The 80/20 Rule: Why Insurers Are Incented Against Lowering Costs (and Integrative Health)
 07/21/2016 06:35 pm ET | Updated 6 days ago

• ​John Weeks Publisher and Editor, Integrator Blog News & Reports

The lesson I am about to share I learned on the mean streets of the early years of integrative medicine and health. This was the time of the first “complementary and alternative medicine” coverage in the late 1990s. The lesson’s a “duh!” no-brainer once you get it. Yet my experience in sharing this perspective with others on an insurer’s perverse incentives tells me that it’s not well-known.
So - if this is new to you - here is a simple lesson that will cement your views about the negative value of insurers in U.S. health reform.
Hard knocks for integrative care advocates: insurers are not aligned
First, context. Many of us have a belief that whole person, natural therapeutics would cost less and have beneficial effects on systems economics. Holistic, integrative and naturopathic medical doctors, chiropractors, acupuncturists and others readily speak of patients getting off drugs or not needing pharma and thus avoiding significant adverse effects. Other patients forego costly tests, procedures and surgeries. Imparting self-care principles reasonably might contribute to long-term cost reductions. Won’t an empowered patient be less likely to need a doctor, or run to the ER?
I called these the “hot-tub claims” of the integrative practitioners. These were beliefs most held, prior to much hard evidence. Integrative clinicians share such patient stories with each other in relaxed moments.
They weren’t the only one’s with such beliefs. In the first era of integration, these expectations of likely savings held across surveys of multiple stakeholders - including employee benefits manager, patients and even some insurers. I captured the survey data on of these perceptions in a March 2000 column for Medical Economics entitled “Is Alternative Medicine More Cost Effective?”
Today we have a growing body of evidence that in many measured environments, these hot-tub claims pretty well hold up. A seminal survey led by Patricia Herman, ND, PhD, an economist-naturopathic physician-researcher with the RAND Corporation, and Harvard’s David Eisenberg, MD, found cost-effectiveness for complementary and integrative care in 28 separate studies. The publicly accessible website of the Project for Integrative Health and the Triple Aim, which I was involved in developing, hosts dozens of studies showing value from integrative strategies in the Triple Aim interest in “lowering per capita cost.” A recent study from the Benson-Henry Institute found 43% reduction in use of medical services.
The perverse incentive in the insurer’s cost-plus business model
So, wouldn’t insurers be gung-ho to examine the potential for savings from integrative strategies? Isn’t this reasonable logic? And if the insurer received, say, $5000 for a family’s premium, and they spent less than that, wouldn’t that mean higher profits for the company? We anticipated a ready willingness from insurers to partner and engage pilot projects to discover whether services were add-on or replacement, what the net would be, and how to implement the new services.
Wrong. In a given premium year, that logic holds. But over the arc of multiple years it does not. The reason is that insurers are essentially cost-plus operators. The more that medical services cost, the higher, over the long term, is their cut.
Here’s how it works. In the United States, we operate with a general agreement that insurers can take roughly 20% of the premium dollar. It’s called the 80/20 rule. Here it is, at at Healthcare.gov: “The 80/20 Rule generally requires insurance companies to spend at least 80% of the money they take in from premiums on health care costs and quality improvement activities. The other 20% can go to administrative, overhead, and marketing costs.> It s quite remarkable the government officials responsible for this statement did not say “profit,” which also figures in heavily. Do the math:

• 1983 The average family premium was $3500. At 20%, the insurer’s split is $700.
• 1999 Family premium was (from the same study) $5700. At 20%, the insurer’s split is $1140.
• 2013 Family premium was $16,000. At 20%, the insurer’s take is $3200.

