Traditional Chinese Medicine

The National Center for Complementary and Alternative Medicine is part of the National Institutes of Health.  Its role is to explore complementary and  alternative healing practices in the context of rigorous science.  While in Beijing last week, I had experiences that  added to my instinct that there is value to be gained in understanding  traditional Chinese medicine (TCM) better.

The first experience was meeting the new Minister of Health for  China, Chen Zhu. He brings a reputation as a world class scientist to his new post. In  addition to our meetings at the Strategic Economic Dialog, Dr. Chen and I had breakfast  on Wednesday. It gave us an opportunity to talk about areas of  cooperation.  It also provided a chance  for me to get to know him on a more personal level. 

I asked Dr. Chen to tell me more about his youth.  He told me that despite having parents who  were both sophisticated physicians in urban areas, during the difficult days of  the Cultural Revolution, Chen Zhu was required by the government to live in  very poor areas of China,  working on the land until his adolescence. Those experiences clearly gave him sensitivity  to the plight of the poor and underserved.  During that time he taught himself English by  comparing the English and Chinese versions of Mao’s Red Book.   He later  became a physician and medical researcher of some renown, becoming a member of  the National Academy of Sciences in France  and China. 

When he was in medical school, Dr. Chen learned western  medicine and traditional Chinese medicine techniques which he had observed as a  boy in the countryside. He described how an insight he gained from traditional  Chinese medicine unlocked a major discovery in developing response for a form  of leukemia.  He had a hunch, based on  what he knew of Chinese medicine, that arsenic could play a productive role in  treatment.  Turns out, he was right.

During a visit at Beijing University of Chinese Medicine, I  visited a museum devoted to recording the history of TCM.  On display are many of the different  botanical, animal and mineral substances used in treatment.  Each of the components in the collection was  displayed in a clear jar with a short description. 

I asked the curator how discoveries had typically been made  and recorded.  She explained that most of  them had come because of the connection between medicine and food.  People were constantly looking for ways to  nourish themselves.  They found that  eating certain things had additional benefits beyond just satisfying their  hunger. 

Walking through the museum, I found myself thinking what a  remarkable earth we live on that can produce so many varieties of  vegetation.  Surely each one of them has  a molecular structure with active ingredients capable of affecting the human  body in different food.  We turn to these  plants for our nourishment; why not for our healing? 

After visiting the museum, I went to a clinic at the medical  school where students were examining patients using TCM methods.  I watched acupuncture therapy being  applied.  I sat in (with the patient's  permission) as a seasoned doctor surrounded by three students interviewed and examined  a patient who had been referred by a local hospital.  He carried with him pictures of the inside of  his stomach taken by a scope of some kind at the hospital.  I watched the convergence of western medical  science and traditional Chinese medicine as the doctor looked at the scoped  photos and then examined his tongue for clues.   His examination was concluded by carefully feeling the patient’s  pulse. 

At the medical school, they teach both western medicine and  TCM.  Apparently it takes many years of  practice before a doctor is able to practice TCM on their own. Much of it is  learned from experience. 

When the examination was complete, the doctor dictated a TCM  prescription which was filled at the pharmacy.   The pharmacist had eight or ten prescriptions being completed at once on  the counter in front of him.  Each one  was the aggregate of several small piles of plant leaves, bark, seeds, flower  pedals and minerals.  The patient takes  them home, and following instructions either boils them, drinking the broth as  the medicine, fries them for eating or grinds them into another form for  ingestion.

I want to be clear here.   I am not advocating a substitution of TCM for the western style  treatment we receive in the United    States.   I would observe that in the United States, a doctor develops  his/her diagnosis based on similar techniques. They take vital signs, ask for a  medical history and seek to understand the nature of the patient's complaint  and its source.  In many cases they would  also offer a prescription which comes in a small plastic bottle containing tablets  of processed elements of the earth, generally in the form of processed chemicals  held together and colored by other chemicals.

Elsewhere on my blog you will find entries about  personalized medicine where patients get treatments customized for their use.  The TCM approach to treatment seems less precise in some ways but the  prescribed medical treatment in many ways is more personalized. 

