synergistic use of both conventional and functional healthcare to provide for a patients’ speciﬁc needs.

95 Using a clinical trial of care is a standard practice in conventional medicine, as well.

26 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

If Dewayne had ended up getting a heart transplant the cost for the transplant and associated care would have been in the ballpark of $658,000.96 The heart transplant ﬁgure includes obtaining a donor heart (~$90,000), evaluation fees (~$23,000), doctor’s fees (~$40,000), hospital costs (~$383,000), post-operative care (~$93,000), and immuno- suppressive drugs (~$29,000). Yearly follow-up treatment for heart transplant patients costs around $21,000 a year.

From July of 2005 to February of 2008, Dewayne was under active care and spent a total of $6,233 which included the clinical nutrition (vitamins, minerals, herbs, and other supplements) he needed as part of his therapy. From early 2008 on, Dewayne has been on maintenance care that is roughly at quarterly intervals.97

Costs of conventional medical care for Dewayne since we began working together in 2005 has totaled around $7,000, mostly associated with monitoring and follow-up care with a cardiologist. The cost for his monthly prescriptions is $45.

The story above is an extreme case, but it does serve as a useful example of the effects of functional healthcare when used judiciously. Dewayne was well within the “gray zone” of the continuum of health and he may have not responded from a clinical trial of care as his heart may have been already too damaged to heal and recover function.

Dewayne’s response to natural healthcare was monitored by objective standards recognized by the scientiﬁc and medical community and he received concurrent care from a cardiologist to complement my work. If he had not responded to natural and functional care, Dewayne would have been informed and the trial would have concluded.

Even if a heart transplant was ultimately necessary, natural and functional healthcare could have been used concurrently with heart transplant, conventional rehabilitation, and follow-up care, to provide improved outcome and decrease overall costs. This is an important point regarding natural and functional healthcare; it is not antagonistic to conventional healthcare, but rather advocates appropriate care for a patients’ condition.

96 Average cost in 2007 according to Transplant Living (http://www.transplantliving.org/)

97 A video of Dewayne telling his story is posted on youtube.

27 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Selfcare As Healthcare Reform The current healthcare crisis is the result of the commonly held belief that you will be healthy if you only get the right healthcare. Its’ not true.

The current healthcare crisis has developed further because of the emphasis on treatment of disease and the lack of preventing disease. Ultimately, the most powerful, predictable, and cost-effective solutions for the current health care crisis won’t come from a restructured healthcare delivery system; it will come from us taking responsibility for ourselves through practicing selfcare.

What you do for yourself on a daily basis to nurture and protect your health will, in the ﬁnal analysis, always have more effect on your health status than any healthcare. Regardless of the essential nature and need for quality of healthcare to the state of your health, your health is really up to you and what you do and don’t do for yourself day by day.

There are occasions when selfcare won’t sufﬁce and healthcare, drugs, and even surgery are essential, rather than an option. But, in most cases the need for secondary healthcare, drugs, and surgery has develops not from overwhelming infection, unalterable genetic inheritance, or injury, but from the outcome of self-destructive behaviors. And, as a remedy for the need for secondary healthcare, ultimately, selfcare has a greater overall effect on long-term health outcomes than healthcare, regardless of the quality, and at far less cost.98,99

Practicing selfcare is an act of self-responsibility. By practicing selfcare you are acting in a way that dramatically diminishes your risks for chronic illness and incurring the associated costs that affect you, your family, and society.

Vital Aging As Healthcare Reform From Ladakh (a region of northern India)... “The old (in Ladakh) are active until the day they die. One morning I saw the eighty- two-year-old grandfather in the house where I lived running down a ladder from the roof. He was full of life, and we exchanged a few words about the weather. That afternoon at three o’clock he died. We found him sitting peacefully as though asleep.100

98 Randomized Controlled Study of a Retiree Health Promotion Program. The Bank of America Study, J. Paul Leigh, PhD; Nancy Richardson, MD; Robert Beck; Clark Kerr, PhD; Harry Harrington; Charles L. Parcell; James F. Fries, MD, Arch Intern Med. 1992;152(6):1201-1206.

99Reducing Health Care Costs by Reducing the Need and Demand for Medical Services. James F. Fries, C. Everett Koop, Carson E. Beadle, Paul P. Cooper, Mary Jane England, Roger F. Greaves, Jacque J. Sokolov, Daniel Wright, for The Health Project Consortium, NEJM,Volume 329:321-325, July 29, 1993, Number 5

100 Ancient Futures: Learning From Ladakh, Helena Norberg-Hodge, Sierra Club Books, 1992.

28 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

From Okinawa... “After getting hopelessly lost on the twisting narrow roads, we finally approached Nakajimasan’s small wooden cottage. There on the veranda, sorting through a variety of gardening tools, was a sprightly man of about seventy. He was casually attired in a white tee-shirt and long pants, and greeted us with a wave and a winning smile. We naturally figured he was Nakajimasan’s son, and asked him in our broken Okinawan where we might find his father. We imagined that the old man was quietly resting in the house, safely protected from the scorching sun, probably dressed in a yukata (the loose kimono worn by males). But in Okinawa things are not always as they seem. The energetic man, dressed in the kind of clothes we North Americans might wear on weekends to putter around the garden, was not seventy, he was one hundred - and gardening was exactly what he was preparing to do.

