For thirteen years I was involved in a cash pay practice. My foray into the medical insurance industry in the last seven months has been an absolute disaster. Let me start at the beginning.
In 1984, I joined an insurance-based practice as a pediatrician. While there, HMOs and PPOs and other “Os” (organizations) started forming. In 1992, a retiring physician asked me to take over his practice, so I made the move to solo practice in a subspecialty of pediatrics called developmental pediatrics—learning disabilities, attention difficulties in children and adults. A large part of my practice was Medicaid. When the Medicaid ‘rules’ changed in Montana, I could no longer make a living in medicine and stay in Montana. We left our dream home that we had just built on 23 acres, and explored 7 practices back east that requested we join them. We made the decision to join a family integrative medicine practice in Cleveland.
Cleveland gave me my first look at a mostly cash-pay practice, and it was extremely busy for me. I had a waiting list of at least six months before patients could see me.
Four years ago, I started a cash-pay practice in Utah, but I could not get sufficiently busy, quickly enough, through word-of-mouth and lectures. I decided that cash pay was not going to work in Utah–at least not as quickly as I needed it to– and so eight months ago I joined an insurance practice. It took 6 months before I was ‘paneled’ (cleared for insurance) by 5 companies. I was “denied” by a number of other companies who had closed their doors to new physicians. (Denial is based on a company deciding they have enough doctors enrolled to meet their specifications to cover their patients.)
Here are some observations from the last 8 months:
- Each insurance company has its own set of rules.
- Each company has its own maximum allowable paid for each code.
- Each code must have ‘documentation.’ The documentation is becoming more burdensome and changes regularly, always in favor of providing less and less reimbursement for patient care.
- There is no monetary value placed on getting a patient well, or in reducing long-term (and short-term) health care costs.
- Prevention and preventive care are defined by conventional medicine standards, while we in integrative medicine consider many treatments harmful, such as:
- Mammograms, which are X-rays of the breast for cancer screening. This is alarming, considering it is well established that X-rays cause cancer, including contributing to breast cancer. Thermograms remove all that risk, cause no pain, and are more sensitive than mammograms at picking up potential cancer in the breast–years before mammograms are able to see it.
- A “preventive” visit (covered by insurance) may turn into a “diagnostic” visit–during the visit. For example, a colonoscopy is preventive, but it changes when a polyp is found. Co-pay is received from the patient upon check-in for a diagnostic or maintenance visit, but not necessary if it is preventive—unless the label changes during the visit.
- Patients go in for their free ‘annual check-up’, but as soon as they talk about their headache, backache, that changes the ‘annual check-up’ to a non-preventive visit, so you are not allowed to bring anything up at that visit. You must return another day to talk about anything that concerns you. How is that medical “care?” It represents egregious medical indifference.
- If medical care is ‘preventing’ diabetes, hypertension or heart disease from getting worse (thereby saving the insurance industry big dollars), it is still not considered preventive care and co-pay is charged.
- Medications (sometimes very expensive) for treatment of symptoms are a covered service, while treatments (often less expensive) that address the causes of the condition are not covered—to name a few: chelation, intravenous nutrition, hyperbaric oxygen, NAET (allergy desensitization).
- Out-of-network providers may not be covered at all for ‘preventive’ care.
- Decisions regarding all of this care are more driven by stockholders and insurance company employees than by patient care.
- Out of touch, retired practitioners make many of these (arbitrary) ‘decisions.’ But what is even more disgusting to me is that medical decisions, more often than not, are made by the insurance case manager. Is there something wrong with this picture? Whatever happened to “practicing medicine without a license?”
- Some insurance companies refuse to arbitrate (even when promised care options are in their contract) over disputes, thus forcing expensive lawsuits to follow.
- An insurance-pay practice requires an insurance biller (extra cost for a full time employee). The doctor is paid a certain percentage of the maximal allowable reimbursement. Someone must follow-up with the insurance company when errors are made, non-payments are overdue, the company loses billing forms and refuses to deal with incompletely filled out billing forms. And the rules change on a regular basis. And there are multiple insurance companies. And …
- Insurance companies pay handsomely for a qualified kidney transplant in an individual who is drinking soda pop and eating processed food on a daily basis, but squawks over paying for supplements and healthy eating to prevent serious illness.
- When Medicare was introduced in the United States, the government made it clear that it would never become the insurance industry standard. (It reminds me of the government promise that federal taxes would never exceed 1%.) Because of its reimbursement scale, Medicare restricts care to the elderly. Overall reimbursement from Medicare is about 60%. How fiscally viable is a practice when physician offices have a 50 to 60% overhead?
Here is a list of a few things that may work for you in navigating the confusing course of health care:
- Carry insurance with a high deductible (which is happening anyway) with a cash slush fund to be used for health care of your choosing (Health Saving Account). Placing control of health back in the hands of the patient (where it belongs) will maximize health over the long term.
- Business initiated Wellness Programs show good statistics in reducing health care costs. One of the core elements is providing Health Coaches that assist with difficult behavioral changes. Patients need them and want them, but behavioral changes are difficult to make alone.
- Reimburse Alternative Medicine care at the same rate as Conventional Medicine.
The health care system is broken. Although the free market system has created problems, the only thing that is worse than what we have is a government-run socialized medicine system. And unfortunately, that’s where we are headed (if not there already).
True preventive medicine treatment lies within the realm of the Alternative Medicine field. Nutrients (real food and supplements) will prevent more disease than anything else. Counseling around issues of sleep, exercise, water intake, attitude and emotional health take time and do not fit into insurance-based reimbursement patterns. (For example, a son of mine was sick 3 times in 2 months. Reason—stress and sleep deprivation. It did not matter how many antibiotics he used. Until he started getting proper rest and reduced his over-committed life, he continued to get sick. When he started sleeping and saying “No” to extraneous commitments, his dis-ease disappeared).
To your dynamic health and energy,