The health care industry has a variety of policies and standards regarding coverages for alternative medicine modalities. From a sociological standpoint, unconventional, alternative, or unorthodox therapies refer to medical practices that are not in conformity with the standards of the medical community. The New England Journal of Medicine defines unconventional therapies, “as medical interventions not taught widely at U. S. medical schools or generally available at U.S. hospitals.
Examples include acupuncture, chiropractic, and massage therapy”(1993). Coverages vary widely among conventional carriers, preferred providers as well as the omnipresent Health Maintenance Organizations (“HMO”). The primary emphasis and, for that matter, the only reason for the existence of insurance companies is a single word, profit. More specifically, premiums less costs provide the all important profit margin, the life blood of the insurance industry.
By not providing coverage for the billion dollar industry of alternative treatments, insurance companies are keeping the cost of the premiums down but at the same time not allowing their customers to use complementary treatments such as chiropractic to prevent or cure illness. The more rigid and restrictive the policy provisos, the more assurance for the companies that they will maximize their bottom lines. Therefore, patients of alternative therapies as well as doctors must show that such unconventional treatment provides relief and prevention of illness.
“The total projected out-of- pocket expenditure for unconventional therapy plus supplements(such as diet pills and megavitamins)was 10. 3 billion dollars in 1990. This is comparable to the out-of-pocket expenditure for all hospital care in the United States in 1990($12. 8 billion), and it is nearly half the amount spent out of pocket for all physicians’ services in the United States($23. 5 billion)”(nemj,1991). From this one may infer that society has become fed up with inadequate results or side effects associated with surgery and drugs which accompany the treatment of modern medicine.
So, in an effort to cope with the inadequate treatment patients are receiving from conventional medicine, they are seeking alternatives such as chiropractic for chronic illness and pain. “Although most doctors wince when you mention chiropractors, some fairly rigorous studies have shown their manipulations of the spine to be effective in relieving lower- back pain. Orthopedic surgeons have even been known to refer patients to chiropractors, and some 30 U. S. hospitals have chiropractors on staff”(Wallis,1991). Relevant Policies and/or Practices “.
In 1997, 42 percent of all alternative therapies used were exclusively attributed to treatment of existing illness, whereas 58 percent were used to prevent future illness from occurring or to maintain health and vitality” (JAMA, 1998). “The magnitude of demand for alternative therapy is noteworthy, in light of the relatively low rates of insurance coverage for these services” (JAMA, 1998). Coverages vary widely depending on the policies provided by the carriers.
In my research, I contacted the Kern County Superintendent of Schools, (“KCSOS”), Personnel Office to inquire into the health policies provided to the nearly one thousand employees of the office. There are a variety of options available to each employee. The basic hospitalization plan used by the majority of employees is the Blue Cross Prudent Buyer Hospital Only plan. As required by State and Federal law, the office is also required to make available approved HMO’s if employees request them.
To that end, the office has a large number of employees enrolled in Kaiser-Permanente and Health Net HMO’s. The administrative agency that provides the programs is the Self Insured Schools of California, (“SISC”), which is a cost-containment consortium of hundreds of California school districts. Currently, SISC provides coverage for more than thirty-five thousand employees and their eligible dependents. In addition to medical coverages, the office also provides life, vision, dental, prescription and mental and nervous policies.
The mental and nervous policy that is provided for each employee and dependents is described as a “carve-out” benefit. Prior to this type of policy utilization, the basic Blue Cross medical plan provided very specific and limited mental and nervous benefits. Carve-out benefits provide coverages for treatments that would not be covered otherwise. Several companies came forward with plans that were more comprehensive and cost- effective and replaced the medical plan component.
An additional benefit was that there was a net premium savings. Three companies, Pacificare, MCC and BHA, offer plans at comparable rates which provide a variety of family and personal counseling services which are more along the lines of preventative medicine rather than the hospitalization plans that were offered under the basic hospitalization plan. Employee unions have been very receptive to these plans due to the cost-containment provisions as well as the intervention value for the employees that they represent.
For example, an employee with an alcohol or drug addiction problem can get confidential assistance to assist in the resolution of these problems and avoid being disciplined for job performance problems. The basic medical plans offered by the KCSOS office provide various levels of coverage for several forms of alternative medicine. The Blue Cross Prudent Hospital Only plan provides coverage as follows: “A doctor of medicine (M. D. ) or a doctor of osteopathy (D. O. ).
