Wouldn’t it be lovely if everybody had a pony? The gentle clip clop of its hooves on the roadway would be heaven. The swishing of the tail and the gentle up and down motion would be a delightful way to destress after a long hard week of work, and besides, decreasing stress makes one healthier, no? In fact, I think the Ontario Ministry of Health should at once buy every person in Ontario a pony to combat heart disease, and the effect on high blood pressure and the decrease in heart attacks would be worth it!
Last week, I was pointed toward a policy statement by Green Party of Canada leader Elizabeth May where a commenter had suggested that the government should fund complementary and alternative medicine (CAM) and that this would somehow save costs for the health care system. I had responded to the commenter with a statement about the lack of evidence for naturopathy, which was a system of medicine overwhelmingly supported by the other commenters, and that there was no evidence at all to support the notion that public funding of CAM would save money. This is not a new suggestion, however, and if this presentation at the IN-CAM Research Symposium in Toronto in November is any indication, this is just the beginning of the discussion of whether Canadian public health insurance plans should cover CAM treatments.
I had a notion that my response on the Green Party website was correct, but I had not reviewed the literature. Risking madness, I decided to take a quick look at the trends in economic research and CAM and see if my notion was correct. Let me first suggest that there are a few ways that CAM could save money and convince me that the government should fund it. The first way was if it was able to prevent the onset disease better than conventional medicine and do so for less money. The second would be if it was able to stop progression of disease with fewer risks, and do so for less money than conventional medicine. The third way would be to save money and resources by diverting the “worried well”, those with a self-limiting condition that would most likely get better on their own, from conventional physicians and save the resource for patients with acute need.
The first question is a more complex one than it looks on the surface. There are several ideas promoted by CAM providers as that are actually also under the purview of conventional medicine and public health. Good nutrition, regular exercise, healthy and adequate sleep patterns and stress reduction are all advice your doctor can give you and is a component of medical training and research. It is however an important question as to whether CAM providers are better at communicating wellness plans and disease prevention than physicians and other mainstream medical workers. Unfortunately, I could find no direct comparisons so there is no way we can answer this question definitively. What is clear, is that CAM providers often spend more time with the patient in regular office visits, and this gives them a much greater opportunity to communicate disease prevention information than physicians. If we could adopt a similar model, or have physician’s assistants or nurses/nurse practitioners detailed to this work, it could be accomplished as a part of regular visits. This report from the Society for Medical Anthropology discussed in detail this question and they do not have satisfying answers. We just don’t have enough data to determine if CAM for prevention is better and saves money, and more research is needed to determine this, if we are going to start paying for it as a society.
The second question is a bit easier to answer, as we have comprehensive reviews of the research in major CAM areas such as acupuncture, chiropractic (see also here, here, here, and here), homeopathy and naturopathy that review their ability to care for acute and chronic health issues. They have not fared well when using the randomized controlled trial (RCT) which has led CAM researchers to call for a different approach that will get them the results that they desire: the patient-reported-outcomes (PRO) model. The PRO uses qualitative and subjective reports by the patient of their well-being instead of controlling for variables. This paper lays out this point of view and requires its own blog post to deconstruct, but suffice it to say it disregards RCT’s as effective for analyzing CAM. The author, Ireh Iyioha from the Faculty of Law at the University of British Columbia puts it this way:
“…the concept of evidence-based medicine looms largely at the centre of discrediting CAM, and it is, therefore, fundamental in the barriers to the recognition of this form of medicine.”
CAM has largely lost the evidence battle when it comes to its ability to treat disease and has retreated instead to the anecdotal evidence of its adherents and those with a vested interest in believing that CAM works, namely those who pay for it. We cannot take this as evidence (although this homeopathy researcher even goes so far as to call the skepticism scientists have of homeopathy based on basic principles of science “plausibility bias” . More in depth discussion at Science Based Medicine).