Were you the owner, or the person responsible for maximizing profits for your shareholders, would you rather play with $700 or with $3200? Are you, the insurer, better off when family premiums are at $3500 or at $16,000?
The dance of insurers on cost saving inside a given premium year is for them the lesser of their two orbits. Think of a moon around a planet. The big game - the sun around which the insurer’s business prospects revolve - is the year to year cycling upward of premium increases. In that orbit, these corporations are perversely incentivized. They benefit from increases in costs. They benefit off the increase of disease. A bit of delayed gratification may be required until premiums rise in a year or two. But they will jack rates and continue to benefit from the over production of high cost and even unnecessary medical procedures.
On the medical delivery side - versus the payment side - the Affordable Care Act is pushing a move away from the industrial focus of churning procedures and enhancing revenues. The direction is toward a value-based medicine. It’s stimulating some opportunities for integrative health.
Yet the 80/20 rule keeps insurers locked in a special, friendly relationship to the disease-focus, to high-production practices, and to the soaring costs of medicine. They are not friends of the integrative health and medicine approaches for which the big money is in saving money.
How does one say public option — or whisper again, single payer?

Crying Infant – Colicky Baby

​Aditi Bhatnagar | Hpathy Ezine, July, 2015 

INTRODUCTION:
“People who say they sleep like a baby usually don’t have one.” Listening to an inconsolable crying new-born baby can be extremely distressful for parents and family. Colic leads to prolonged spans of inconsolable crying. Parenting a cranky baby puts forth a huge challenge. A baby is unable to explain its problem which makes the diagnosis of this disease a difficult task. Despite this condition it should be noted that statistically speaking these babies generally turn into healthy babies.
It is also comforting to know that such problems generally persist in babies up to the age of 4 months.
 
WHAT IS INFANTILE COLIC?
An infantile colic is defined as episodes of crying for more than 3 hours a day, for more than 3 days a week for 3 weeks in an otherwise healthy and well fed infant between the ages of 2 weeks and 4 months. But, it is important for parents to know that not all fussy infants suffer from colic. It is normal for most infants to cry for 2-4 hours per day spread across a period of 24 hours as compared to a colicky baby who cries persistently as stated above.
 
EPIDEMIOLOGY:

• Infantile Colic is very common, occurring in around 10-30% of infants. It affects males and females equally. Breast-fed and formula-fed infants are equally affected. It is one of the most common reasons for parents to consult their doctor in the first three months of their baby’s life. Smoking and also nicotine replacement therapy during pregnancy have been shown to be risk factors for baby colic.
• A multicentre trial found that mothers who report colic or excessive infant crying have higher scores on the Edinburgh Postnatal Depression Scale (EPDS), with increased odds of high scores at six months even if the crying is resolved.
• Baby colic may be associated with intolerance to cow’s milk in some cases. The composition of intestinal microbes, especially an inadequate amount of lactobacilli and an increased concentration of coliforms, has been suggested in some studies to influence the pathogenesis of baby colic.

 
WHAT CAUSES BABY COLIC?
The cause of colic is generally unknown. However, some theories behind what could be the possible cause are:

• Immature nervous or digestive system
• The baby needs comforting, or is over or under-stimulated by light, noise
• The baby may have swallowed air, especially when feeding
• The baby may be reacting to something in the mother’s diet (if the baby is breastfed)
• The baby is allergic to some foods, such as milk (if the baby is on formula).
• Fewer than 5% of infants who cry excessively may have an underlying organic disease like Constipation, Gastroesophageal Reflux Disease, Anal fissure, Subdural Haematomas, Infection –of the ears or urinary tract, Pressure or inflammation of the brain and nervous system, Eye trouble – like a scratch or increased pressure, Irregular heartbeat, Injury to bones, muscles, or fingers, Infantile Migraine.