Who is licensed to practice medicine or osteopathy where the care is provided, or one of the following providers, but only when the provider is licensed to practice where the care is provided, is rendering a service within the scope of that license, is providing a service for which benefits are specified in this Plan Description, and when benefits would be payable if the services were provided by a Physician as defined above: a dentist, optometrist, dispensing optician, podiatrist of chiropodist, psychologist, chiropractor, acupuncturist(but only for acupuncture and for no other
services), certified registered nurse anesthetist, clinical social worker*, marriage, family and child counselor*, physical therapist*, speech pathologist*, audiologist*, occupational therapist*, respiratory therapist*. Note: Services by the providers indicated by asterisks (*) are covered only by the referral of a Physician as defined above”(SISC III, 48). “Health Net has partnered with American Specialty Health Plans (ASHP) to offer Chiro Net quality, affordable chiropractic coverage. With this program, you’re free to obtain this care by selecting a participating chiropractor from the Chiro Net directory.
Although you’re always welcome to consult your Primary Care Physician, you won’t need a referral to see a participating chiropractor. What’s covered Office visits $10 per visit 30 visits per year There is a $50 annual chiropractic appliance allowance toward the purchase of chiropractically necessary items such as supports, collars, pillows, heel lifts, ice packs, cushions, orthotics, rib belts and home traction units.
What’s not covered Limitations and exclusions Air conditioners, air purifiers, therapeutic mattresses, vitamins, minerals, nutritional supplements, durable medical equipment, appliances or comfort items Conjunctive physical therapy not associated with spinal, muscle or joint adjustment Diagnostic scanning, MRI, CAT scans or thermography.
Exams or treatment of strictly non-neuromusculoskeletal disorders Hypotherapy, behavioral training, sleep therapy, weight programs, educational programs, nonmedical self-help or self-care, or any self-help physical exercise training Lab tests, X-rays, adjustments, physical therapy or other services not chiropractically necessary or classified as experimental Pre-employment physical or vocational rehabilitation arising from employment or covered under any public liability insurance.
Treatment for temporalmandibular joint syndrome (TMJ) Treatment or services not authorized by ASHP or delivered by an ASHP provider This is only a summary”(HealthNet, 7). Nowhere in the Health Net coverage guide did it mention coverage, limitation, or exclusion of the numerous treatment modalities of alternative medicine except for chiropractic treatment, which it supported in explicit detail. From this one may conclude that chiropractic is the only alternative treatment that has established a beneficial reputation in possibly preventing illness and promoting wellness in the western world.
An extremist might say because Health Net does not include any other forms of alternative medicine, that these modes of treatment are not generally accepted by the medical community or deemed effective or appropriate in treating illness. Kaiser Permanente’s coverage plan has a significantly larger number of exclusions and limitations regarding treatment coverage compared to Blue Cross and Health Net within the SISC administrative agency.
The exclusions section of Kaiser’s coverage guide states in section i, “Chiropractic services and services of a chiropractor,” which is in contrast to both Blue Cross and Health Net, each of which fully recognize and provide coverage for chiropractic services. In section j of the exclusion section it seems that Kaiser is attempting to eliminate coverage of all other alternative medicine treatment by stating, “Experimental or Investigational Services and those procedures not generally and customarily provided to patients residing in the Service Area.
“(Kaiser, 13) Their definition of Experimental and Investigational Services is, “any service or item that is not recognized in accord with generally accepted medical standards as being safe and effective for use in the treatment of the condition in question, whether or not the service is authorized by law for use in testing or other studies on human patients; or any service requiring approval by any governmental authority prior to use when such approval has not been granted prior to provision of the service or item.
” (Kaiser, 27) This seems to be an attempt to classify all other forms of alternative medicine treatments, with the possible exclusion of chiropractic, as experimental forms of treatment. If this proves to be a fallacious statement, by concluding that section j was an attempt to deem that alternative medicine as an experimental service; then one might conclude that Kaiser dismisses alternative medicine treatment altogether by not including them in their coverage plan at all.