So there is very little if any evidence that CAM can cure disease, either chronic or acute, but what about the last question? Can we use CAM practitioners to ease the burden of the “worried well” on an over-worked medical system? Most visits to CAM practitioners, as described in this study were for chronic conditions, with the greatest number being for fatigue, headache and back pain: non-specific conditions that mainstream medicine does not have easy answers to. In fact the National Health Service of the U.K.’s NICE guidelines for low back pain lasting more than 6 weeks suggest that manual therapies, including the spinal manipulation offered by chiropractors and osteopaths, be suggested by physicians as part of the treatment plan (despite evidence that the effects are only temporary). I will agree that if the guidelines suggest a procedure as part of a normal treatment plan, it should be covered by the government. The problem is that chiropractors are not only offering manual therapies for low back pain, they are offering unsupportable treatments for such things as infantile colic and ear infections in children and heart disease in adults; none of which have any support when the evidence is looked at on the whole (colic, ear infection, heart disease) and which should therefore not get any support from the public purse.
When we look at the bigger picture, several studies have tried to review CAM as a whole to see if it makes economic sense to fund. They may be the best way to answer the final question of whether CAM helps with low-risk chronic conditions that none-the-less are a burden on a person’s quality of life. Acupuncture and manual therapies seem to be the most reviewed, perhaps because that is where the most data lies. A systematic review from the University of Ottawa showed no improvement in the medium or long term in low back pain and neck pain with either accupunture or various manual therapies. It is a comprehensive study that compared these therapies to both normal treatment, sham CAM treatment and doing nothing, and came up emtpy.
I found five reviews that discussed the cost efficiency of all CAM therapies and all but one found that there is not enough evidence to warrent drawing a conclusion that CAM is cost-effective. The studies done thus far, and 3 of the reviews were from 2012, are not sufficient, have different units of measure, are not applicable outside of the context of the country it was done in, and are not clear enough to recommend paying for CAM as a whole. With the exception of low back pain, the evidence is poor (1,2,3,4,5) This study found decreased insurance expenditures in patients using CAM for fibromyalgia, back pain and menopause syndromes, which is not surprising, given the subjective nature of the symptoms, the frustration with mainstream medical solutions to these problems, and the better therapeutic relationship, given more time available, with the CAM practitioner. The study did note that they just assessed health expenditures, not health outcomes so we cannot draw direct conclusions about the efficacy of the CAM therapies.
I should make a note here and discuss the one study that did find better outcomes with CAM. It used a costs-savings model in an in-patient oncology setting and was very well designed. Cost Savings in Inpatient Oncology Through an Integrative Medicine Approach is a study, given its clear outcomes, that I can get behind. The integrative approach here was not using herbal medicine or dis-proven acupuncture, it ”incorporated yoga therapy, holistic nursing techniques, and a “healing environment” into routine inpatient oncology care.” Not energy healing or reiki, but techniques that, while hard to quantify, were non-the-less successful at decreasing length of stay and saving money while providing excellent care. If this is where integrative medicine is going then I think it is a model that shows promise (this cost effectiveness study shows that it can save money, though I would take issue with the more dubious assertions of integrative medicine that focus on stress and life-style as the cause of all disease and the fallacy that drugs only cure symptoms). We just need to police the wackier CAM solutions, like “energy healing”, and ensure that evidence based medicine is married to patient-centerd care, and we can see gains to individual health (I still won’t get my pony, though).
Finally, a Canadian study out of the Fraser Institute called Unnatural Regulation is worth a look, to give us a hint of where the major arguements from the CAM community are going to come. This study compiles a lot of the most recent data about the use of CAM in Canada and the attitudes of Canadians towards it. Unfortunately, there is a distinct willful ignorance in the work that ignores whether or not these therapies work and instead favours the argument that if it is popular then we should fund it. The paper is far too long to deconstruct at the end of this already long post, but I will present by itself in the near future as part of a plan to deconstruct the rift that exists between CAM and conventional medical theory. (EDIT: Scott Gavura already covered one aspect of this document in his post here so I will not duplicate his work)
In spite of the cautious success of integrative medicine movement, which is, I believe, distinct from most of the traditional complementary and alternative medical establishment, I keep coming back to the same conclusion: if it has been shown not to work or at best be a placebo, limited public funds should not pay for CAM delivery. The “health liberty” movement that frames the debate in the terms of the freedom to make choices is a false argument. I could just as easily fight for the right for “transportation freedom” and to not wear a seatbelt while in a motor vehicle – or indeed ride around town in a clunker with poor brakes and no exhaust system: its my right! However, we limit choice in society when we see a danger to society at large or the vunerable within it. We need regulation to keep people from taking advantage of others and we should not waste public resources on medicine that does not work just because people want it.
I would love for the government to buy me a pony, but it aint’t gonna happen.