Tuesday, November 27, 2012

I2P: It's all in the Mind

What level of Individual Responsibility do we each have in managing our Health and Well-Being, given that 40% of "total health" is due to lifestyle choices and behaviour and only 10% Healthcare Delivery? [1]

How much "free" healthcare, taxpayer funded, are we prepared to give individuals?
Should we limit it? How? Unlimited Free Goods guarantee unlimited demand for them.

The typical rationing systems are "cost-shifting", like co-payments or insurance "gaps", or under-servicing through crowding, delays and queues. The George Institute recently cited 11% of Australian Bankruptcies are due to ill-health or lack of health insurance. One 52-yo breast cancer survivor was left with $31,000 in medical bills not covered under Medicare [7]

The Oregon Health Plan explicitly addresses rationing through a multi-pronged approach. [2][3]
One avenue is the Priority list: only the most important 90% of conditions are treated and fully funded.
Another are their policies limiting spending when it will yield negligible benefit:
410-120-1200 (l) That are requested by or for a Client whom OMAP has determined to be non-compliant with treatment and who is unlikely to benefit from additional related, identical, or similar services; [4]
Guideline note 12, treatment of cancer with little or no benefit provided near the end of life.
This guideline only applies to patients with advanced cancer who have less than 24 months median survival with treatment. [5]
Their current "Action Plan" [6] has 8 Foundational Strategies to achieve their Triple Aim:
  • Improve the lifelong health of all Oregonians 
  • Increase the quality, reliability and availability of care for all Oregonians 
  • Lower or contain the cost of care so it is affordable for everyone
Prevention is now their top Medical priority:
  • Weight Loss programs and counselling, especially for Diabetics, are paid-for, but bariatric surgery isn't available, nor are supplements.
  • Drug and Tobacco addiction-breaking programmes are supported.
  • Many specific programs for identified High Risk groups with well known conditions.
So in Oregon, the growingly popular "Pharmacy weight loss programs" won't be State subsidised.
After 6 months of counselling, if you're not losing weight, funding stops.

This strategy of focussing on the biggest determinants of health, on every-day actions and lifestyle choices that people make, seems worthy of investigation. Like "Weight Loss" and "Quit" (smoking) programmes, a whole range of useful ancillary Health Products and Services could be delivered through Pharmacies: they are accessible in the community, have high social trust/standing, have trained specialist staff and already deliver similar Goods and Services.

We know the mind is powerful over itself: Hypnosis demonstrates this with 10-15% of people "highly suggestible" and candidates for anesthetic-free procedures.
An ABC program recently reported an interesting line of research at Macquarie University using hypnosis to produce temporary and reversible "delusions" and obsessions in subjects, so they could be studied at will. The differences in brain function within an individual with/without a condition could be studied. [12]

An emerging field of Immunology, Psychoneuroimmunology [8], describes the links and their mechanisms between our brains, psychological state and immune system. It seems the Mind is also powerfully connected to our Body and Immune system.

The adverse effects of stressors on Health has long been known and proven, forming the basis of successful non-traditional medical approaches, e.g.:
  • Dr Jon Kabat-Zin, "Mindfulness Based Stress Reduction" (MBSR) [9]
  • (Dr) Patch Adams, 40 years of clowning: happy people heal quicker and better [10]
  • laughter clubs: faking smiling and laughing induce the real emotions, reducing stress and improving Health and Healing [11]
All these medical approaches have been researched, published and shown to work. They aren't new, untried or untested. (I've not researched the impact of Hypnosis or Self-Hypnosis on reducing stress, increasing well-being and Health, though you might think there'd be a link, especially for the "highly suggestible".)

This medical evidence is distinct from the wholistic mind-body meditation and nutrition programmes for cancer sufferers, such as Ian Gawler's programs. It's medicine as if people matter.

These approaches support the statistics that people in loving relationships and those with a "faith" live longer, are healthier and have a higher quality of life. Is the converse necessarily true: those who are constantly angry, judge others and are "grumpy old people" have more disease and lower lifespans? I don't have the data nor statistical competency to answer that question.

I'd stop a very long way short of saying that people that don't actively manage their stress, don't have a strong belief system and loving relationships are harming themselves, are the agents of their own disease, even though this message may be inferred from the evidence.

Should rational Healthcare Authorities be insisting on individuals taking responsibility for the 40% of their health outcomes within their control with lifestyle & behaviour choices? Why medically treat conditions once they've formed, and with 400% less efficacy, when they can be prevented for little or no cost to the system?