Either way Kaiser must view alternative medicine as being inadequate or inappropriate treatment for illness, providing relief of symptoms or improving their patients degree of health. Preventive medicine, wellness and alternative therapies are fundamental components of a growing national trend. According to a survey conducted by The Journal of the American Medical Association, “… use of at least 1 of 16 alternative therapies during the previous year increased from 33. 8 percent in 1990 to 42.
1 percent in 1997, and the probability of users visiting an alternative medicine practitioner increased from 36. 3 percent to 46. 3 percent” (1998). More and more Americans are seeking options other than conventional forms of medical treatment. Conventional or modern medicine can be defined as treatment that is widely accepted by U. S. medical schools and insurance companies as being beneficial to the treatment of disease and illness with scientific evidence. “In 1993, the National Institutes of Health chose Dr. Joe Jacobs to head their new Office of Alternative Medicine.
The office was created last year under pressure from a Congress alarmed by the soaring cost of high-tech healing and the frustrating fact that so many ailments such as: AIDS, cancer, arthritis, back pain, which have yet to yield to standard medicine”(Toufexis,1993). The cost of standard medical care has risen dramatically. For example, a simple arthroscopic cartilage repair on an outpatient basis costs in excess of five thousand dollars for a thirty minute procedure. A simple Magnetic Resonance Imaging, (“MRI”), costs over a thousand dollars.
In contrast, a visit to a chiropractor costs less than forty dollars. The Journal of Occupational Medicine performed a study comparing costs of treating back injuries with chiropractic and traditional medicine. Using identical diagnostic codes for 3062 claims, the report reached the following conclusion: “For the total data set, cost for care was significantly more for medical claims, and compensation costs were ten-fold less for chiropractic claims. “(1991).
Major Position or Argument Is it better to exercise preventive medicine rather than focus on curing disease after the fact? In response, a growing number of people have concluded that it is a quality of life decision for them to opt for optimizing their health rather than seeking cures. According to the study that represented the use of unconventional therapy for the 10 most frequently reported principal medical conditions, published in the New England Journal of Medicine, “… a full third of the respondents who used unconventional therapy in 1990 did not use it for any of their principal medical conditions”(nejm,1991).
From this fact we can infer that a substantial amount of unconventional therapy is used for non-serious medical conditions, health promotion, or disease prevention. “The probability that an individual patient who saw a medical doctor also used unconventional therapy in 1990 was higher than one in three for patients with anxiety(45 percent), obesity(41 percent), back problems(36 percent), depression(35 percent), or chronic pain(34 percent), relaxation techniques, chiropractic, and massage were the unconventional therapies used most often in 1990” (nejm,1993).
How can the insurance companies ignore the fact that, “an estimated number of ambulatory visits to providers of unconventional therapy in 1990 was 425 million? This number exceeds the estimated 388 million visits in 1990 to all primary care physicians(general family practitioners, pediatricians, and specialists in internal medicine) combined. Also, if one assumes that charges for visits to providers of alternative therapy were paid in full, Americans spent approximately 11. 7 billion dollars for these services in 1990″(nejm,1993).
Nutrition stores have multiplied in the past few years due to the growing demand for a variety of vitamins and potions regarded by many as a viable means to fend off disease and to improve on one’s daily health. Additionally, fitness centers and exercise facilities have sprung up on every street corner. Some are open twenty-four hours per day and provide numerous forms of equipment, technical assistance and even personal trainers to assist dedicated individuals in improving their general well-being and appearance.
Society has become aware of the benefits and effectiveness of unconventional therapies shown by a study that those who sought treatment from providers of alternative medicine has seen the provider an average of ten times in the past twelve months(nejm,1991). Body of Paper The American Chiropractic Association defines chiropractic as follows: “Chiropractic is a health care discipline which emphasizes the inherent recuperative power of the body to heal itself without drugs or surgery.
” “The practice of Chiropractic focuses on the relationship between structure, (primarily the spine), and function, (as coordinated by the nervous system), and how that relationship affects the preservation and restoration of health. In addition, Doctors of Chiropractic recognize the value and responsibility of working in cooperation with other health care providers when in the best interest of the patient. ” (ACA, 1998).
