Committment and Affordability for Patients

My introduction to functional medicine was in an integrative clinic that was run as a not-for-profit. The founder had started it for a cause dear to his heart, and whenever the business ran into the red he poured more money from his for-profit business into the coffers. This meant, basically, that we could keep costs reasonable for the patient, and hardly turned anyone away. The founder also used the clinic to offer health insurance for his employees in his other business. They were seen for free at the clinic if they chose to go there. Boy, was that a dream for us as the practitioners! We offered a D.O. and an M.D., a nurse, medical assistants, reflexology, acupuncture, massage therapy and osteopathy, nutrition consultation, and I.V. therapies. We had a dietary supplements retail section to meet the doctors’ recommendations, but did not have a high profit margin. We essentially met the AMA recommendations that dietary supplements sold out of a physicians’ office be sold for cost, at most. (refer to ethics article, September 2012)

Life changes took me to another state and another integrative clinic. The offerings were almost identical, but the costs were certainly not. When I worked the front desk, I saw the patients suffer severe sticker shock when they got their bills and a big bag of dietary supplements sold for at least 100% markup. No insurance of any significance was processed, mostly because the majority of the treatments were not covered. The first bill easily ran $1000 or more with laboratory tests and supplements. For subsequent visits, the fee for the office visit gradually reduced, but the dietary supplements and the use of multiple and repeated laboratory tests significantly cost the patients. These tests are highly useful, and are crucial to this modality of medical practice. However, the prescribed treatments of dietary supplements, foods, holistic healing arts, and I.V. therapies are not the treatments recommended by the AMA, thus U.S. insurance companies do not provide coverage the way they do for standard lab tests, pharmaceutical medications, and surgeries.

Many of the patients I knew at this second clinic struggled mightily. They, their spouses, or their children were suffering intractable chronic illnesses, this was often their last resort, and the stresses had mounted already before the first bill arrived. I saw huge disagreements about whether or not to spend the money with the clinic. I saw divorce, refinancing and second and third mortgages, bankruptcies, breakdowns. Maybe it is not so different from families with a loved one going through any expensive illness when they have poor coverage and slip through the cracks. But this should never be the case with evidence based and highly effective medicine.

Functional medicine developed to meet a need: remediation of the burden and the cost of chronic, non-communicable disease. According to the site for the Institute for Functional Medicine (http://www.functionalmedicine.org/files/library/sp-problem-solution.pdf), chronic conditions comprise more than 75% of U.S. healthcare costs. Worse, it is predicted that by the year 2020 we can expect 80% of diseases globally to be non-communicable, thus assumed to be chronic. For complicated and drawn-out chronic diseases like diabetes and heart disease, autoimmune disorders, cancer, hormonal imbalances, and even mental illness functional medicine seeks to provide a new model of healthcare and prevention to reverse this epidemic. This newer model Functional Medicine and the Global Economic Crisis of Chronic Disease takes into consideration the intersection of genetic predisposition, environmental exposures and detoxification ability, and unhealthy lifestyle. These are the causative factors in chronic diseases.

But functional medicine does not merely seek to introduce an alternative method of treatment. It seeks to re-educate and replace the current outdated model. Yet it is currently available for higher income patients only. It is not covered by private insurance, medicaid, medicare, or worker’s compensation. It is generally not provided in free clinics, inner cities, or underserved rural areas. It is currently funded by the higher socioeconomic stratum of developed countries. Yet, even lower income patients are so desperate for it that they will go to great lengths to employ a doctor and pay for the tests and supplements. They are sacrificing emergency funds and good credit to try to find a solution for their ailments. Ideally this demand and the political efforts of organizations like the Institute for Functional Medicine will ultimately change the face of healthcare the world over.

In the meantime, how many can afford this care, no matter how effective it might be? How many who can afford it will actually commit to the changes in lifestyle they will be required to make? And how can we know our doctors are ethical in the fees they charge for visits, laboratory tests, and the dietary supplements they sell out of their offices? I knew, at least, at the first clinic where I worked that they kept their fees and markups to a minimum. This was largely possible, though, because the clinic was sponsored and funded; not quite socialized medicine, but headed in that direction.