Should those rational Authorities should be requiring of individuals, especially those predisposed to serious conditions, undertaking Evidence-based approaches to Stress Reduction and promoting Health and Well Being?

That sounds reasonable and medically and financially sound to me, not to mention a whole new line of products and services for Pharmacies. The clincher would be to get more regional Healthcare Authorities to follow the OHA and embrace active Prevention as their primary medical strategy. It's backed by incontrovertible evidence that it is the cheapest, most effective and least intrusive/injurious medical treatment possible.

Along these lines, I've always wondered at the lack of research, the seeming disinterest by the medical and research community, into two of the most well documented, effective and least understood healing mechanisms of the human body:
  • Placebo Effect, and
  • Spontaneous Remission
Perhaps psychoneuroimmunology has some of the answers...

For some people, is disease All in the Mind? Or is it everyone? How could we even tell?

The Mind healing the Body when it can, would be the ultimate non-invasive, non-injurious and effective medical treatment.
But because you can't bottle it, patent it or limit access to it, economics suggests it won't be investigated or solved anytime soon.

Medical Science likes to be able to replicate results to prove causality: how do capture this lightning in a bottle?
How does Science investigate and discover the mechanisms of cures, not just treatments, that are unpredictable and, by definition, one-off?

It isn't impossible, but the current methodologies don't take us there.


"It's all in the Mind, you know" was a catchphrase of the BBC's Goon Show.

1. Figures cited by Dr Brent James in "Managing Clinical Processes: Doing Well by Doing Good".

Contributors to Good Health. Slide 9 "Total Health: How long, how well we live":
40% - Behaviour under control of the Individual (loosely, 'lifestyle choices'). Tobacco, Alcohol, Movement Deficit Disorder [humour!]
30% - Genetics
20% - Environment and Public Health
10% - Health care Delivery (Hospitals and Clinics)
McGinnis JM & Foege WH. Actual causes of death in the United States. JAMA 1993; 270(18):2207-12 (Nov 10).
McGinnis JM, Williams-Russo P, & Knickman JR. The case for more active policy attention to health promotion. Health Affairs 2002; 21(2):78-93 (Mar).
2. A Brief History of Health Services Prioritization in Oregon

3. Medical Necessity and Defined Coverage Benefits in the Oregon Health Plan

4. http://www.dhs.state.or.us/policy/healthplan/history/genrules/120rb0106.pdf

5. http://www.oregon.gov/oha/OHPR/HERC/docs/L/Oct2012/Oct12List.pdf

6. Oregon Health Authority 2010 Action Plan

Strategy #1 – Use purchasing power to change how we deliver and pay for health care
Strategy #2 – Shift focus to prevention
Strategy #3 – Improve health equity
Strategy #4 – Establish a health insurance exchange to make it easier for Oregonians to get affordable health insurance
Strategy #5 – Reduce barriers to health care
Strategy #6 – Set standards for safe and effective care
Strategy #7 – Involve everyone in health system improvements
Strategy #8 – Measure progress
7. Medicare rebates don't keep up with inflation and families struggle with medical bills

8. Wikipedia on Psycho-neuro-immunology, including links between stress and disease

9. Wikipedia on MBSR:

2003 meta-review conclusion:
Our findings suggest the usefulness of MBSR as an intervention for a broad range of chronic disorders and problems.
Mindfulness-based stress reduction and health benefits. A meta-analysis.
Grossman P, Niemann L, Schmidt S, Walach H.

10. Patch Adams Mission:
... holistic medical care based on the belief that one cannot separate the health of the individual from the health of the family, the community, the world, and the health care system itself.

Gesundheit’s model is designed to protect care as the core of the medical interaction.

Our model is organized around these principles:
  • Care is free.
  • Patients are treated as friends.
  • Ample time is given to the care interaction (e.g. initial interviews with patients are 3 hours long).
  • All complementary medicine is welcomed.
  • The health of the staff is as important as the health of the patients.
  • Care is infused with fun and play.
11. Laughter Yoga, Indian physician Madan Kataria

News, including research articles:

From: http://laughteryoga.org/index.php?option=com_content&view=article&id=7439:new-laughter-yoga-research-from-australia-for-workplace-wellbeing&catid=125:latest-&Itemid=275
A new study, recently conducted by Deakin University's School of Psychology, on the effects of Laughter Yoga found that it has a real and positive effect on workplace wellbeing weeks after laughter sessions are finished.
12. ABC Radio National:  Delusions for Research http://www.abc.net.au/radionational/programs/allinthemind/hypnotic-delusion/4373812

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