Original Content at
March 4, 2010
Short Sighted Health Insurer Policies Which Refuse to Pay for Healing & Preventive Services Hurt Patients, Cost Fortune
By Lewis Mehl-Madrona
I don't know anyone who is happy with their health insurance... I'd like to weigh in on what people don't get with today's health insurance, because I know what I don't get paid by insurance to do.
The health care debate continues in Washington, D.C. and across the nation. What impressed me this week was the Republican assertion that Americans were by and large happy with their health insurance. I don't know anyone who is happy with their health insurance, and, as a physician, I know many people who have health insurance and use it. Advocates for President Obama's plan point out that people will have much better coverage of services under their plan even though individuals will pay 10 to 13% more. Republicans argue that people would rather keep the plans they have and save the 10 to 13% increase in premiums.
I'd like to weigh in on what people don't get with today's health insurance, because I know what I don't get paid by insurance to do. If I see anyone more than once per week, I don't get paid. I remember my surprise when I saw an 86 year old woman with heart failure daily in order to keep her out of the hospital (her wishes) and as able to do so. Medicare, however, paid me only for the first visit of the week and denied all the others as medically unnecessary. Had I admitted her to the hospital (she certainly would have qualified), presumably Medicare would have paid the hospital, though they might have scrimped on my daily visits to her. Heart failure is the number one cause of geriatric admissions to hospital. Imagine the savings that might accrue if we had geriatric home teams who could manage such patients outside the hospital. However, contemporary health coverage will not permit that.
another example. I work with many seriously mentally ill people. The
most common diagnosis they receive is schizophrenia. I work with a
small subset of these patients intensively, for no charge (since no one
will pay me). The patients I see once or more per week use much less
medication and have many fewer hospitalizations than the patients I see
once per month (what insurance will allow). I like to work with these
people in a group format because they learn from each other. Insurance
will not allow that either. The cost of the medication that the
insurance does cover ranges between $500 and $1000 per month. I can
usually keep the patients with whom I work more intensively below $200
per month in medication costs.
What's also important, but rarely considered by today's insurance companies, is the level of suffering. I imagine insurance executives sitting in board rooms thinking that we doctors would see patients daily for hours if we could and that nothing would come of it besides our income. I don't even think that happened in the heyday of psychoanalysis when people were seen daily (that's been rare since 1970). I've submitted a paper for publication on the outcomes of 51 people diagnosed with schizophrenia whom I saw for more than four hours per month over several years. Over 80% of these people were doing well and were off medication at seven year follow-up. Imagine the cost savings if we were actually paid to help such patients. People with schizophrenia die, on average, 25 years before age-matched controls without that diagnosis and the last year of their life is quite expensive.
fact, 70 to 80% of the total amount spent during a person's life is
spent in their last year of life. That could be reduced if doctors
spent more time talking to families, which is also not currently often
reimbursed. In fact, the patient must be present in order for insurance
to be billed, and that is sometimes not in the patient's best
interest. Sometimes it is very important to have conversations with
family members that the patient may not want to hear.
I remember a 104 year old man for whom the family wanted full resuscitation efforts were his heart to stop. The insanity of this was that chest compressions would have probably killed him by breaking all his ribs and bruising his heart. We were able to spend several hours discussing this with family members over two weeks and eventually consensus was reached for a "do not resuscitate" order. My bill for these meetings was denied by Medicare as medically unnecessary. Imagine the cost of transporting him from the nursing home with ambulance sirens blasting, paramedics working, and then the ensuing chaos that would have ensued. I did see this happen once and watched the code team half-heartedly pursue resuscitation of a 108 year old man. Not a single person thought it would work, but the family insisted, and at least a $20,000 hospital bill was generated.
Another example comes from a chronic pain patient. People
with chronic pain are largely failed by the medical profession. Within
the medical model of a pill for every woe, the pill offered is often a
narcotic. Narcotics lead to tolerance and tolerance is a sign of
Once people are addicted,
physicians will often then refuse to treat them. What now! Chronic
pain, however, is largely a central nervous system phenomenon. The
brain learns about acute pain from a sudden injury and then changes and
adapts to continue to feel that pain long after the injury has stopped
transmitting pain signals. This fact is part of virtually every
continuing education course for physicians in chronic pain, but largely
ignored in practice because the ways of approaching central nervous
system change are largely not covered by health insurance. Cognitive
behavior therapy, hypnosis, narrative therapy, neurofeedback,
biofeedback, and many others have shown useful in studies, but are not
covered. Only visits to physicians for medications and sometimes the
medications themselves are covered. I have worked with many patients to
reduce chronic pain using these tools, and insurance has paid me less
than 10% of the time.
Success is irrelevant to the insurance industry because what matters is short term (quarterly) profit and loss, not people's health in the long-term or even long-term cost-savings. Take my patient Mary as an example. Mary was referred by a mutual friend to work with me to reduce pain and restore functioning. I worked with Mary for eight sessions and we started making progress toward reducing medication and reducing pain. Then Mary heard from her insurance company that they would not pay any more than 8 sessions. Because we were making progress, I offered to work with Mary for whatever she could afford, even if it was only $5 a session. She declined saying she only wanted to do what her insurance would cover.
Why do I see select patients for little or nothing? Because I need to feel effective. Within the constraints imposed by contemporary health insurance, rarely can I help people with chronic disease and suffering in a meaningful, transformative way. I have invented ways to circumvent this healing circles that are peer-led or relatively leaderless in which everyone helps everyone else and no fee is charged. It is the patients whom I see for next to nothing who are improving and reducing costs to the health care system. The ones insurance cover are not getting well very fast.
We should consider this in the health care
debate. Data is available for discussion. Numerous studies have shown
that 80% of primary care visits to health care practitioners involve the
ordinary suffering of daily life and not diseases that need treatment,
yet we throw pills and potions at these woes as if that is their
Health care reform will never work unless we find
cost-effective ways to address the ordinary woes of daily life and stop
attempting to medicate them away. This will not happen until insurance
coverage is expanded to include coverage of prevention and
non-pharmacological therapies. I would be thrilled if we moved toward a
system that rewards good outcomes.
If I were paid in accordance with people's getting better instead of compliance with a list of covered services, I would be much better off finacially and might find more effectiveness and sense of satisfaction from within insurance reimbursed services. That would be a novel experience I would welcome.