PRESENTING SYMPTOMS OF A COLICKY INFANT:
There are no clear symptoms seen in an infant considered as having colic and diagnosis is generally through exclusion. Colic is diagnosed after other potential causes of crying are ruled out and the physician is sure that the infant is otherwise healthy. Some common features of colic may be:

• Inconsolable crying – typically, high pitched and occurring frequently in the afternoon and evening
• The crying or fussing most frequently begins suddenly and often after a feed
• The baby cries for more than 3 hours on at least three occasions a week over the course of at least 3 weeks, but is otherwise healthy.
• Baby kicks a lot, pulls his legs up close, and makes tight fists.
• Baby’s abdomen seems to be distended, prominent or hard
• Baby burps and passes gas often
• The crying sounds as if the baby is in great pain
• Baby spits up frequently after feeding
• There may be flushing of face

It is certainly known that amongst all colicky babies, there are factors that may worsen the colic symptoms:

• Overfeeding in an attempt to lessen crying
• Feeding certain foods, especially those with high sugar content (for example, undiluted juices), may increase the amount of gas in the intestine and worsen the situation
• The presence of excessive anger, anxiety, fear, or excitement in the household

 
There are certain features which indicate need for a special concern:

• Elevated temperature
• History of breathing problems
• Poor weight gain

 
Red flags which indicate a need to rule out organic causes and may need further investigations:

• Vomiting (green or yellow, bloody or occurring more than 5/day)
• Change in stool (constipation or diarrhoea, especially with blood or mucous)
• Abnormal temperature (a rectal temperature less than 97.0 °F (36.1 °C) or over 100.4 °F (38.0 °C)
• Irritability (crying all day with few calm periods in between)
• Lethargy (excess sleepiness, lack of smiles or interested gaze, weak sucking lasting over 6 hours)
• Poor weight gain (gaining less than 15 gram a day)

 
MANAGING COLICKY BABIES:
Managing colicky babies is a very stressful phenomenon for parents. Such parents always require support, as they will be anxious and worried as to the cause of crying and their inability to help the baby. It’s important that the physician should be caring and compassionate and offers them reassurance. Main line management is through conservative means. Certain calming measures may be of use to console the crying baby:

• Swaddle your baby with legs flexed
• Hold the baby on its sides or stomach
• Swing the baby side to side or back and forth while supporting the head
• Try giving him more time in a front baby carrier (the kind you wear over your chest)
• Make eye contact, talk, hold the baby
• Take your baby for a ride in the car (but not when you are sleepy)
• Use “white noise” (such as static on the radio or the vacuum cleaner), classical music, or a “heartbeat tape” next to the crib, or make a shushing sound
• Try infant massage
• Put a warm water bottle on your baby’s belly.
• Have baby suck on a pacifier
• Soak baby in a warm bath
• Try an infant swing
• Increase or decrease the amount of stimulation in the environment, like light, noise, heat, cold, etc.
• Watch out for over-stimulation or increased fatigue

Dietary advice:
There is no specific evidence for restricting certain foods or changing over to certain foods. However, some infants benefit from modifications in the diet:

• Change from one cow’s milk formula to another
• Change from a cow’s milk formula to a soy formula
• Change from a regular formula to a “pre-digested,” hypoallergenic formula
• If you’re breastfeeding, avoid eating certain foods such as caffeine, excessive use of milk products, certain vegetables like cabbage, broccoli, cauliflower; nuts, too much animal protein and taking herbal supplements
• If breastfeeding, nurse whenever your baby seems hungry, usually every 2 – 3 hours. Elevate your infant’s head during and after feedings
• If bottle-feeding, ask your baby’s paediatrician to recommend a formula that is not based on cow’s milk and that is not iron-fortified
• Keep the baby in a sitting position when feeding, and massage her back to get rid of gas bubbles. Burp after every ounce or two of milk
• Try the “colic carry” — Place your baby, chest down, on your extended forearm, with his head supported by your hand and his legs on either side of your elbow. Use your other hand to provide additional support and walk around with the baby
• If bottle feeding, try to limit milk intake, and if that doesn’t work, avoid limiting milk intake
• If your baby is spitting up, keep him upright after he feeds