One more thing; I don’t know exactly, but I’m guessing the  total cost of the elements for any one of the TCM prescriptions would have been  under a dollar.  When I was in western China a year  ago, I came to understand better why that is significant.  If a nation is responsible to provide health  care to 1.3 billion citizens, on an average of $6 to $12 dollars a YEAR, they  probably won’t be able to afford many brand name pharmaceutical products.  It should also be noted that the mortality  and morbidity results in China  and the United States  are not all that different. 

Through the National  Center for Complimentary and  Alternative Medicine at NIH, and a number of other institutions within the United States,  researchers are working to find ways to understand TCM better.  We need to do more of that.  Dr. Andy Von Eschenbach, the Commissioner of  the United States Food and Drug Administration, and  Director of the National Institutes of Health,  Dr. Elias Zerhouni and I have been discussing a trip to China next year to  increase the levels of collaboration.

During our visit at breakfast, Minister Chen and I agreed to  actively explore ways we can work together applying rigorous science to  traditional Chinese medicine.  More  science-based understanding could lead to a convergence of real value. 

Meeting China's 'Netizens'

In a compact Beijing studio on Monday, Li Xing, the International News Editor of China Daily had questions for me. She asked me about meeting a little girl in western China who had contracted the H5N1 avian influenza virus. We then talked about import-safety agreements with the Chinese governments and the availability of health insurance to U.S. citizens. The questions she asked for more than a half-hour were not just her curiosities, but rather questions e-mailed from China Daily’s online readers whom she refer to as netizens.

I like the concept of netizens. I have to admit, I hadn’t thought much about the term until Li Xing used it. We are citizens of nations but also find ourselves members of global communities connected not by geographic boundaries but our collective interests and passions. When I saw a stream of questions filling Li Xing’s computer screen from some of the estimated 10 million China Daily-reading netizens located all over the world, the term was abruptly given more meaning.

As we talked, two studio-quality digital video cameras streamed our conversation over the Web. Our words were simultaneously transcribed into text. The next day China Daily’s print edition published an article summarizing our interview. That is a combination of digital mediums with serious reach and the capacity to interactively engage people.

I’ve become a novice blogger. I started a few months ago. My first effort was a blog related to pandemic flu. The input we received from netizens (though we didn’t refer to them as such) was remarkably good and persuaded me to spend more time exploring different combinations of media as public policy tools.

In the space of an hour, my encounter with Li Xing and her colleagues at China Daily elevated my thinking some. It seems possible I should be embarrassed not to have realized this before. I suspect there are 26-year-old netizens reading this saying, “Where has this guy been?” Well, despite what most would call a pretty good technology pedigree, the term netizen and its sociologic potential just eluded me.

During our conversation I told Li Xing about my blogging adventure. She volunteered to tell China Daily’s netizens about it. I hope she will because I want to continue the discussion I started with Li Xing and her ten million friends. I have a lot to learn about good netizenship.

For those who linked here through China Daily, it might be helpful for me to tell you about my blog.

First, I am committed to write it myself. For better or worse, what you get are my words, not the product of my staff. They manage the blog and occasionally clean up the postings some but I write the content. I also attempt to read the comments. Time simply doesn’t permit me to regularly respond to the comments. However, once in a while I’m inspired or agitated enough to respond. But time is a real issue. I was the first U.S. Cabinet Secretary to use a blog. So far, I’ve enjoyed it and I find it helpful in hearing different points.

I aspire to write a couple times a week. Lately it’s been more like once a week. Most of the posts are written on my laptop while I’m sitting on an airplane or in a hotel room. Tonight, as I write, I’m on an airplane winging my way back from Beijing.

I’m learning about the blog culture as I go. So, occasionally I make errors, but readers have been good-natured in pointing out my mistakes. For example, when I get on a roll and I tend to be too long. A couple of readers pointed out it would be better to break it up some with subheadings or even individual posts. I’m working on that.

