OPINION: Lower health care costs come with change in attitude
by GAIL LOWENSTEIN, MD


Washington's health care reform continues to spark controversy. After a year of debate and, then, passage with the help of legislative maneuvering, the reform remains the target of efforts to "repeal and replace" it.

Some of the objections are political, but the reform does indeed have an underlying structural problem. Financial modifications on an inherently flawed system aren't going to solve our nation's health care woes. It may seem obvious, but it's too often ignored: The best way to reduce health care costs is for people to remain healthy.

To accomplish this, people need to take responsibility for their own health through choices they make in what they think, eat and do. When we truly take on this responsibility, we become artificers of our own destiny, rather than victims of a dreaded disease and a health care system fraught with unnecessary interventions, medical errors and known adverse reactions.

Many of us use financial advisers. We put lots of effort into safeguarding our money for the future. But how many of us put this effort into safeguarding our health for the future? Instead, we wait for the inevitable emergency, become overwhelmed, follow the path of least resistance - and then sue the health care providers for unfavorable outcomes. We don't want to face the fact that there were things we could have done to prevent this severe decree.

Simply taking control of what we eat and what we think will go a long way toward keeping us healthy. When you compare the foods that are widely available now with what humans originally evolved to eat, it's obvious that we've strayed quite far from the lean muscle meats, limited fatty organ meats, and wild fruits and vegetables that sustained our ancestors. But our underlying genetic inheritance remains basically the same. The highly processed, sugary and salty foods too many of us eat with abandon are discordant with our bodies.

Many of us also tend to think in an unhealthy way. We are judgmental, angry, fearful and live frenetic lives. In the ancient traditions of medicine, there is a quality of emotion, feeling and thought that appears to optimize genetic codes and "turn them on" - providing longevity, vitality and tremendously enhanced immune systems. Few practitioners of Western medicine, however, encourage this kind of reflection in their patients.

So we all must do more to address those basic elements building our bodies and our minds. But doctors today tend to treat illnesses, not the people who have them. We've evolved from the general practitioner who made house calls and knew the entire family, to a system in which we have a different physician for every body part. Today's health care system has a dearth of physicians capable or willing to pull together a person's individualized health care program.

When given the choice, elderly and chronically ill patients may choose comfort measures over aggressive medical care with its associated drugs, tubes, needles and other medical intrusions. So doctors must learn to ask patients what their goals are for treatment.

I've learned through my own practice that this question is essential for forming a plan that is right for individuals, rather than for their diseases. I remember well a letter I received from a patient's daughter: "Although my mother had signed a living will, the temptation was ever there to try more aggressive means and to look for the cause of her decline. It was only through your support that I was able to make what I am convinced was the correct decision - to let my mother die peacefully. I was able to . . . see that she received kind, palliative care, and be with her . . . until the end."

Treating people instead of diseases not only provides individuals with autonomy in making health care choices, but it also lowers health care costs through reducing hospitalization, which is the most expensive health care setting.

Hospital errors, pressure ulcer development and overhydration are not uncommon. Transfer trauma - changing the location of a person with underlying dementia - can cause delirium, falls and a host of behavioral changes when the individual is moved to a hospital setting.

Statistics from the Centers for Disease Control and Prevention show that deaths linked to hospital germs represent the fourth leading cause of mortality - that's more than heart disease, cancer and strokes. Infections connected to hospital-based germs kill more people annually than auto accidents, fires and drowning combined. This is not to imply that hospitalization cannot also be tremendously beneficial. But it shouldn't be the default answer. Instead, it should be a carefully weighed option in a broader consideration of burden vs. benefit and the goals of treatment.

One early casualty in the health care reform debate was the so-called death panels. Ironically, this was a highly beneficial part of the proposal. It would have encouraged people to discuss their end-of-life wishes with their providers by making certain that health insurers would cover those consultations. It was axed because of the concern that people would be pressured to forego life-sustaining treatments. Actually, the reverse is currently true: People are at times harangued into accepting aggressive treatments they do not want.

There is a serious mismatch between where people want to die and where they actually do. Most people would choose to die not in a hospital, but nearly half of all deaths related to chronic, life-limiting illnesses happen there. About 20 percent of Americans die in hospital intensive care units, where many have endured torturous and futile attempts at a cure, surrounded by strangers and in pain. Even though nine out of 10 people in the United States say they would prefer to die at home, only about a quarter of deaths occur there.

Our society views death as failure, rather than as a natural part of living. The humorist Art Buchwald checked himself into a hospice, expecting to die within 10 days of discontinuing dialysis. Close to a year later, he passed away with his family holding his hand. He wrote that if he had known dying would be this much fun, he would have done it sooner.

Attitude is key. And changing our focus from a health care system that expects sickness to one that rewards wellness and personal autonomy is the first step to affordable health care for all.

Reprinted with permission of Dr. Gail Lowenstein from Newsday, June 6, 2010
Dr. Gail Lowenstein of Nassau County, New York, is board-certified in internal medicine, palliative/hospice care, geriatrics and holistic medicine.