August 1998 Issue | Regina Herzlinger, Ph.D.




Welcome to Functional Medicine Update™ for August, 1998. So much is happening in our field; we are taking part in what I believe is going to be a reforming of the healthcare delivery system globally. I just had the opportunity to travel to Brazil, where I was impressed by the number of practitioners who have caught the wave of functional medicine and nutritional medicine. About 600 medical doctors attended a presentation I made in San Paulo as part of a four-day program. Several hundred practitioners at the meeting were involved in learning new skills in functional and nutritional medicine.

Functional medicine began to pick up speed in 1993 with the landmark paper by Dr. David Eisenberg that appeared in the New England Journal of Medicine. That paper alerted physicians around the world to the fact a second-tier medical system — called alternative care – was going on right beneath their vision. It was extraordinarily large, and many of their patients were involved with this system most doctors knew nothing about.

The Eisenberg paper, titled “Unconventional Medicine in the United States – Prevalence, Cost, and Patterns of Use,” alerted practitioners to this extraordinary trend and the changes that were occurring as a consequence.1

I think the most interesting thing in that study was the recognition that not only was there a high prevalence of use, but the individuals using these services were highly educated, had reasonably high discretionary incomes, and were electing out-of-pocket to support these services of complementary medicine.

Has this trend continued? What is the basic nature of the change? What is the mechanism by which people decide to employ the services of a complementary physician? Those questions are addressed in a more recent paper by Dr. John Astin, which appeared in the Journal of the American Medical Association. Titled “Why Patients Use Alternative Medicine – Results of a National Study,”2 the article describes the results of a study looking for variables of age, ethnicity, gender, education, and income that characterize individuals who use alternative medical services.

With regard to age, use of alternative therapies is pretty well distributed – age 18 through age greater than 65, with the greatest prevalence being probably individuals 50 to 64 years of age (42 percent), and 35-49 years of age (44 percent). Ethnicity was also fairly well distributed – a very high prevalence of use in the Native American population; fairly high in the Asian Pacific and Hispanic populations; and a reasonably high percentage of Caucasians (41 percent) used alternative medicine. Usage by gender was reasonably well distributed between male and female – about 39 percent of males, 41 percent of females. Fifty percent of those who used alternative therapies were people with graduate degrees; and 45 percent had bachelor’s degrees. With regard to household income, about 44 percent were people with income greater than $60,000 per year; about 44 percent were people with household income between $40,000 and $60,000 per year.

Chronic pain was number one reason people consulted alternative practitioners, with exercise, chiropractic, and massage being right at the head of the list of alternative approaches. Next was anxiety – exercise, relaxation, herbs, and music therapy. Third, chronic fatigue syndrome – massage, exercise, self-help and nutritional intervention. Next, sprains and muscle strains – chiropractic, exercise, massage, relaxation, and herbs. Addictive problems ranked next – psychotherapy, self-help groups, and nutrition intervention. Next was arthritis or rheumatism – probably tied together with chronic pain – exercise, chiropractic, homeopathy, herbs, diet and nutritional intervention. Severe headaches were next – chiropractic, massage, exercise, relaxation. Then, digestive problems – lifestyle and diet ranking number one – relaxation, herbs, and chiropractic. Last, blood sugar irregularities and/or diabetes – nutritional intervention, exercise, and stress reduction.

The article concluded that the majority of those who used alternative medicine appeared to be doing so not because they were dissatisfied with conventional medicine, but because alternative health care fit in with their own values. It matched their beliefs about their bodies in relationship to their health, the environment, and their philosophical orientations toward health and life. We are seeing a philosophical shift in the belief system about medicine, healing, and the body’s natural recuperative or repair mechanisms


Clinicians of the Month

Regina Herzlinger, Ph.D.

B: We are pleased this month to have as our Clinician of the Month Regina Herzlinger, Ph.D., the Nancy R. McPherson Professor of Business Administration at Harvard Business School. She is an expert in healthcare assessment and the economics and trend analysis in health care. Her recent book, Market-Driven Health Care, Who Wins, Who Loses in the Transformation of America’s Largest Service Industry, was published in 1997 by Addison-Wesley. It has caused a transformation in my thinking and provides information on what is happening in the field of health care, how it might change the future, and how we see ourselves as part of that future.

JB: Dr. Herzlinger, many market forces are at work on the healthcare system. What do you see as the predominant market forces shaping the healthcare system?

ball.gif (524 bytes)RH: One force is the consumer. Consumers nowadays are very smart. They are well educated; they are assertive; they are pragmatic. Although they love their physicians, and they like nurses and medical technology, they are very unhappy with the managed care movement which, essentially, says no to these activist, assertive, pragmatic people.

The second market force is employers who, in the United States, pay a large share of the healthcare bill. This bill was spinning out of control, and they thought they found a magic bullet with managed care. It turned out that instead of a magic bullet, the managed care movement was more like a gun to their heads. As employees became more and more unhappy with managed care, they took their complaints to the media and to the Congress, and they made employers feel very bad about their choices. Furthermore, many HMOs are raising their rates much faster than the increase in inflation in the economy as a whole. So they are not controlling healthcare costs, and they are causing a lot of unhappiness among the employees. The U.S. has a 4 percent unemployment rate. Keeping and finding good employees is very hard, and the last thing employers want is dissatisfaction with health care.

JB: I was pleased to see the quote by Dr. Daniel Johnson, Jr., President of the American Medical Association, on the cover of your book. He said, “Based on remarkable insight into the problems of our health care system, Market-Driven Health Care shows us how to transform our system into a more cost-effective one by putting the patient in the driver’s seat with the doctor ‘riding shotgun.’ ” Do you think that is an accurate perception of some of the things that these market forces may create within the field of medicine?

ball.gif (524 bytes)RH: Dr. Johnson is a remarkable person and a very visionary and charismatic man. I think he very nicely encapsulated what my book is about and, indeed, what is happening in health care. In the healthcare system of the future, there will be a “back-to-the-future” movement, with a partnership between customers and their physicians. Physicians will take up more and more of the actual management of care and interact directly with their customers. In business parlance, the insurance function will be disintermediated. This intermediary will have less and less to say, and physicians and customers will have more to say about what goes on in health care.



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