The truth about health insurance

About 99% of all prospective new patients who have ever called our office tend to lead off with two questions. 1) how much? and 2) do you take insurance? It annoys me to no end. Sure, they're fair questions and yes, some complementary/alternative medicine services may be recognized and (at least partially) covered by some health insurance plans. But there's more to the story. (Isn't there always?)

First, insurance sucks. Yes, I know it's expensive. That's why I haven't purchased a policy yet myself and when I do, it'll be major medical coverage only, because the return on investment for anything more is a joke.

Don't expect insurance to pay for everything, even if you're coughing up a grand a month on your family policy. This goes double if your insurance policy is less expensive. When your employer offers you a choice between plans, don't choose the cheapest policy and then complain that nobody will take your insurance or that it won't cover anything. You get (kinda) what you pay for. Choose the cheapest major medical policy and then expect exactly that: major medical. Then, pay your doctor for preventive stuff like you'd pay for anything else.

Your doctor is not a dick for not taking your insurance. Here's how insurance works: each year, insurance companies must not only turn a profit, but they have a legal duty to their stockholders to INCREASE this profit every year. If not, the board of directors of the company can be ousted and a new board voted in. Blame the shareholders and the system, not your doctor.

Here's what this increase in profits means: they have to cut corners--I mean COSTS, somewhere. During the last few decades, these cuts have come in several forms, mainly cutting reimbursement to doctors for the services they provide, and also cutting benefits out of your plan and redistributing them to higher-priced plans.

So why does it matter when insurance companies cut reimbursement to doctors? Don't they make enough money already? Well, yes and no. Sure doctors charge high fees. Having been through med school myself, I can tell you it's no cakewalk; that's why not everybody goes through med school. I can tell you that when we graduate with that license and title, we deserve it from what we've already been through. We can literally kill ourselves (or at least eat ourselves alive) going through school. Sure, it's a choice we made, but sometimes it turns out to be a little more than we bargained for.

Anyway, we put ourselves through this because of what the future return will be - we have a certain vision in our minds. The specific vision is different for each doctor, but almost all of us have one that we cling to going through school. We envision caring for patients in a certain way, a certain number of them per day or week, and taking home a certain level of compensation for the work we put in. We also begin to make decision early on that affect our overhead.

When we graduate and get started, we incur a certain level of overhead that includes building rent for office space, equipment, salaries, utilities, malpractice insurance, continuing education, and much, much more. Some of those expenses are "fixed" and won't change much.

We also begin to see a certain amount of income. But the catch is, that's variable. And what's more is, remember I mentioned that insurance companies have been cutting payments to doctors for their services? That means that when I do an ultrasound on a patient today, I make a certain amount of income. Next year, that number will almost always go down. It may not be by much, but it adds up if I do a lot of ultrasounds, and it also adds up each year as reimbursements are cut EVERY year.

What does this mean to you as a patient? Not much on the surface, as most of it goes on behind the scenes. However, you may notice your visits get cut a little shorter, or the doctor seem more hurried. Maybe the doctor is less familiar with your case because s/he wasn't able to spend any of his/her own time investigating your problem (hardly any doctor these days does that anyway). Maybe you had to wait a little longer in the waiting room to see the doctor. Maybe you had to wait several months to get an appointment with that doctor. Why? Because when you have lower reimbursement and thus lower income per service you're providing and you have to meet expenses that are the same or greater than last year, you have NO CHOICE but to make it up in volume. Since you have the same number of hours in a day that you had before and no more opportunity than that, and time is money, that means cramming more patients into the same workday. The lesser service you receive is a product of your demand for insurance coverage.

The truth is, health insurance was never meant to cover EVERYTHING. Yeah, I know what they told you. They lied. Seriously, they did. If health insurance covered everything and still remained affordable, they would operate in the red and go bankrupt very quickly. So do the math - they can't possibly cover much without making premiums astronomical (although many would claim they've done the latter). Expecting health insurance to cover your acupuncture, chiropractic, massage therapy, and nutritional counseling visits is like expecting your car insurance company to cover your oil changes and brake pads. It won't happen, nor should it. Those are normal maintenance expenses and every car owner should be able to shoulder them themselves. Health insurance operates the same way, or at least it should - covering you when you get into a major situation, but leaving the little stuff to you.

Here's the other part you may not realize. PAPERWORK. Every year in almost every medical office, there is a mind-blowing amount of money wasted on full time personnel just to fill out and file insurance paperwork. These folks sit in back rooms for 40 hours a week, putting numeric codes on paper, dotting every i and crossing every t, and they also sit on the phone, wrangling with inept insurance companies and their extensive phone menus and un-knowledgeable customer service reps. It's not the CSR's fault - most of them don't hang around very long, so most of them are new. And of course, their hands are tied behind their backs, crumbling under the weight of the bureaucracy that is an insurance company. I should know, I've had dear friends whose spirits were vacuumed away by these wretched companies whose sole goal in life is to suck in your premium checks but avoid paying anything out to anyone in benefits.

But that paperwork costs your doctor dearly, whether s/he does it him/herself or pays someone else a full salary (typically with some benefits) to do it. Many doctors are shedding this hefty expense (and the extra rent for the bigger office space to do this) and are all the happier for it.

I remember when my significant other saw a reimbursement schedule from one of the lesser-evil insurance companies. They were going to reimburse them a TOTAL of $24 for what added up to essentially a 15-minute service. That might sound like a lot, but it isn't, especially when you figure we spent $160k EACH to go through school. And that 15 minutes doesn't include the unpaid 30 minutes of paperwork that follows, just to get paid by the insurance company. Which doesn't include the 2 hours of waiting on hold when calling the insurance company just to verify a patient's benefits, nor does it count the entire workday to wrangle with said insurance company when the invoice we sent them comes back denied for absolutely no reason. Now, $18 doesn't look so great, does it? Divide that $18 by the total time invested and we made far less than minimum wage. Now figure that we did this for every patient. Yikes.

It doesn't just cost us, it costs you, too. Some people were so hell-bent on utilizing their insurance so-called benefits that they ended up paying MORE in just their in-network co-pay than they would have just paying out-of-pocket (without utilizing insurance). Yeah, it didn't make any sense to us, either. He paid $59 when he could've paid $55. Wow.

As a Functional Medicine doctor, insurance doesn't even have any codes for what it is I do. They don't really even recognize it or know what it is. FM has been around for 30 years, but that doesn't mean the insurance companies are paying any attention. Why should they, when they have no intention of covering it? And yet, people ask. Even knowing all of the information above and after having been told the following:

1) Insurance takes paperwork time, which takes away from your case
2) Insurance doesn't cover longer visits, only shorter ones
3) Insurance doesn't cover complete testing, only incomplete
4) Insurance doesn't cover appropriate treatments, only band-aid ones
5) Insurance requires codes that describe what's going on, but doesn't provide any such accurate coding

...it still doesn't always sink in.

Seriously people, it's time to wake up. Health insurance is a middle man that takes in more than it gives out. This means you always pay for more than you get. It's also SUPPOSED to be a simple safety net, like legalized gambling, to protect you from those major accidents/operations that could set you 6 figures in the hole overnight, or those genetic disorders that spell disaster and cost millions over the course of your lifetime. THAT is what insurance is for. Not your chiropractic adjustment, your nutritional counseling, your 1-hour massage, or your acupuncture treatment.