The fact is, disease care is expensive. Whether the care is a conventional model or a new and innovative model, a lot of money is required to treat chronic diseases once they have reached the clinical stage. With the current clinical model, according to the www.cms.gov National Health Expenditures Fact Sheet for 2012, “NHE grew 3.9% to $2.7 trillion in 2011, or $8,680 per person, and accounted for 17.9% of Gross Domestic Product (GDP)”. How does that compare to our other federal expenditures? It is more than many areas combined; including education, welfare, and national defense. For the functional medicine model, patients are bearing the brunt of the expenses out of pocket. Either way, we are all paying atrocious costs for disease states allowed to progress so far that they are often intertwined and very difficult to manage.

What about the old adage, “An ounce of prevention is worth a pound of cure”? Prevention has always been the answer, but it requires convincing the potential patient of the benefits long before a consequence has manifested. Perhaps it will be the findings in genetic research that will help drive preventative medicine, and the functional medical model is perfectly aligned to provide the necessary information and recommendations. If we know more about our individual genetic makeup, and we understand more about the effects of toxic exposure, then we may be more inclined to modify our lifestyles proactively to prevent disease before it ever starts. In my practice and those of integrative physicians in my area I see that more and more people are recognizing the role that balanced hormones play in their sense of well-being. The desire to live longer, and to look and feel better while doing it, is driving more and more interest in the effects of hormones in our bodies. Thus, many patients in their 40s and 50s are making their way into the functional medical model before they are too far down the rabbit hole of chronic disease. Some are even younger than that, entering integrative medicine because of reproductive disorders and perceived toxicities that Functional Medicine and the Global Economic Crisis of Chronic Diseasethey want to learn how to manage. We as practitioners feel these changes, the increase in demand, and it is exciting to see more and more such clinics opening in any given area of the United States. Talk show hosts like Dr. Oz and Oprah, as well as multiple celebrities, have helped to spread the word for those who can relate to their messages. But statistically speaking, the majority of adults in the U.S. are still either unaware of what prevention can do for them, or unable to access it either by location or financial means.

The Institute for Functional Medicine and other Integrative Medical programs do seek to change the education offered to medical students and available to physicians as continuing education. Fortunately some changes in federal policy are opening the doors and providing grants for functional medicine curricula to be taught in medical schools, such that the mindset of new graduates in the medical fields can be shifted. But to educate the consumers, the patients, we must start much earlier. Certainly, both the insurance and the healthcare models have to shift; patients must understand the economic ramifications of poor lifestyle choices, and perhaps be encouraged with incentives for adopting health-promoting strategies. Yet the education really must begin in elementary schools, re-educating our population through its children about common sense nutrition and health. Children are little sponges and bring information into their homes that may affect the adults in their families. If they learn early about the needs of their brains, eyes, livers, digestive tracts, skin, lungs, and blood it may make more sense to them to engage in preventative lifestyle practices. Understanding our genetic heritage, consumption of whole foods, eating for colors, avoiding toxins when possible, getting regular exercise, minimizing sugar, alcohol, tobacco, and drugs, all may become desirable choices if our population is educated early on about the inevitable consequences of choosing otherwise.

For the current adult population, insurance coverage options may change also with the implementation of the Affordable Care Act (http://www.functionalmedicine.org/home/Affordable_Care_Act/). This may encourage more patients to seek integrative medicine for their longevity interests as well as for their treatment of chronic diseases. All of us as Natural Practitioners are poised to receive these “newbies” to functional medicine, and hopefully inspire them and their belief in a new medical model. We all must do our utmost to provide the highest standard of care, at the most fair price, and with the greatest ethic possible as we work to usher in a new era of medicine and have it be widely recognized and highly esteemed. It is only through collaboration with the current medical model that we can reverse this heavy financial burden of chronic disease nationally and globally.

Originally published in, Natural Practitioner Magazine March 2013

Ramy Mam