Actitudes e ideologías en torno a la alternancia y mezcla de códigos

Before we leave this chapter addressing trends and forecasts affecting CAAs,

particularly chiropractic, it is important to note that much of the demand for CAAs does not conform to the medical or health care approach. Some people view acupuncture or chiropractic or massage services as they would the services of a spa, gym or fitness club. As noted in Chapter 4 below, it is estimated that up to 35% of visits to

chiropractors are “wellness visits,” not related to an immediate complaint.

This is a very different model than the one focused on “appropriate services” to be provided by a health care system. Recall that health care systems have shown

themselves liable to generate overspending for unnecessary or inappropriate services. Individuals choose to buy services, as well as guides to services and discounts, based on recommendations from groups such as AAA or AARP. Likewise individuals choose to join for-profit health and fitness clubs such as Bally’s or non-profit groups such as the YMCA.

For many CAA providers in 2010, these wellness services will be a significant portion of their business. The questions that determine “appropriateness” in the managed care context should not be applied here. Yes, consumers should be protected from fraud; they should know who the best providers are. But they should be able to spend their discretionary resources on wellness services of their choice, much as they choose to spend their discretionary income on health clubs. The trends toward smarter markets noted above will mean that consumers will be able to buy with greater assurance of quality. The “report cards” available to consumers will help them choose among local providers.

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As we shall see in Chapter 4, on chiropractors, this demand for wellness services will play an important role in determining if there is a surplus of chiropractors in 2010 as their number doubles. Demand from consumers for wellness services from other CAA providers will also play an important role in determining overall demand for chiropractic services.

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ENDNOTES FOR CHAPTER 3

1 _{D. Stipp, “Gene Chip Breakthrough,” Fortune, 31 March 1997.}

2 _{A. J. Nichols, ”Genomics: The Promise and the Cautions for Accelerating the Quality of Prevention, Diagnosis, Treatment and} Cure,” in Bezold, McCarthy and Frenk, eds., The Future of Health in Latin America: The Prospects for Achieving Health For All (Mexico: Fundacion Mexicano Para Salud, 1998).

3 _{“Developing Prescriptions with a Personal Touch,” Science, Vol. 275, February 7, 1997, p. 776.} 4 _{“The Genomics Gamble,” Science, Vol. 275, February 7, 1997, p. 770.}

5 _{M. Gianturco, “Superbugs, Superdrugs,” Forbes online edition, March 4, 1997.}

6 _{J. Siegel, “Weizmann Institute Scientists Discover Gene That Could Fight AIDS,” Jerusalem Post Internet Edition, February 9,} 1997.

7 _{MHSS 2020 Bio/Nano Technology Report (1997), "Focus Study of Biotechnology and Nanotechnology,"}

http://keydet.sra.com/hs2020/homepage/hs2020.htm. The principal author of this report is Robert Olson, Institute for Alternative Futures, Alexandria, VA, with contributions by Ed Ponatoski, SRA International and Major Suzanne Pielick, US Army.

8 _{S. Davidson, "The Future of Therapy," in C. Bezold and E. Mayer, eds., Future Care: Responding to the Demand for Change (New} York: Faulkner & Gray, 1996).

9 _{T. Friedman, “Overcoming the Obstacles to Gene Therapy,” Scientific American, Vol. 276, June 1997, p. 96.} 10 _{MHSS 2020 Bio/Nano Technology Report (1997), op. cit.}

11 _{MHSS 2020 Bio/Nano Technology Report (1997), op. cit.}

12 _{R. Olson, “Information Technology in Home Health Care,” in C. Bezold and E. Mayer, eds., Future Care: Responding to the}

Demand for Change (New York: Faulkner & Gray, 1996).

13 _{S. J. Ellis, “Volunteering a Strategy for Future Change," in H. G. Brown and J. R. Seffrin, eds., Horizons 2013: Longer, Better Life}

Without Cancer (Atlanta: American Cancer Society, 1996).

14 _{R. Olson, “Information Technology in Home Health Care,” op. cit.}

15 _{US Military Health Services System, “2020 Report: Envisioning Tomorrow’s Focus for Today’s Resources” (1996),} http://keydet.sra.com/hs2020/homepage/hs2020.htm

16 _{MHSS 2020 Bio/Nano Technology Report, op. cit.; AOL News “Rapid Saliva HIV Test To Be Marketed in the United Kingdom,”}

Vancouver Washington (Business Wire), August 20, 1997.

17 _{J. Gordon. Manifesto for A New Medicine (New York: Addison Wesley, 1996), p.60.}

18 _{J. A. Johnson and J. L. Bootman, “Drug-related morbidity and mortality: a cost-of-illness model,” Archives of Internal Medicine,} Vol. 155 (1995) pp. 1949-1956. Also see H. R. Manasse, “Medication use in an imperfect world—misadventuring as an issue of public policy,” ASHP Research and Education Foundation (1989) (composite average of studies cited is 10% of admissions). Also see J. L. Bootman, D. L. Harrison and E. Cox, “The health care cost of drug related morbidity and mortality in nursing facilities,”

Archives of Internal Medicine, Vol. 157 (1997), pp. 2089-2096 (principle results of the paper).

