Book Review: Breaking the Iron Triangle: Reducing Healthcare Costs in Corporate America

Book Review: Breaking the Iron Triangle: Reducing Healthcare Costs in Corporate America

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Our national deficit debates are increasingly turning to healthcare costs and the need to evolve our current dysfunctional healthcare system. A recent addition to this debate is a new book by a founder of Tai Sophia in Laurel, Maryland. In his book, Breaking the Iron Triangle: Reducing Healthcare Costs in Corporate America, Robert Duggan notes that our current debate frames healthcare as an “iron triangle”. The iron triangle refers to healthcare cost, quality, and access. According to Duggan, “common sense tells us that is impossible to maximize quality and access while minimizing cost.” He argues the iron triangle can be broken only by abandoning cherished, destructive assumptions and complementing our existing “disease system” with a strengthened “wellness system”. The book includes several examples of institutions – including many local to Maryland – that are currently taking up this challenge.  

The Crisis

For decades, much of the U.S. public has been deluded into imagining we have the greatest healthcare system in the world. Thankfully, this illusion is beginning to crumble. Although we can and should recognize the incredible advancements in medical technologies that have happened in the United States, these advancements have not translated into a superior healthcare system. Healthcare systems can be evaluated in three major ways: cost, access, and quality; the “iron triangle”. In all three areas, the U.S. is failing. In terms of quality, in 2000 the US was ranked as 37th in the world. In terms of access, the US is the only wealthy, industrialized nation in the world that does not ensure that all citizens have coverage. And for this sad state of affairs, we pay over 17% of our GDP, more than any other country. The Swedish health care system, the 2nd most expensive healthcare system in the world, has outcomes which are far superior and costs only 11% of GDP.

Why is our healthcare system so damaged? Capitalism, entrenched interests, and neoliberalism have been discussed in prior Indyreader articles. Here, Duggan brings our attention to another culprit: the Western healthcare system monopoly. When we debate “health care”, we unknowingly limit our debate to the western system of health care. This system has brought many great advances, but is also based on a disturbed notion: that the mind is separate from the body. Candace Pert, the Hopkins-educated pharmacologist, claims this assumption goes back to a turf war with Descartes and the Roman Catholic Church. Descartes was allowed to study science, as we know it today, but only if he left the soul, the mind, the emotions, and consciousness to the realm of the Church. This turf battle reverberates with us today.

In the realm of research, this turf battle evolved into a reverence for the “gold standard” of research: the standardized double-blind clinical trial. Although useful, this research tool tends to ignore the unique biochemistry of each individual. The double-blind trial also purposefully excludes all components of the placebo effect (e.g., the interpersonal role of the healer), rather than attempt to understand and improve it.  With a reliance on this type of evidence as the “gold standard”, it is perhaps unsurprising that we have become a society that values medications over healers. This framework exists not only in the research community, but also presents itself in society at large in terms of our assumptions surrounding healthcare.

Cherished and destructive assumptions

When Duggan refers to “cherished” assumptions, he isn’t kidding around. He pulls no punches and wastes no time immediately going for the jugular on one of the most cherished and personal assumptions linked to our healthcare system: death. Duggan argues that we are headed towards bankruptcy due to our unwillingness to recognize death as an inevitable aspect of life. He argues that by seeing death as a problem to be prevented at all costs, we give up our ability to exit this existence gracefully. Duggan notes that by avoiding death as inevitable aspect of life, we not only suffer from exorbitant healthcare costs, we also extend unnecessary suffering in our loved ones. He argues not for euthanasia or interventions to hasten death, but rather for allowing the natural course of a disease in hopeless cases. Here he notes that “a large percentage of our national healthcare budget is spent in the last year of life, preventing death at great expense to the individual and to the health-care system and the government, and with great added suffering to the individual and families.”

