Wednesday, 12 December 2012 16:58
By Walter Alexander, Contributing Writer – Vol. 13, No. 4. Winter, 2012
Escape Fire: The Fight to Rescue American Healthcare is not the first documentary to bemoan the inadequacies of healthcare here in the US. But it is unique and commendable for the way it looks at potential solutions already known in “real world” practice.
Before exploring ways out, Escape Fire does provide the de rigueur cold water bath of unpleasant healthcare cost data, personal health tragedies, practitioner entrapment, and political/social deadlock. The arc of current cost expansion, if followed unabated, is projected to gobble up $4.2 trillion annually (~20% of our gross domestic product) in ten years. At present, US yearly expenditure on pharmaceutical drugs (about $300 billion) nearly matches the amount spent by the rest of the world.
The rationale for the film’s title is explained by Don Berwick, MD, former Medicare/Medicaid head. It derives from a life-saving strategy invented on-the-spot by a forest fire fighter trapped with fellow smoke-jumpers in the midst of a wildfire speeding uphill towards them. He throws a match to create a safe burned out area, and begs his fleeing companions to join him. They do not listen, and most of them perish, while he survives nearly unscathed.
The analogy the filmmakers propose is that while our healthcare system is “burning up around us,” rescue solutions are already before us, but people are so embedded in the status quo that tragically they can’t recognize viable escape strategies even if they’re staring them in the face.
Intellectually, the analogy is a bit weak but the directors have documented some impressive and frightening “flames.”
Case in point is Erin Martin, MD, a general practitioner on her last day at a low-income primary care clinic in Oregon. She resigns because of the demoralizing effect of her 25-patient per day schedule. At the same time that she despairs she cannot devote the time needed to truly help her patients, the clinic administration is constantly asking her, “How can you get your productivity up? You need to see more patients because we’re in the red.”
Directors Matthew Heineman (Emmy nominated) and Susan Froemke (four-time Emmy winner) follow Dr. Martin as she finds her way to the University of Arizona’s Program in Integrative Medicine, and then to a Washington State community clinic that is physician owned and operated and that promised her the ability to shape her own practice.
There she now can devote the time to “act more as a guide for patients and spend the time to educate them, and help them make lifestyle changes that affect their health.” Ultimately, we learn, that clinic, too, has come under serious pressure to increase productivity. Dr. Martin is not covering her costs, and diminishing reimbursements are seen as a significant threat to the clinic’s viability. Dejected, she finds herself back where she started.
Also woven into the film’s fabric are other poignant stories from both the physician and patient side. We learn of military applications of acupuncture for pain relief, the film-makers document skeptical battle-hardened veterans as they find their way to “weird” but effective alternatives after conventional polypharmacy has failed them.
We follow the progress of Sgt. Robert Yates, a US Army infantryman and wheelchair-bound self-proclaimed “redneck,” who embarks on a quest to wean himself from a regimen of 32 drugs prescribed for his severe combat injuries and PTSD. Over a period of months, his health—and his outlook—are completely turned around thanks to an innovative Army program including yoga, meditation and acupuncture.
Narrow Strength, Broad Weakness
While acknowledging the strengths of American healthcare, Dr. Berwick shows also its unsatisfactory overall consequences. “If you need real serious technology today, like very complex cardiac surgery, you’re lucky to be in this country. Rescue care is second to none. But as an overall system, we’re not anywhere near the best in the world…Our lifespan isn’t even in the top twenty.”
Profit-driven healthcare, as opposed to patient-outcome driven healthcare, takes a beating from a variety of critics in Escape Fire. Physician-luminaries offering analyses include Cleveland Clinic chairman of cardiovascular medicine, Steve Nissen, MD, University of Arizona’s Andrew Weil, MD, and Dean Ornish, MD, whose pioneering research first showed that combinations of lifestyle change, meditation, exercise and psychosocial support could quickly reverse coronary artery narrowing.
