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BAD MEDICINE – SHOULD WE ESCAPE IT OR CHANGE IT?

A review of the film “Escape Fire – The Fight to Rescue American Healthcare”

By Jeff Gee, MD

“Escape Fire – The Fight to Rescue American Healthcare,” a documentary about the US health system by Matthew Heineman and Susan Froemke, was released on October 5 in cities across the country. It will be widely viewed by the general public and therefore deserves thoughtful discussion by progressive healthcare advocacy groups. In summary, “Escape Fire” points out the most serious problems of U.S. medical care, but lacks a coherent, systemic analysis, and provides halfhearted solutions that may fix some things for some patient populations, but do not address the root causes of the mess we’re in. It might be fine as a taking-off point for debate but ends up being more of an exposé than an inspiring message.

The title reflects this skewed view – an escape fire refers to the practice of deliberately setting a fire to clear vegetation so a rapidly approaching wildfire will bypass the cleared area, thus allowing an “escape” for threatened firefighters or property. However, unlike a backfire, it is not intended to control, much less stop, a wildfire. Unfortunately, this safety zone concept characterizes most of the movie’s approach to the medical care dilemma.

“Escape Fire” is well filmed and narrated. It features Dr. Don Berwick, the outgoing director of the Centers for Medicare and Medicaid Services, who advocates fundamental realignment of healthcare incentives and delivery but provides no plan to achieve this goal. The movie begins with vignettes of several people who have been poorly served by modern healthcare. Briefly, these include a primary care physician who quits an overwhelmingly busy public clinic in Arizona where she’s expected to treat 6 patients per hour, only to find that the small group practice in Oregon she joins is also being forced to increase patient volume. Next, there’s a veteran of the Afghan war who  has developed severe PTSD and lumbar disc disease with radiculopathy. He’s heavily medicated with narcotics but is weaned off after a course of acupuncture and meditation. We then meet a middle aged woman who had a MI followed by a CABG at age 35 – in the subsequent years she underwent “27 cardiac catheterizations and at least 7 stents,” all while her hypertension, diabetes, dyslipidemia, and obesity were poorly controlled. She finally seeks treatment at the Cleveland Clinic, where Dr. Steven Nissen, the wise chief of Cardiovascular Medicine opines that invasive interventions relieve angina but do not prolong life or prevent cardiac morbidity. Instead, our patient is started on an intensive program of medical treatment to manage her risk factors as well as diet and exercise.

The movie does not inform us that the Cleveland Clinic is a multinational health corporation, which grossed $9.14 billion in 2011 and has built nine regional hospitals in northeast Ohio, as well as health centers in southern Florida, Toronto, and Las Vegas. The latest jewel in their crown will be a 364-bed hospital in Abu Dhabi scheduled to open in 2013, with additional facilities planned in Austria, Singapore, and other countries. Several large US corporations (including Lowe’s and Kohl’s department stores) have partnered with them for fixed price cardiac surgery, and a dozen more including Boeing and others are in negotiations.

Dr. Dean Ornish, in a cameo role, endorses the lifestyle modification approach to good health, showing his famous catheter images of plaque regression. A Nobel Prize-winning researcher at UCSF demonstrates the reversal of telomere damage with better nutrition and yoga classes. Dr. Andrew Weil joins in from the integrative medicine perspective.

The quite valid consensus of all the civilian and military physicians interviewed in “Escape Fire” is that the disease-diagnosis-drug model of medical care, controlled by powerful health insurance, pharmaceutical, and medical equipment manufacturing corporations and legalized via their well-funded lobbyists, is leading to disaster for American wellness. There is a growing epidemic of obesity and diabetes, patients are overmedicated, over tested, and treated unnecessarily, leading to enormously expensive premiums for persons and businesses with measurably poor public health outcomes.

The solution? Promote a primary care emphasis in healthcare delivery by shifting reimbursement from high-tech invasive specialty care to comprehensive, multidisciplinary, preventive medicine; educate and incentivize patients to comply with lifestyle modification; and train a new generation of health professionals to provide complementary wellness care and to act as a catalyst to launch a vaguely described “grassroots movement” for health promotion.

Examples of the solution? Well, the Cleveland Clinic, of course. But even better, Safeway CEO and Chairman Steve Burd is lauded for an innovative plan to reduce corporate medical insurance costs at the retail giant. Safeway has started wellness programs for its employees – health food cafeterias, gyms, and running teams. Mr. Burd comments that “medical problems are driven by behavior” and that preventing these is just like “currency” for the company. The Healthy Measures Employee Insurance Plan tests for cardiovascular disease, diabetes, cancer, and obesity. Employees are rewarded for passing or improving each test (such as losing weight) by a reduction in their insurance premiums. These changes are “primarily targeted at our 30,000 nonunion workforce.”

What’s missing from this fairy tale? For one thing, the observant viewer will notice that the cafeteria, gym, and jogging group are at corporate, not at the local supermarket, but the tests are applied to everyone in the program (74% of nonunion employees). In 2010, Safeway earned $589 million on $41.05 billion in revenues (the 11th largest retailer in the US), and in 2011 Mr. Burd was paid $1.5 million in salary and $10 million in stock options and other compensation. The company is notoriously aggressive in fighting unionization and in contract negotiations – most of us will remember the widely publicized strike by the United Food and Commercial Workers in southern California, which lasted 5 months in 2003-2004 and was countered by a lockout. Nonetheless, Safeway has designed a plan that has kept per capita healthcare costs flat between 2005-2009 while most American corporations’ costs increased by 38% during this period. This is not a positive model for public healthcare but an example of capitalist ingenuity at its best: a corporation seizing the initiative to reduce spiraling costs, resulting in a stronger market position, happier shareholders, and perhaps marginally happier nonunion employees. Wellness, once again, is not the fundamental goal of this process, but a possible byproduct.

To be fair, the filmmakers did include a telling scene where hundreds of uninsured small town folks gather in bleachers to wait hours for long-postponed medical care brought to them by traveling health providers in nearby abandoned barns and “tent clinics.” Many had to be turned away. The movie also pointed out that a McDonalds burger is only 99 cents, while the healthier salad costs $6, a major deterrent for the poorest Americans.

In a sense it’s true that most of the limited reforms that have led to better health for people in the midst of this disaster have occurred in isolated pockets, as if created by escape fires: a couple of clinics manage to secure adequate funding to provide more comprehensive care for their underserved communities, a business co-op funnels a significant portion of its profits back into healthcare for employees and their families, and cities like San Francisco subsidize access for the uninsured. But only when communities, providers, union members, nonunion workers and small business owners join together to fight the big wildfire in an organized way will we have the strength to achieve better health for all, not just for a few. This movement must be broad-based and should eschew trickle down reform doled out by Big Business, whether it be a supermarket chain or a health care conglomerate. We will also need to take the profitable accelerants out of the hands of Wall Street and Big PhARMA arsonists at the leading edge of the wildfire.

“Escape Fire” offers some on-target looks at the terminally ill state of U.S. healthcare, but it is short on realistic and rational solutions to its critical problems. Although holistic, preventive care would be a tremendous improvement over the fragmented disease-driven approach we are compelled to follow now, it cannot serve the broader public without widespread availability ensured by an equitable financing mechanism, i.e. a national, single-payer health program. Yes, people should be educated to maintain personal health by modifying diet and exercise, but we must also understand how deliberate social, economic, and political policies keep the majority from making and maintaining those healthy lifestyle choices. Just as in the struggles for better education, jobs, and housing, it will be vital that enough people who need and want to rescue American healthcare make the 1% who benefit from those policies an offer they can’t refuse.