My blog also serves as a combination journal and sounding board. However, I confess to being a little bit circumspect at times given the nature of my responsibilities.

I hope you enjoy occasionally reading my thoughts. I’ll look forward to hearing the reaction of my fellow netizens.

Electronic Medical Records and the Medicare Sustainable Growth Rate

[Note: This afternoon, I notified Congress we (the Administration) support a requirement that doctors adopt e-prescribing and electronic medical records in order to get the full Sustainable Growth Rate update (HHS statement). I've written more below about why I think this is important.]

When I was a boy, there was a Tennessee Ernie Ford ballad titled, “Sixteen Tons.” It told the story of a coal miner who bought all of life’s necessities from the company-owned store on credit. 

Apparently, the miner in the song spent more at the company store than he earned, but the company store just kept running his tab up higher and higher, making it more and more difficult for him to ever pay it back. It created a hopelessness reflected in the song.

The chorus of the song was:

"You load sixteen tons, and what do you get;
Another day older and deeper in debt.
Saint Peter don’t you call me cause I can’t go;
I owe my soul to the company store."

This week, the Congress will begin working on the Medicare Sustainable Growth Rate (SGR) or what people call the “doc fix.”  The doc fix is a ritual crisis brought on annually by a terrible system Congress put into place in 1997 to manage the amount Medicare pays doctors for various procedures.   

Here’s how it works: Each year, the Secretary of Health and Human Services is required by law to establish a target for the rate of overall spending on Medicare Part B. (Think of that as the total of all the miners’ wages)

If, collectively, doctors bill Medicare for more than the target, the Secretary of HHS is then required by law to make it up on future updates. (The mining company reduces the future wages to pay off past debts at the company store)

However, the doctors just keep billing more and more procedures to Medicare and spend far more than the target.

This has gone on now for more than 10 years and Medicare has now paid so much more than the target that the formula in the law dictates that doctors receive negative updates, cutting the amount they get paid for each procedure. This year, the SGR hole is so deep the law requires HHS to reduce the future rates we pay doctors by 10%.

So, each year Congress steps in and overrides the system by instructing Medicare not to cut the reimbursement rates.  Consequently, the amount that doctors get paid at least stays the same or is a little more.

Here’s an important point.  When Congress overrides the law, it doesn’t fix the system or pay off the deficit which is now so large it would require nearly $200 billion to pay off the backlog. 

This is a lousy system and it hasn’t reduced Medicare costs.  The total expenditures just keep going up.  Why? When rates per procedure don’t go up, doctors have simply done more procedures.

Moving toward a long term solution

Long term, the solution to this problem is to change the way we pay doctors.  At least some portion of their payment should be based on how successful they are in keeping people healthy, rather that just the volume of procedures they perform.  Sometimes that is called pay for performance or value-based health care. Whatever you call it, we cannot make progress unless doctors adopt a system of electronic medical records. Such a system depends on being able to gather quality data electronically.

Electronic medical records are widely accepted as providing significant long term efficiencies. The technology is maturing but doctors have not adopted them in sufficient numbers to create critical mass. 

Doctors want Congress, in the next couple of weeks, to once again override the Sustainable Growth Rate law.  It will cost taxpayers at least $4 billion. This year it’s a 10% reduction they will be overriding.  Next year it will be 15%.  We just dig a bigger and bigger hole. We need to begin the process of moving toward a longer-term solution.

It is the position of the Administration that any new bill overriding the SGR law should require physicians to implement health information technology that meets department standards for interoperability in order to be eligible for higher payments from Medicare. 

The benefits of utilizing interoperable health information technology for keeping electronic health records, prescribing drugs electronically and other purposes are clear.  This technology will produce a higher quality of care, while reducing medical costs and errors, which affected an estimated 1.5 million Americans last year through prescription drug errors. 

Such a requirement would accelerate adoption of this technology considerably, and help to drive improvements in health care quality as well as reductions in medical costs and errors.  I’m confident that many members of Congress are of a like mind on this issue and I look forward to discussing it with them in the next few days.