There can be little doubt that chiropractic treatment is valuable as both a standard medical treatment and as an alternative form of medicine. There may very well be some scientific justification in the manipulation of the spine because almost every nerve in the body runs through the spinal cord. Chiropractors maintain that they can treat illness by adjusting the vertebra of the spinal column to relieve nerve and muscle tension(Wallis,1991). This position may, at first, seem contradictory but with further analysis and explanation, it will become clear that it is a supportable premise.
“The visits to practitioners of alternative therapy in 1997 exceeded the projected number of visits to all primary care physicians in the United States by an estimated 243 million; visits to chiropractors and massage therapists accounted for nearly half of all visits to practitioners of alternative therapies” (JAMA, 1998). As an example, a simple on-the-job back strain could be treated in several ways. The simplest and seemingly least costly treatment would be for the employee to go home and rest in bed.
However, this form of treatment may actually keep the employee away from work for the longest period of time which would make the cost factor to the employer higher in the long run due to Worker’s Compensation premium costs and the costs associated with replacing the injured employee such as sick leave benefits and the costs of providing substitute employees. The more traditional treatment would be for the employee to seek treatment from an urgent care facility or from a family physician.
Treatment would generally require X-rays, an MRI or a CAT scan to assist the physician in diagnosing the source of the injury. Depending on the nature and severity of the injury, surgery and rehabilitation through physical therapy may be required to resolve the injury. Otherwise, in the case of a minor injury, cold packs, pain medication and rest may be appropriate treatment. Costs for traditional physician treatment are generally very high. For example, a standard MRI will cost at least a thousand dollars.
Referral to an Orthopedic Surgeon and subsequent treatment including possible surgery, medication and subsequent physical therapy can cost tens of thousands of dollars and extended periods of lost work time. All of the medical plans that I examined provide full coverage, less applicable deductibles or co-payments, for the cost of most forms of treatment with the exception of those considered to be experimental. A third alternative may be acupuncture treatment.
The acupuncturist may or may not be licensed to provide or order X- ray, MRI or CAT scans. If not, the treatment may be the traditional acupuncture treatment. Rest is generally recommended. Generally, the cost of acupuncture is covered, subject to deductibles and co-payments, by most health plans with the exception of Kaiser-Permanente. The fourth and most appropriate treatment, in my opinion, is chiropractic. A chiropractor has the ability to order or to provide X-ray examinations as well as to order MRI’s or CAT scans as necessary. In the event that structural damage such as a ruptured disc or fracture exists, the chiropractor would refer the employee to an orthopedic physician.
However, if the injury is due to a subluxation, the chiropractor would typically perform an adjustment to the spine or other form of manipulative therapy to realign the spine and remove nerve interference and to relieve pain and discomfort. The chiropractor may also prescribe cold packs, rest and, in some cases, physical therapy. The initial examination, which include: the patient’s history and assessment, X-rays, spinal adjustment, and recommendations for improving of making changes in their lifestyle to promote a healthier life (nutrition, massage therapy, exercise, rest, etc.).
The initial examination costs a few hundred dollars, which is covered by Blue Cross and Health Net less the deductibles and co-payments. Follow up exams include spinal adjustments and recommendation or advice on questions pertaining to the treatment and your lifestyle. The cost of these exams usually cost around fifty dollars per visit, which Blue Cross covers the full amount after the deductible has been paid; Health Net requires a co-payment of ten dollars per visit up to thirty visits per year, and Kaiser doesn’t cover any of the expenses of chiropractic care.
According to an article in Kiplinger’s Personal Finance Magazine, “An initial visit to a chiropractor could cost $40 to $80, plus the cost of x-rays; follow-ups are around $40 to $60. Insurance laws in most states require insurers to reimburse for treatment by chiropractors if they reimburse for comparable treatment by M. D. ‘s, and coverage is mandated in Delaware, Maryland, New Mexico and North Dakota. There is no requirement in Oregon, Utah and Vermont.
Self-insured plans are exempt from the state-mandated-benefit laws. Also, according to Don White of the Health Insurance Association of America,insurers are “much more willing to pay than they used to be” when alternative therapies are recommended by a doctor after conventional methods fail”(Clark,1993). Chiropractic is not without its own set of risks just as other forms of traditional medicine.