19 _{MHSS 2020 Bio/Nano Technology Report (1997), op. cit.}

20 _{B. Gottlieb, ed. New Choices in Natural Healing (Emmaus, PA: Rodale Press, 1995), p. 25.} 21 _{D. Ullman. The Consumer’s Guide to Homeopathy (New York: GP Putnam’s Sons, 1995), p. 8.}

22 _{D. Ornish. Dr. Dean Ornish’s Program for Reversing Heart Disease (San Francisco: Random House, 1990).}

23 _{“Should a Low-Fat, High-Carbohydrate Diet Be Recommended for Everyone?” New England Journal of Medicine, Volume 337,} No. 8, pp. 562-567.

24 _{HealthComm International website: http://www.healthcomm.com}

25 _{M. Lerner. Choices in Healing (Cambridge, MA: MIT Press, 1994). See Commonweal website:} http://www.commonwealhealth.org/choiceschap17.html

26 _{Healthy Source website, http://www.healthysource.com/alternative.html} 27 _{In their study the authors used "CAM" rather than CAA.}

28 _{J. Goldsmith, “Managed Care Comes of Age,” in Bezold and Mayer, eds., Future Care: Responding to the Demand for Change,} op. cit.

29 _{J. Weeks, “United Health Care Pilots’ Acupuncture Program,” Alternative Medicine Integration & Coverage, Vol. 2, No. 3 (Reston,} VA: St. Anthony’s Publishing Inc., 1997), pp. 1-3.

22 _{L. Sportelli, DC, “In My Opinion: Managed Care vs. Care That is Managed,” White Paper, 1996.}

31 _{M. Donaldson, K. Yordy and N. Vanselow, eds. Defining Primary Care: An Interim Report (Washington, DC: National Academy} Press, 1994); as cited by C. Hawk, “Chiropractic and Primary Care,” Advances in Chiropractic, Vol. 3 (Mosby-Yearbook, Inc., 1996), p. 296.

32 _{C. P. Tresolini and the Pew-Fetzer Task Force. Health Professions Education and Relationship-Centered Care (San Francisco,} CA: Pew Health Professions Commission, 1994), p. 15.

33 _{D. Redwood, “Pathways for an Evolving Profession,” in Contemporary Chiropractic (New York: Churchill Livingstone, 1997).} 34 _{Pew Health Commission Report on the Health Professions website: http://www.futurehealth.ucsf.edu/pewcomm.html} 35 _{R. A. Cooper and S. Stoflet, “Trends in the Education and Practice of Alternative Medicine Clinicians," Health Affairs, Fall 1996,} pp. 226-238.

36 _{See for example Nursing: C. Bezold and R. Carlson, "Nursing in the 21}st _{Century: An introduction," Journal of Professional}

Nursing, Vol. 2 , No. 1 (January-February 1986), pp. 2-9; for Pharmacy: Bezold, Clement et al., Pharmaceuticals in the 21st _Century,

Alexandria, VA: Institute for Alternative Futures and Project HOPE; and for Allied Health, Bezold, "The Future of Health Care: Implications for the Allied Health Professions," Journal of Allied Health,Fall 1989, Vol. 18, No. 5, pp.437-57.

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37 _{US Military Health Services System, “2020 Report: Envisioning Tomorrow’s Focus for Today’s Resources,” (1996), website:} http://keydet.sra.com/hs2020/homepage/hs2020.htm.

38 _{See for example “Dentists and Dental Care,” pp. 44–64, and “Ratings of HMOs,” pp. 69-73, Washington Consumer Checkbook,} Vol. 10, No. 1 (Summer/Fall 1996). For more information see C. Bezold, “The Future of Therapeutics” in Bezold, McCarthy and Frenk, eds., The Future of Health in Latin America: The Prospects for Achieving Health For All (1998), op. cit.

39 _{“Slower (low-velocity) techniques in which the joint remains within its passive range of movement. The treatment can be} monitored and resisted by the patient, who therefore has final control.” As defined in D. Chapman-Smith, LLB, The Chiropractic

Profession: Myths & Facts (Palmerton, PA: Practice Makers, 1993), p 13.

40 _{Report of the Ad Hoc Committee on Complementary Medicine To The Council of The College of Physicians and Surgeons of}

Ontario, September 22, 1997.

41 _{“Slower (low-velocity) techniques in which the joint remains within its passive range of movement. The treatment can be} monitored and resisted by the patient, who therefore has final control.” As defined in D. Chapman-Smith, op. cit. 42 _{This work is taken from the writings of Richard Miles, Health Frontiers in Oakland, CA.}

43 _{Based upon IAF’s work with the International Council of Nurses (ICN); The Future of International Nursing, IAF, February 1998.} 44 _{David S. Hilzenrath, "Disability Claims Rise for Doctors,” The Washington Post, February 16, 1998.}

4-1

Chapter 4

ISSUES, TRENDS AND FUTURE