Doctors emerge, not as “evil-doers” but as victims of a system that leaves them few options. Dr. Nissen: “Physicians are well-intentioned. Even when bad things happen, it’s not because people have bad intentions. It’s that our system is all fouled up.” He does go on to say, “When medicine became a business, we lost our moral compass and I think we’ve gotten into a great deal of trouble because of that.” He added, “What I’m arguing for is not to make things tough on industry, it’s to make things safe for patients, putting patients first.”
Dr. Weil points out, “A great deal of what’s done in conventional medicine is to put band-aids on things or to suppress symptoms.” After noting that profit-driven pressures have shrunk the time allowed for patient visits to 7 minutes with a patient, he warns that the “two-minute visit” is being discussed seriously. “Literally 30 patients an hour…And this is not the choice of the doctor,” he said.
Such a system, said Shannon Brownlee, medical journalist and author of Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer, is really a “disease care system” that “doesn’t want you to die and doesn’t want you to get well – it just wants you to keep coming back for care of your chronic disease.”
We hear from Wendell Potter, former director of Communications for CIGNA, who after a crisis of conscience left the insurance industry to speak against its practices (read HPC’s in-depth interview with Wendell Potter).
Steve Burd, CEO and president of the Safeway grocery chain outlines the company’s program to incentivize weight loss, smoking cessation and exercise for 30,000 Safeway workers, a program that has kept the company’s healthcare costs flat while the national average between 2005-2009 rose 40%. “Safeway employees will be less of a burden on Medicare of the future because we have adapted to this culture of health and fitness. You allow and encourage your employees to become healthier, they become more productive, your company becomes more competitive…Making money and doing good in the world are not mutually exclusive.”
Dr. Nissen’s Cleveland Clinic was founded by four physicians who realized they did better as a team than as individual practitioners. They formed a group practice and decided they would pay themselves a salary and that the money left over would go into growing the organization. That model has continued to this day. “We’re all salaried. So the decision on what we do for a patient is dependent upon what the patient needs, not on our financial incentives.”
“Achieving real solutions,” said Andrew Weil, will call for a “massive rethinking about healthcare at all levels of society…a huge effort.”
Escape Fire also spotlights Dr. Ornish’s decades of work to provide the hard science verifying the ability of non-pharmaceutical, non-surgical approaches to impact atherosclerosis and prostate cancer, even to influence gene expression, and teleromerase and teleromere length. “People often think it has to be a new drug or a new laser or something really high tech and expensive to be powerful, and they have a hard time believing that these simple choices that we make in our lives each day can make such a powerful difference,” Dr. Ornish said.
As Dr. Ornish—and the film viewers find out—the data were not the game-changer he’d hoped they would be. Data alone is seldom strong enough to dislodge entrenched behaviors, especially when the data fly in the face of their closely held beliefs and habits of thinking. It took a more fundamental understanding–that without reimbursement, the Ornish program, whatever its potential benefits would remain on the fringes of American medicine.
It took 16 years of persistence to wrest the power of the purse from a variety of insurers. In January 2011, Medicare finally agreed to reimburse physicians for implementation of the Ornish program for CVD reversal.
Escape Fire Premieres
In an interview conducted after a New York City screening of Escape Fire, Dr. Ornish commented that procedure-based reimbursement patterns are now shifting towards more diagnosis-based ones, such that a patient with a diagnosis of coronary heart disease will get a set amount of dollars for care. “So the kinds of things that we are doing, ultimately will be not just the right thing to do, but also a much more financially viable and sustainable way to practice.”
Cardiac surgeon Mehmet Oz, MD, director of the Cardiovascular Institute and Complementary Medicine Program at New York-Presbyterian Hospital, and host of the wildly popular “Dr. Oz Show,” acknowledged that excessive cardiac treatment occurs even though “sometimes there’s a simpler way to provide a more comprehensive solution to what patients need.” In remarks following the film, Dr. Oz commented that while changing the incentives in healthcare may help the situation, physicians, themselves, must make changes.
“Part of it is professionalism. Professionals police each other… If you’re clever enough to become a specialist in cardiovascular services, you ought to be clever enough to realize that bettering the field of medicine is part of our covenant.”