Ian Coulter, Ph. D. identified those risks and facts as follows: “chiropractors perform more than 90 percent of spinal manipulations (manipulation is the generic, non specific medical term for adjustment); the risk of complication with cervical (neck) adjustments is 6. 39 per 10 million adjustments; the risk of complication with lumbar (low back) adjustments is 1 in 100 million adjustments.
The risk of complication in some common medical procedures and medications were not as good: the risk of complication with the use of NSAIDS (aspirin, tylenol, ibuprofen, etc. ) is 3. 2 in 1,000; and the risk of complication in cervical spine surgeries is 15. 6 in 1,000. By way of commentary, there has been a lot of news coverage concerning the dangers of Chiropractic care over the past few years.
This article clearly points out that Chiropractic procedures are significantly safer than many common medical procedures. For the best reflection of how safe Chiropractic is, ask your Chiropractor how much his/her malpractice insurance costs. Then ask your medical doctor the same question. The difference will surprise you. ” (Chiropractic America, 1999). The preceding procedures treat injuries and the pain associated with the injury in widely differing manners. It is also important to consider how each form of treatment personally affects the individual. Obviously, the less invasive the treatment, the quicker the recovery. Pain control is another serious consideration.
Simply resting may be adequate in some instances but if a serious injury exists, the long term result may be negative. Surgery generally generates substantial pain which requires pain control medication which, in some instances, can become addictive. In contrast, acupuncture causes very little, if any, discomfort and may provide a long term solution. “Acupuncture is most often used to treat pain, and is also used for ailments such as hypertension and gastrointestinal disorders. Needles placed on points on the body are said to transmit impulses to the brain and then to the affected organ.
An initial visit might cost $225; follow-ups run about $75, including a supply of Chinese herbal medicines, which are part of an acupuncturist’s treatment”(Clark,1991). However, chiropractic would be my first choice for treatment because of the immediate nature of the relief this form of medicine provides. It provides for safety in that prior to a subluxation adjustment, the chiropractor would use X-rays to determine the efficacy of this form of treatment. If a structural injury exists, such as a disc problem or fracture, the chiropractor would be at liberty to refer the patient to a physician.
Otherwise, chiropractic is neither invasive nor uncomfortable. In a report released in July 1991 by the Rand Corporation, a prestigious research organization in Santa Monica, California, “… a panel of leading physicians, osteopaths and chiropractors found that chiropractic style manipulation was helpful for a major category of patients with lower-back pain: people who are generally healthy but who had developed back trouble within the preceding two or three weeks. By some estimates, 75 percent of all Americans will suffer from low back aches and pains at some point in their lifetime.
The annual cost to U. S. society of treating the ubiquitous ailment was recently tallied at a crippling 24 billion dollars, compared with $6 billion for AIDS and $4 billion for lung cancer. If spinal manipulation could ease even a fraction of that financial burden, remaining skeptics might be forced to stifle their misgivings or get cracking themselves”(Purvis,1991). In almost all cases, drugs are discouraged so that drug reactions and addictions are never an issue as a result of treatment. It is recognized in almost all medical circles that many illnesses are generated by the mind.
“A growing number of doctors around the country have become more open to alternative approaches, looking particularly at the way that body, mind and life-style interact. Andrew Weil, a Harvard-trained M. D. and author of The Natural Mind, practices this sort of ? holistic’ medicine in Tuscon”(Wallis,1991). Stress from many sources including work and family is the cause of many maladies.
That is why it seems very curious that some health organizations ignore the positive aspects of some or all forms of alternative medicine. On one hand, the medical community recognizes the mental side of medicine and then they summarily ignore forms of treatment that people believe in and that result in healing whether the source is medical or physical. It seems to be a territorial response to what the medical community perceives to be a threat to its existence.
Dr. Saper, a neurologist, “… confirms that lowering a patient’s stress level, with relation techniques or simply encouraging trust in the doctor, can be healing. Research suggests that stress triggers the release of chemical messengers from the brain that suppress the immune system; relaxation would therefore revive the immune response”(Wallis,1991).
However, the trend seems to be towards acceptance of alternative medical practices. A telephone poll of 500 American adults was taken from TIME/CNN on October 23, 1991 by Yankelovich Clancy Shulman that contained three questions about their use of alternative medicine. The results of the survey were: 31 percent of the poll sought medical help from a chiropractor, 6 percent sought help from an acupuncturist, 5 percent went to an herbalist, 3 percent visited a homeopathic doctor, and 2 percent sought help from a faith healer.