The second cherished assumption Duggan sets out to knock down is the idea that health is the absence of suffering, symptoms, and disease. I have thought that I had heard this argument before. I had thought that Duggan was going to say that health is not merely the absence of disease, it is also about living a life full of joy and activities. He does say these things, but more importantly he says that symptoms are teachers. In his view, symptoms are not to be avoided, but to be embraced as a natural warning sign that lifestyle changes may be needed. For example, he reports about Charlie, a patient who told him, “I never thought asthma would become my friend. But since I’ve started acupuncture, I realize I get minor symptoms of asthma long before the attack…. If I pay attention to those minor symptoms, I find they are alerting me I’ve not been getting enough sleep, I’ve been in upset with my family or my work, or I’ve been having too much caffeine and not eating properly. They alert me to pay attention to my lifestyle. Since I’ve been doing that and paying attention to the minor asthma symptoms, I have not had a single major incident.” If Charlie was simply provided with an asthma inhaler, he may have reduced his symptoms, but he would not have had such major insights. Life is difficult, and suffering is part of life.

Assumption number three is that experts can diagnose us and fix us. This is clearly another cherished assumption in our society of western medicine, which venerates diagnosis as a science that identifies real, independent, and homogenous categories. Duggan argues that disease labels are very specific, technical descriptions of certain biological activities, but that they are incomplete and of limited utility without an understanding of the individual. He describes an encounter with a man who asked him if acupuncture could help with gout.  Studies have in fact reported that people with gout have been helped by acupuncture, but Duggan noted that, “I never met gout walking around by itself. It usually comes attached to a very complex individual who has other symptoms and other ailments and also has lots of life issues – from family to money to work to age. So I may be able to help you; and you may be able to manage your gout if you are stronger. You are not your gout.” Tend the Whole person.

Duggan continues to challenge us with the final, perhaps most difficult assumption for us to accept. This is the assumption that our lifestyle doesn’t matter because disease functions separately from our activities. He describes this assumption dramatically in his story regarding a successful businesswoman patient. The patient had been examined by not only mainstream doctors, but by four of the top complementary doctors in the United States. Although Duggan was excited to see the patient and the reports from such prestigious mainstream and complementary doctors, he doubted he could be of assistance with such a difficult case. However, he saw the patient, who seemed to be suffering from a constellation of symptoms broadly consistent with a diagnosis of chronic fatigue, lupus, or a degenerative disease. Duggan asked her about food. She said, “I had a doughnut in the morning. I worked really hard all day and then grabbed a hamburger at McDonald’s on the way home, about 11 o’clock at night.” This was apparently typical for her, as was getting less than 6 hours of sleep, drinking lots of Coke and little water, and very little exercise. Finally, Duggan asked her if her symptoms have ever gone away. The patient thought and said, “Oh, they completely disappeared for two weeks when I was on vacation in Canada with my friend last year.” To which he replied, “So you’re telling me you don’t get enough food, you drink hardly any fluids except for caffeine, you don’t get enough sleep, you don’t exercise, and all the symptoms went away when you went on vacation. That’s quite fascinating. I think that perhaps instead of the $100,000 you’ve spent on all this testing, perhaps a $100,000 vacation might be the beginning of a cure. And then you can begin to look at ways to take care of yourself.” We have become at war with our bodies. Duggan notes that acupuncturists, chiropractors and the like can also create dependency and be disease-focused. Instead, he suggests we need more health professionals to act as wellness educators. Our mind and body are totally interactive.

Another assumption challenged is the idea that healthcare access needs to be increased. Duggan argues that rather than constantly seeking to increase access, we should seek ways to reduce access because over 70% of those seeking medical care are in the wrong place. They are given access to a disease-care system when they need access to a wellness system.

Wellness System Resources in Maryland and Beyond

Duggan devotes considerable space to discussing various initiatives currently addressing these issues. Importantly, for readers of Indyreader, there are several things happening here in Maryland.

Dr. Gary Millis in Howard County started a clinic, supported by local physicians and community organizations, to serve individuals who did not have access to health care. Several evenings a week, people could see a nurse practitioner who would tend to them or refer them. Many uninsured people took advantage of this service, saving money that would have been spent at the Emergency Room. The clinic likely saved its owner, the Johns Hopkins Hospital System, millions of dollars – dollars that went somewhere else, but not to support the clinic itself, Duggan laments.

