The independent documentary Escape Fire: The Fight to Rescue American Healthcare by Matthew Heineman and Susan Froemke is a thoughtful indictment of the status quo. Instead of focusing on political polarization, the pros and cons of Obamacare for instance, the film mainly documents the absurdity and waste of what we have now. Instead of a system to promote health, Americans have a “disease management system” that spends almost twice as much as any other country — and nearly as much on prescription medicines as the rest of the world combined — yet we are 50th in life expectancy, and almost 75% of healthcare costs are spent on preventable diseases that are the major causes of disability and death in our society. Economic incentives maintain this status quo. High-tech interventions are reimbursed generously, yet reimbursement for face-to-face primary care often does not even cover the cost to deliver it. As a result, fewer new physicians enter primary care, and doctor visits become shorter and shorter. Meanwhile, unnecessary medical and surgical procedures are prevalent despite their risks, and cost thousands of lives each year.
Escape Fire uses a firefighting metaphor to make its main point. In forest fires, sometimes a smaller fire is set in order to deprive the main fire of fuel, creating a firebreak. Such firebreaks can allow firefighters to escape the area — thus an “escape fire.” The filmmakers use this metaphor to say that the status quo in health care isn’t working, and that we may need counter-intuitive and non-traditional solutions to save the system. I confess that I find this metaphor somewhat ill-chosen: The remedies suggested in the film do not “fight fire with fire.” And there is no escaping our need to address health care.
The film spends much time on the military, in part as a microcosm of the problems facing our larger society. Soldiers’ use of prescription drugs has tripled in the past five years. A large section of Escape Fire, including fascinating footage inside a C-17 Medevac plane as it crosses the Atlantic, follows Sergeant Robert Yates returning from Afghanistan. Severely injured in a battle that killed most of his platoon, he suffers chronic pain and PTSD. Sgt. Yates was given a shopping bag full of pills, but later replaces them with stress- and pain-management techniques he learns as part of an innovative Army program.
Although the film never mentions psychiatry as a medical specialty, mental health issues loom large in both military and civilian health care. Again and again, patients are depicted in primary care offices reviewing their antidepressant medications, or breaking down in tears. The current system, devoted to disease management, offers poor care to such patients. They need time, not reimbursed procedures. As medical journalist Shannon Brownlee notes on camera: “Health care should have a lot more care in it.”
The film proposes several escape fires, i.e., solutions, to rescue American health care. In 2005 Safeway began to provide financial incentives for employees who engage in healthier behavior, and thereby lowered its health care costs by more than 40%. (That’s how the film puts it. Actually, from 2005 to 2009 Safeway’s health care costs remained flat for the 30,000 employees enrolled in the program, while most companies’ costs rose by 40% over the same period.) This was the one example of a monied interest realigning financial incentives to promote health. The film would have been stronger with more such examples — I hope there are some.
The military provides a solution of a different type. Often innovation gains a foothold there before achieving acceptance in civilian society. Just as America’s armed forces were on the vanguard of racial integration and later gender equality, perhaps they can lead the way on health care too. The Army Surgeon General established a Pain Management Task Force to look at alternatives to narcotics, and now the Army is using acupuncture and meditation to decrease narcotic use in the wounded. Sgt. Yates, the self-proclaimed “redneck hillbilly” who didn’t believe in Eastern Medicine, “decided to give it a shot,” and it worked.
I found the profile of Dr. Erin Martin the least hopeful in the near term. Initially shown as a primary care doctor in a low-fee clinic, Dr. Martin had high ideals, but was demoralized by too many patients and too little time. She was dissatisfied and frustrated by a system that made her job nearly impossible. Her escape fire was literally to escape: She quit the clinic, became a fellow in Dr. Andrew Weil’s Integrative Medicine program, and found a practice that supported her patient, humane approach. The film endorses this as the escape fire for primary care — but of course those clinic patients still need a doctor.
Dr. Martin’s path is similar to the one I took myself. Early in my career I worked for two years in a public mental health clinic. The patients were in great need, but the system was frustrating and the work demoralizing. Providing comprehensive, humane mental health care in such a system is an uphill battle at best, and in some respects nearly impossible. I have much admiration for those who work in such settings. However, like Dr. Martin, I chose to leave and practice in a way that makes more sense to me. While the makers of Escape Fire would likely endorse my choice, public mental health clinics still need doctors too. Moreover, it will be a long time before the American health care system rewards Dr. Martin and others who aim to avoid commodity care. Indeed, the system is accelerating in the opposite direction. Those of us who build this particular escape fire in essence work outside the larger system.
As I wrote at the outset, Escape Fire is a thoughtful indictment of the status quo. The film has been reviewed positively, and it strikes a nice balance between worrisome facts and emotional interest, ending on a hopeful note. We should have no illusions about easy solutions though. Healthier lifestyle choices are hard to pursue when fast food is cheap and tasty; a shift to preventative care from disease management would represent a fundamental sea change and a realignment of billions of health care dollars. For a start, at least, we can agree that American health care is burning, and that new solutions are desperately needed.