After recovering from our initial shock and getting to know each other, we completed a full geriatric assessment, including an electrocardiogram. Nakajimasan was in outstanding health, with the exception of a mild cardiac disturbance known as a ﬁrst degree heart block. It is a mild slowing of the conduction of electricity through the heart and considered harmless and very common - it’s often seen in the elderly. When we informed him of our ﬁndings, he exclaimed, “Chaganjuu,” which in the Okinawan dialect means “I am in perfect health!” And he was right.

Except for the mild conduction delay and slight variance in arm size owing to a childhood snakebite, he was utterly healthy. After a hundred years of use, there was basically nothing wrong with his body! And this was a common ﬁnding during our ﬁeld research of the Okinawans and their way of living.101

Some people put great emphasis on the beneﬁt of longevity. In terms of decreasing healthcare cost longevity as a direct goal is not advantageous. Unless the goals of maintaining function and minimizing disability are achieved, increased longevity is associated with exponential increases in health care costs.102,103

There are many ideas circulating about how old we should be able to live. The evidence seems to support a model that your optimal and natural lifespan is ninety years, plus or

101 The Okinawa Program, Bradley Willcox, MD, D. Craig Willcox, PhD, and Makoto Suzuki, MD, Three Rivers Press, 2001.

102 Preventing fatal diseases increases healthcare costs: cause elimination life table approach. Luc Bonneux, Jan J Barendregt, Wilma J Nusselder, Paul J Van der Maas. BMJ 1998;316;26-29

103The Effect of Longevity on Spending for Acute and Long-Term Care. Brenda C. Spillman, Ph.D., and James Lubitz, M.P.H. NEJM Volume 342:1409-1415 May 11, 2000 Number 19

29 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com minus ten years depending on genetic constitution and the quality and consistency of your selfcare.104

Living long is not much of an achievement of your quality of life is compromised by illness and disability. There is much evidence that using lifestyle habits supporting optimal function lead to longevity and minimize the loss of abilities that most people consider to be normal and essential to aging.

Rectangularization of the survival curve is a model for the observation that some groups of people are able maintain their health with little decrease of ability until shortly before death. Some researchers have argued that this phenomenon represents normal aging.105

This model for longevity both increases quality of life and lifespan for individuals and diminishes healthcare costs for society.

Functional Selfcare As A Means To Vital Aging Aging with vitality and robustness, free of disabilities, and able to live your life as you please is a possible, even highly predictable outcome of long-term, disciplined, and functional selfcare.

The model of functional selfcare leads to healthy and optimally functional children and adults, healthy mothers who give birth to healthy infants, and elderly that lead robust and independent lives.

Aging well (vital aging) is a responsible act towards friends, family, community, and yourself because through it you are able to remain more independent and self- responsible. It is also a ﬁnancially responsible act because it results in decreased consumption of resources in healthcare and maintains ones’ ability to be productive and independent throughout life.

Okinawans are the longest lived group of people in the world and they tend to be vital and live independently throughout their lives. Their long and vital lives have been extensively studied and are attributed to their diets, exercise, and peaceful and purposeful lifestyles, all of these factors being inexpensive, self-determined, without side effects or health risks, and proven, both by observation and research.106

Is there something special in addition to their lifestyle habits about Okinawans that accounts for longevity and quality of life?

104 For more on the topic see Longevity in Wikipedia (http://en.wikipedia.org/wiki/Longevity)

105 “The phenomenon of rectangularization of the survival curve in the Czech population as a result of the concept of successful aging and geriatric medicine,” Z Kalvach, Cas Lek Cesk,. 2000 Nov 22;139 (23): 715-2.

106 The Okinawa Program, Wilcox, Wilcox, and Suzuki, Three Rivers Press, 2001

30 Mark Force, DC …functional & natural healthcare Ashland, Oregon, USA theelementsofhealth.com

Though Okinawans do represent a unique genetic group, the phenomenon of vital aging is reproducible in a wide range of ethnic types and not limited to that group. Researchers have found that there are numerous pockets around the world of long-lived people and study of the factors that lead to their longevity has shown common lifestyle patterns.107

Vital aging is also producible in people who have been distinctly unhealthy earlier in their lives. Paul Bragg was expected to die from tuberculosis when in his teens. He was sent to a TB sanitarium in Switzerland where he learned how to use diet, fasting, and exercise to heal. He healed and became very robust. For the rest of his life, Paul Bragg wrote and lectured about his experience and shared what he had learned. Bragg died at 93 shortly after a surﬁng accident in Hawaii.108

Jack LaLanne was very ill and sickly as a teenager when he attended one of Paul Bragg’s lectures. Following basic principles of diet, exercise, and other simple lifestyle factors, he also became robust and vital and, now in his 90s, is stronger and has more endurance and vitality than most men in their 30’s. His wife, Elaine, enjoys similar outcome from the same basic lifestyle habits.

Clarence Bass when in his early 60’s was tested at the Cooper Clinic in Texas and was found to be ﬁtter than 95% of men in the 20 to 30 year old age group! His outcomes have also come from very simple habits that include whole foods and exercise. Now in his early 70s, Clarence Bass still embodies the kind of health, ability, and well-being that can be had through practicing simple selfcare habits over time.109

These people and the Okinawans represent a group of living proof that confirms the value of basic and self-directed lifestyle factors in leading to long and vital lives that are free of disease and significant disability; that experience vital aging as a direct result of their life-affirming habits.

107 The Blue Zones, Dan Buettner, National Geographic, 2008

108 The Miracle of Fasting, Paul Bragg, Health Science, 2004

109 Challenge Yourself At Any Age, Clarence Bass, Ripped, 2003