The book notes Healthy Howard by Peter Beilenson, MD, former health commissioner of Howard County, Maryland, and former health commissioner of Baltimore, MD (1993-2005). Since the book’s publication, Beilenson resigned as health commissioner and became CEO of evergreen cooperative, a healthcare cooperative. Healthy Howard is referred to as an “experiment” and a “relatively small project”. Evergreen health COOP is orders of magnitude more ambitious, having received a $65 million federal loan under the Affordable Care Act (“Obamacare”).

Maryland Community Health Initiative, also known as “Penn North”, is located at the Corner of Pennsylvania and North Avenues in Baltimore. The program serves participants with a goal of helping the whole person. Most of the participants are in recovery from use of cocaine, heroin, and other street drugs and many have spent time in jail. Al Duha Chase was one of the initial directors of the program and a trained tai chi master. Speaking of his journey of recovery, he said, “As a street person in Baltimore, heroin was for me a very faithful friend. If you want me off my heroin, you had better build me a friendship community.”  Penn North attempts to provide that community through a diverse array of activities: Narcotics Anonymous, domino games, tai chi, yoga, high-school equivalency diploma classes, computer skill training, job readiness support, acupuncture treatment, and long-term intensive counseling. Duggan’s son, Blaize Connelly-Duggan is the current director of the program.

Another resource nearby in the DC metro area is the Samueli Institute in Alexandria, VA. This institute was founded by Henry and Susan Samueli in collaboration with Wayne Jonas, MD, a former director of the NIH Office of Alternative Medicine, now known as the National Center for Complementary and Alternative Medicine (NCCAM). The Samueli institute, founded in 2001, focuses on researching optimal, holistic healing and community wellness/resilience. They have received funding from the US military and Veterans Administration, as well as hospitals, worksites, and community organizations. They have proposed a Wellness Initiate for the Nation (WIN), a vision for national policy working in collaboration with industry and community to proactively prevent disease, increase health and productivity, and create a wellness-based healthcare system.

One can surmise from the title that Duggan is focusing his argument to the bottom line for corporations. Others have focused on healthcare as a human right or on military services (Samueli). Given the current dysfunction in Washington, strategically it arguably makes sense to begin by addressing corporate powers. Despite the title, Duggan spends some considerable space on government interventions as well. In fact, his first explicit recommendation involves states. He notes that states can deal with their own budget difficulties by enhancing the wellness of employees and their families. “Those potential benefits, as illustrated by the results at Dow Chemical and the Cleveland Clinic, can generate substantial savings for taxpayers, profits to entrepreneurs, and happier and healthier agency employees serving the public good.”

While some may disagree on the strategic tactic of targeting corporate bottom lines, it is vital that we discuss and act to develop a competing narrative and strategy to that of “entitlements” as a budgetary drag. This conversation is needed to enhance health. If progressives and independent-minded people do not have this conversation, the financial impact will continually be used to justify the ending of “entitlements”. We can do so much better as a nation. Enhancing health need not be a cost. As noted in the book, Dow chemical found that for every dollar spent on prevention and wellness, they saved three dollars. There are real opportunities here in Maryland for us to have an impact.

The book is not perfect. As the author himself admits, it is repetitive and sometimes short on backing references (with the notable exception of Essay 4, “A disaster for America”). However, this book is not intended as the final word on the subject. Indeed, the book ends by saying:

Our nation is worthy of large-minded national discourse. These conversations and existing demonstrations must now be elevated to center stage in our national arena. To avoid enhancing this discourse is to risk national bankruptcy. This wellness conversation, this quality-of-life conversation, is now ready for the national stage.

Indeed, it is my hope that we all can further this conversation. There are important questions for the activist community in Baltimore. For example, what does holistic health and wellness mean for a single-payer platform? For many reasons, Maryland seems to be a great place to address these issues and I have noted above some important resources.  I was excited to read this book and expand my awareness of the local resources to address this perplexing and difficult issue. I hope this article can help to do much of the same for others. I am interested to learn more about how I can contribute to others’ efforts. To contribute your voice, please contact me or join the facebook group “B-more Health”. Local grassroots networking can be an important element in addressing this issue.

Paul Truman

Paul Truman is a health psychologist/epidemiologist interested in mind-body medicine, health disparities, and policies affecting social justice.