 
MANAGING BABY COLICS WITH HOMOEOPATHY:
Managing a crying and fretful, colicky baby is both stressful and exhausting for parents. At times, they find themselves helpless when nothing works out to soothe the crying baby. The standard advice given by regular G.P.’s is winding techniques, infacol or gripe water. These measures are often ineffective. Here arises the scope of homoeopathy. Homoeopathic medicines not only relieve the baby’s pain and discomfort but also help to build up the immature digestive system. Homoeopathic medicines accentuate the natural process of healing without any adverse effects and thereby help in development of the baby. However, it’s a challenge to get a detailed history as the baby can’t talk. So, the physician should have the skills of keen observation and sharp senses in order to pick up the characteristic symptoms.
The following hints during history taking may help him to build a totality in order to make a suitable prescription:

• Baby’s posture during pain e.g. Doubling up, lying on painful or painless side, stretching out, etc.
• Factors which bring about relief e.g. Carrying, rocking, applying pressure, rubbing, massaging
• When is the colic worst, like morning, night, before eating, after eating, before sleep, during sleep, before stool, during or after stool
• Other aggravating factors like motion, jar, movement
• Emotional factors that help to either pacify or aggravate the baby like: carrying, rocking, holding, touching, company, etc.
• Stool – colour, consistency, odour, constipation, diarrhoea
• Abdomen – distension, firm, hard, soft, noises from abdomen like gurgling
• Appetite, hunger, thirst, thermals
• Kind of cry – whining, moaning, high pitched, low pitched, screaming, howling etc.
• Mother’s emotional status – angry, disturbed, anxious, fearful, depressed etc.

 ​

Conventional medicine has little to offer, often relying on sedatives or tranquillisers but homeopathy, writes John Hughes-Games, can be very effective 

