While the arguments over this act
continue, and Republicans want to repeal it, several elements of this
bill are finding homes in strong Republican states. Ohio Republican
governor John Kasich is actively pushing the idea of Accountable Care
Organizations, included as a major emphasis in the ACA, to change the
nature of our system; and it is apparently appreciated in his very
healthcare conscious state.
Accountable Care organizations do not charge on a fee-for-service basis, but on per capita. Under a fee-for-service system, the emphasis turns more into maximizing the bill by doing more for the patient that is really necessary. And there is less emphasis on preventive measures because the system, the doctors, the hospitals, the drug companies, and everyone involved, get paid more when the patient is sicker.
Health Maintenance Organizations had a
similar per capita basis, but their emphasis was saving money for
their stock holders, and they often did this by denying expensive
care. Accountable Care Organizations are monitored by the health of
their patients. This different emphasis will put pressure on our
system to adapt in a very healthy way as it searches for ways to
increase its profits by making us healthier.
The first pathway to this end is the increased use of protocols. Experience has shown that certain elements in practice work better, like a team approach to managing diabetics, or the use of certain drugs that are often not considered at critical times, like the use of beta-blockers after a heart attack. Such protocols are beneficial, but there are others that may be even more so; and they don't require a doctor.
One of the easiest pathways to this end is looking at what Williams and Nesse called Darwinian Medicine in their book, Why We Get Sick. They point out that our current system is based on the idea that we regain our health by balancing symptoms. We got this idea from our roots humoral medicine and while we have found more scientific humors the model is still the same--we balance symptoms to make us healthy. So we try to balance a fever with drugs that lower our temperature, or our GI upset with drugs that calm it, or our runny noses with drugs that dry it up or turn off the taps.
Williams and Nesse show, however, that in our continual interaction with our environment we have developed defenses that help us survive better. They point out that a fever helps the immune system better fight off infection. Animals that are experimentally infected die more often when they are prevented from developing a fever. Hobbling that defense makes them less able to overcome the challenge of the infection. Hobbling the defense of your favorite football team is not a very good idea if you want to win the game. The same is true with us in our ongoing game with all of the infectious and noxious agents in our environments.
In much the same way nausea, vomiting
and diarrhea are a back up defense for times when we eat something GI
immune system considers harmful. Our primary GI defenses are the acid
in our stomachs and the friendly bacteria that populate our GI
tracts. Gastroenterologist now tell us that using the many available
drugs that interfere with our primary defenses, (to slow or block the
uncomfortable symptoms brought on by our secondary defenses) may
increase our risk for more problems such as irritable or inflammatory
bowel disease when diarrhea is stopped. Alternatively slowing the
removal of the noxious agents when infection is the problem may give
the intruder time to set up house.
Then we run the risk of being a
carrier, like "Typhoid Mary," of the problem germ. A much better
choice is to use oral re-hydration salts which replace the fluids used
to clean the GI tract. Developed in the 1970s oral re-hydration was
called one of the most significant medical advances of the last
century. The combination of sugar, salt and water turns on the pump
in the stomach that pushes the water into the body. It is by far the
easiest, safest and least expensive way to get water into the body. But, it is little used in this country because the
combination of sugar, salt and water cannot guarantee the monetary profits
than those of a drug can.
Without profits drug studies, to
satisfy the FDA cannot be done and without FDA approval no
manufacturer can make the claims that are clearly applicable for this
combination. The same problem is present with the
ways to help our nasal defenses. These are provided by the
combination of the mucus in our noses, which is sticky enough to trap
almost all foreign material we breathe in, and the cilia, the
microscopic hairs that constantly sweep the mucus to the back of the
nose where we swallow and recycle it in our stomachs.
This process is handicapped when the air is dry (which is why we have a cold season that corresponds so well with when we turn on our heaters) and our use of drugs that block the back up defense, which is triggered by histamine in the nose and made up more water, more sneezing, more mucus, and, if the problem is great enough, shutting down the airway (as in asthma) to protect the more vulnerable lungs from the pollution sensed in the back of the nose. Helping these defenses is a better choice; saline nasal sprays do this a little, as do neti pots. Xylitol is also used to help nasal defenses, both by unhooking pathogenic bacteria and by increasing the water supply in the nose so that the mucus is more optimal.
These advances depend on those practicing medicine seeing differently. Such shifts are always difficult but in these cases there is no great learning curve and with all of the them being safe and available outside of the Food and Drug Administrations restrictions people can and should lead the way. Just as with our football teams, having a good defense will help us win the game; in living that means a safe and effective way to make us healthier.
[The ideas proposed in the above are discussed in greater detail in The Boids and the Bees: Guiding Adaptation to Improve our Health, Healthcare, Schools, and Society.]