Medical Migration

The insurance model of health care insulates the patient and physician from the costs and billing burdens. As a result, patients may become frustrated with their physician, because they cannot spend enough time with them. On the other hand, physicians have to be very diligent with their time, in order to pay their overhead costs.  For many reasons, the practice of medicine has become a business. Hospitals have become very profitable business entities who know how to work the system in order to generate healthy profit margins. It is naïve, and perhaps unethical, to afford hospitals non-profit status when they generate large profits within the insurance based model. Taxpayers are indirectly pay hundreds of millions of dollars to hospitals for ‘unfunded care’ that is shrouded by deceptive billing practices.

I read an article in the October 10, 216 issue of Modern Healthcare about Dr. David Reiss, a practicing psychiatrist in southern California for 32 years.  He stopped accepting new patient with private insurance at his private practice. He’d had enough of filling out paperwork and fighting with health plans to convince them that the treatment he prescribed was appropriate. Medicaid and Medicare reimbursements were unpredictable and did not pay enough to cover the office visits. He realized his decision may contribute to the shortage of mental health providers in the country.

About 55% of US counties, all rural, have no practicing psychiatrists, psychologists, or social workers, according to a 2013 report to Congress from the Substance Abuse and Mental Health Services Administration.  Just 55% of psychiatrists accepted private insurance as payment in 2010, compared with 89% of doctors in other specialties, and the percentage has declined by 17% since 2005, according to a 2014 study published in JAMA Psychiatry. The same study found 55% of psychiatrists accepted Medicare reimbursement and 43% accepted Medicaid (JAMA Psychiatry. 2014;71 (2):176-181).

Passage of the Affordable Care Act hoped to improve access to mental health services. Unless the root cause of the problems regarding reimbursement is addressed, access to mental health services will continue to be a problem. More importantly, mental health care must be scrutinized critically to see if the current practices that include antidepressant and anti-psychotic medications are actually effective.  Recent reports in the New England Journal of Medicine and non-biased analyses of the anti-psychotic medications suggest these medications are not effective, and they may be causing unexpected metabolic problems. The field of psychiatry may need to migrate towards a different health care paradigm that includes nutritional interventions that address the root metabolic dysfunction that is at the promoting neurologic chaos.

I can hear the cynics scoffing that nutritional intervention has any benefit with chronic diseases. A favorite quote of mine is, “A person with experience is never at the mercy of a person who wants to argue.” I have had many successful, clinical experiences with patients who have implanted significant behavioral and nutritional changes. I am secure with the nutritional results I have seen to believe there is merit in exploring the nutritional role in more depth.

For any practice to survive there must be enough revenue to pay for the administrative overhead. Many physicians are unaware of the cost for their visits, procedures, and the discrepancies between the billed rate and the amount they are reimbursed for their time and effort. Medical school training does not prepare physicians to be business owners. As a result, many physicians become slaves to a larger entity, such as a hospital or large group. The financial burdens imposed on graduating physicians force them to find ways to pay for their student loans. Many graduating physicians become employees of hospital or urgent care chains, because they have debts to pay, and the thought of running a practice seems overwhelming.

Patients who want a quick fix to their medical challenge will pursue health care in urgent care settings. Urgent care settings are terrific for answering emergent needs, but these locations are not suited for addressing chronic diseases. Since the implementation of the Affordable Care Act (ACA) patients are utilizing emergency rooms for chronic metabolic challenges. They cannot afford the copays for outpatient visits and cannot afford to meet their deductible. Patients and physicians are frustrated because this is not the setting to address these needs. For me, there is very little professional satisfaction in providing medical care that only responds to crises.

Most chronic diseases have a common thread of inflammation. Addressing the metabolic dysfunction that promotes inflammation is more likely to address hypertension, diabetes, and heart disease. Changing behaviors that contribute to metabolic dysfunction requires patient involvement.  Writing a prescription for the urgent needs is important. But when the patient understands why they have a chronic illness, and they are willing to make the appropriate changes, good quality health care is provided.

Patients are looking for answers rather than a Band-Aid for their medical problems. The time and effort needed to address chronic diseases is not sustainable in most practices that rely upon insurance. People want to address the root of the problem and are very interested in finding a physician with an understanding of nutritional options to address their medical need, rather than persist with the medication approach.

The quality of health care provided should not be based upon the government’s standards. For example, cardiovascular disease may not be due to cholesterol. There may be better ways to address those at risk for cardiovascular than to decrease cholesterol.  In fact, it is important to realize that we need cholesterol. There are a few books you may want to read, if you are interested in knowing more about this subject.

1. Fat and Cholesterol are GOOD for You! – Uffe Ravnskov, MD, PhD
2. The Cholesterol Controversy – Edward Pinckney, MD
3. The Great Cholesterol Myth – Stephen Sinatra, MD

Insurance originally started to cover unexpected events. The monthly money spent is never seen again. Insurance premium inflation has been disconnected from actual medical inflation.  This was a progressive distancing that happened as a result of physicians and patients becoming less knowledgeable about the actual expenses. The distance between premium inflation and medical inflation was exacerbated by physicians who concluded they were billing the insurance company instead of the patient. In addition, patients felt entitled to ‘everything’ because they paid insurance premiums. The amount of money spent on Health Insurance does not equate with good health care.

The amount of money spent on Health Insurance does not equate with good health care. Look at the chart below. This is a comparison of the quality of health care as determined by the World Health Organization, Commonwealth Fund, and International Health Policy. If you focus on the United Kingdom and the United States, there are some telling highlights. Despite spending the most for healthcare, the United States rank 11th in Healthy Lives. Interestingly, the United Kingdom rank 1st in most areas observed but 10th in Healthy Lives. So putting more money towards the healthcare system is not the answer. With regards to the United Kingdom’s high ranking in most areas, they are not successful in achieving healthy lives. Despite ranking high in most areas, the end result of healthy lives is not achieved in the UK. Conversely, the amount of money spent in the US does not equate to healthy lives either. So what does?

France, Sweden, and Switzerland have the highest rankings regarding healthy lives. They spend approximately half of what the US spends/Capita on health care. Food choices, lifestyles that include more activity and less reliance on the healthcare system are important. These same countries rank lower than the US regarding effective care, patient-centered care, and timeliness to care. And yet, they have better outcomes. So the answer to healthy lives should focus on diet and exercise and not insurance. When individuals have control of their health care dollars, they are more motivated to make healthy choices. Spending more money on insurance is NOT the answer.