Medically, the mental or emotional aspects of stress are exceedingly important. Unhappiness, shock, illness, fear and much else can cause stress, which in turn can make people vulnerable to so many different illnesses both mental and physical. Stress and anxiety go hand in hand; every illness has a degree of anxiety. Even a predominantly physical illness like a sore throat can cause some stress. Certain illnesses have a very large stress component; particularly illnesses like depression, anxiety states and panic attacks.
A person’s tolerance of stress varies enormously – some people thrive on it; high-powered businessmen, for instance, who constantly have to make important decisions. Others buckle under quite small stresses and this may lead to illness.
Types of stress 
Stress can be divided into four types. Firstly, there is everyday benign stress, the mild stress that stimulates us to get on with things and which stops us from becoming “cabbages”. For instance, on a cold winter’s morning it might be very tempting to stay in bed but the stress of knowing that things have got to be done – jobs, housework, paperwork – makes us get up. Nobody likes paying bills but the consequences of not doing so would certainly lead to worse stress, so we do them! This sort of stress motivates us.
The second is healthy stress – having to meet deadlines, having to speak in public or, on a more physical level, competing in a race or competition. This is the sort of stress that makes us do things we might not particularly want to do but having done them we have a sense of achievement and satisfaction that is extremely good for us.
The third is acute stress – resulting from the shock of, for instance, a burglary, a sudden bereavement or a road accident, or even a more physical cause like being “mugged”, an operation, a haemorrhage.
The fourth might be called malignant stress – for instance, the anxiety, frustration and unhappiness resulting from an unsatisfactory marriage or relationship, having chronic financial problems, having to look after a difficult, disabled or ill relative or having a chronic or disabling illness oneself. This is the sort of stress about which we can do nothing and it is this particularly that concerns us as doctors, as it can lead to mental or physical disease.
If a doctor is good at reassurance he will be able to help his patients through many traumas in their lives. I once had the privilege of working with Dr Blackie who had this quality to a remarkable degree. Directly she came into the sickroom there was an immediate feeling of “thank goodness here she is, now we will be all right”. The intense worry and anxiety, which were compounding the illness are removed and this “energy”, instead of being dissipated in worry, is redirected to helping the patient to get better. Dr Blackie had the quality that used to be known as “the bedside manner”; a combination of wisdom, knowledge, compassion, humour and common sense – a somewhat rare mixture nowadays when knowledge is considered far more important than any other quality. However perhaps knowledge without wisdom can be dangerous.
How can homeopathy help? 
To start with, the homeopathic enquiry is a very profound one and very often during a consultation various factors come to light, which may be creating some degree of anxiety or stress in the patient’s life. A discussion as to how they may be overcome, removed or mitigated, can often be very helpful. Discussion itself can be extremely therapeutic. In many cases the patient is anxious or worried because nobody has taken time to talk to them. The homeopathic physician spends a lot of time with patients. It is however very important that the practitioner should have a sound knowledge of conventional medical diagnosis because during the discussion signs and symptoms of disease which need conventional (sometimes urgent) treatment may emerge and a qualified doctor with a knowledge of diagnosis knows when to refer a patient urgently to the appropriate specialist and is able to do so.
Having carefully assessed the patient, taking into account not only his illness and how he is reacting to it, but his whole make-up, the homeopathic physician then tries to work out the patient’s constitutional remedy. If he succeeds in selecting the right remedy, the patient’s well­being, resistance, resilience, general health and ability to cope are enhanced and many stress symptoms can be helped.
There are a number of polychrests (medicines of many uses) often prescribed constitutionally, which are particularly appropriate for different sorts of worry and stress. The following I have used to good effect on many occasions: Lycopodium for the patient who greatly underestimates their abilities and anticipates every ordeal however small with pessimism; Silica patients are terrified of failure and Calc carbs are just too weak and exhausted to attempt anything! These medicines are only effective, of course, if they “fit” the patient so far as his whole constitution and make up is concerned.
There are, however, some homeopathic preparations, which are particularly appropriate for acute situations. Here are a few with their indications:
Aconite
This is the most useful medicine in homeopathy for shock whatever the cause, whether physical or mental. It can be a great help for the unfortunate patient who suffers from panic attacks – a tablet or pill in a potency of 30c to be taken at the first sign and if necessary repeated every ten minutes.
Ignatia 
This is excellent for bereavement, whether through death or desertion. I once had a family in general practice who had the horrifying experience of having two cot deaths – two sisters whose babies died within forty-eight hours of each other. The whole family was much helped by taking Ignatia 30c every two to three hours.
Argentum nit 
A most useful medicine for people who feel extremely nervous before an ordeal particularly when the nervousness is felt in the gut and they have diarrhoea or the “collywobbles”. I recommend the 30c potency to be taken before any ordeal.
Gelsemium
Another medicine that can be taken before ordeals, it is appropriate for the patient who freezes either mentally or physically – whose brain seems to seize up under the stress of an examination for instance. 30c is a useful potency.
Arnica
One of the great stand-bys in homeopathic medicine, it is useful for bruises or falls or any sort of trauma as it promotes healing, but it is also very useful in high potency for physical or even emotional exhaustion. For instance for the mother with the very fractious baby who keeps waking up in the night, perhaps due to teething, or the person who is exhausted by having to look after some chronically ill relative. If used in this way Arnica should be given in a potency of 10M once a week only. 

​Doctors in Germany are prescribing homeopathic and herbal remedies to around one in five children they treat. Vitamins, minerals and supplements are the most popular ‘alternative’ therapies, and are being given to one in three children, a major new international survey has discovered.
In all, 1,164 doctors in Germany, Spain, Russia, Bulgaria, Colombia and Israel were surveyed about the way they treat children up to the age of 12 years. Not surprisingly, pharmaceuticals and other conventional therapies were the leading treatments being used, and were prescribed to around 40 per cent of children, but in some countries the alternative remedies were running them a close second. In Colombia, for instance, one in three children are regularly prescribed vitamins and minerals.
Natural and homeopathic remedies are most commonly prescribed to treat colds, colic, sleeping problems, and recurrent infections, say researchers from the Blankenstein Hospital in Germany. Doctors were also influenced by the preferences of parents who were worried about side effects of conventional drugs.
The doctors surveyed had a “high interest” in alternative remedies, although their knowledge was sketchy, the researchers said. A lack of proof of effectiveness, and knowing how the remedies work, were the main reasons why some doctors were reticent to use alternatives.

                   
Author, Bryan Hubbard