When those who had sought medical help from alternative medicine providers where asked if they would go back to an alternative doctor, 84 percent of them said yes, and only 10 percent answered no, with the 6 percent of ? not sures’ being omitted. Among those who had not sought help from a practitioner of alternative medicine, 62 percent said that they would consider seeking medical help from an alternative doctor if conventional medicine failed to help them(Wallis, 1991).
If a high percentage of illnesses are truly psychological and if these people believe that these forms of alternative medicine will cure them, then the insurance companies should provide coverage for them. Ultimately this is cost effective because in comparison to cost of other forms of medical treatment, alternative medicines are much less expensive. By providing coverage for alternative medicine, society should in fact increase their health either physiologically and/or psychologically, which will in turn decrease the number of illnesses and health care premiums will decrease.
Maintaining wellness is a emerging focus of both employers and HMO’s. Use of at least 1 of 16 alternative therapies during the previous year increased from 33. 8 percent in 1990 to 42. 1 percent in 1997. This shows that society is accepting alternative medicine on an ever increasing basis. Alternative therapies were used most frequently for chronic conditions, including back problems, anxiety, depression and headaches. Also, more than half of these visits were paid for out-of-pocket, that is health insurance would not or did not pay for the cost of treatment (JAMA, 11/98).
Incidentally, more and more insurance companies are providing coverage due to member demand. Therefore members who believe in treatment through alternative medicine should make a concerted effort to make their demands heard. One study, conducted in England, found that “for patients with low-back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison to standard hospital outpatient management.
” An extended follow-up of the same patients found that chiropractic patients continued to fair better than their medically treated counterparts (Meade, 1431-7). “At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long-term satisfaction than those treated by hospitals”(Meade, 349-51). Cost-containment is of vital importance, especially to those that must pay out-of-pocket for their medical treatments.
According to the JAMA: “The majority of people who saw alternative therapy practitioners paid all the costs out-of- pocket in both 1990 (64. 0%) and 1997 (58. 3%). ” Even so, the trend is apparent. More and more people are turning to alternative therapies. It must be remembered that the AMA has a vested interest in the results of such a trend and therefore would be inclined to put the best “spin” on the survey. “In 1990, a full third of respondents who used alternative therapy did not use it for any principal medical condition.
From these data, we inferred that a substantial amount of alternative therapy was used for health promotion or disease prevention. In 1997, 42% of all alternative therapies used were exclusively attributed to treatment of existing illness, whereas 58% were used, at least in part, to ? prevent future illness from occurring or to maintain health and vitality. ” The AMA is apparently recognizing the fact that many people use alternative therapies not only to cure but to prevent illness and to improve health.
This is a revealing statement for the medical community to make. The article goes on to say that: “As alternative medicine is introduced by third-party payers as an attractive insurance product, it would be unfair for individuals without health insurance and those with less expendable income to be excluded from useful alternative medical services or consultation (eg, professional advice on use or avoidance of alternative therapies). ” (JAMA, 1998). The AMA is actually recognizing the value of alternative medicine when it refers to them as:
“… useful alternative medical services…. ” In fact, the most impressive statement made by the AMA was: “An increasing number of US insurers and managed care organizations now offer alternative medicine programs and benefits. The majority of US medical schools now offer courses on alternative medicine. ” The Journal of the American Medical Association in a study conducted by the Stanford Center for Research in Disease Prevention concluded that: “Research both in the United States and abroad suggests that significant numbers of people areinvolved with various forms of alternative medicine. However, the reasons for such use are, at present, poorly understood. ”
The study went on to say: “Three hypotheses were tested. People seek out these alternatives because (1) they are dissatisfied in some way with conventional treatment; (2) they see alternative treatments as offering more personal autonomy and control over health care decisions; and (3) the alternatives are seen as more compatible with the patient’s values, worldview, or beliefs regarding the nature and meaning of health and wellness.
Additional predictor variables explored included demographics and health status. ” The conclusion of the study was quite interesting. “Along with being more educated and reporting poorer health status, the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life. ” (JAMA, 1998).