Erik Goldman07.01.08
Insurance & Holistic Medicine: Uneasy Allies
How can these two entities team up to solve the healthcare crisis?
ByErik Goldman
Over the years, I’ve heard many holistic and naturopathic medical practitioners wrangle with the thorny question of whether greater insurance coverage would help or hinder the evolution of these approaches to healthcare.
Some contend that if insurance plans were more generous in covering holistic health services, practitioners would have a far easier time making a decent living, and the entire field of natural medicine would grow and flourish. Others warn that the insurance companies have an inherently corrosive effect on healthcare, and that increased growth fueled by insurance reimbursement would come at a sore price of greater overhead, increased bureaucratic hassle and a much more restrictive practice atmosphere.
Certainly the sorry history of mainstream medicine over the last 30 years of insurance domination would suggest that the business imperatives of for-profit insurance plans are often at odds with the desires and objectives of physicians and their patients. At the same time, it is clear that the steady stream of patients and payments flowing from insurance plans to MDs has been a major factor in keeping the conventional medical paradigm in its dominant socioeconomic position relative to alternative healthcare approaches.
By and large, the debate over insurance coverage of holistic medicine has been theoretical. Most insurance plans do not routinely cover anything related to nutrition-based medicine, herbal medicine, homeopathy, or most other dimensions of holistic healthcare. Sure, they’ll cover a limited number of chiropractic visits (a testament to the chiropractic profession’s ability to play politics), or limited acupuncture coverage for very specific conditions. But with few exceptions, the major insurance carriers have not embraced holistic medicine.
Insurers have been slow to cover much of what falls under the preventive healthcare banner. In part because the science has been variable. But an equal factor is a rather shortsighted actuarial logic that goes like this: If I, as an insurer, pay for all these preventive goods and services, it costs me money now. But you beneficiaries out there will probably change jobs, and with that, insurance carriers, over the next five to 10 years. So the money I spend now will probably only benefit one of my competitors. That heart attack you didn’t have because my plan paid for preventive medicine, ends up saving money for another plan, because odds are, you’ve changed insurers over the interim years.
There are signals that things may be changing, though. I recently attended the World Health Care Congress, an annual healthcare angst-fest sponsored by the Wall Street Journal and attended by Fortune 500 CEOs, heads of major insurance companies, federal and state healthcare policymakers, leaders of the big medical organizations, health policy analysts and all manner of blue-suit wearing, briefcase-toting bureaucrats. I’ve covered this meeting for the last five years, and a few very clear themes emerge from it.
Firstly, everyone…and I mean everyone….now acknowledges that the current systems are not sustainable for much longer. The cost of acute-stage care combined with the aging population and the growing burden of chronic disease will bankrupt Medicare and Medicaid, and seriously hobble the corporations that still cover their employees (a dwindling number, I must add). Unlike the Clinton healthcare reform era of the early 1990s, no one now expects that managed care plans will save the day. That’s been tried. It hasn’t worked. The large employers are especially disgruntled, and they’re starting to put pressure on insurers to change the way they do business.
Nearly all the pundits speak of the need to shift the focus away from acute care and toward comprehensive preventive healthcare. To hear their words alone, you’d think you were at a holistic meeting. The problem, of course, is that most of the fiscal juice in healthcare is on the high-tech, acute care side of medicine, and no one wants to give up their share of it. As one presenter pointed out, “All that excess spending everyone is complaining about is somebody’s profit.”
The system is crashing, though, because the employers are starting to push back. They’re the ones who end up footing the bills (along with the government), and they’re saying “No” to continued premium increases. In fact, they’re starting to use their massive purchasing power to push insurers to focus on prevention.
There’s a growing consensus among employers, insurers and policy-makers that the key to changing healthcare is in empowering people to take better care of themselves. I can’t tell you how many times I heard the terms “consumer-driven” and “patient-centered” at these meetings. Employers and insurers want to put more of the fiscal responsibility on individuals, and they also want to “enable” them via all manner of electronic support tools, to make better healthcare choices.
Corporations big and small are eager to keep employees out of hospitals and minimize sick days. They’re contracting with all types of companies providing “corporate wellness” and “disease risk management” solutions. The big insurers are flirting with all sorts of “health and wellness” programs, although most of these would strike seasoned holistic/natural living folk as fairly laughable.
Proper Representation
The problem is, our industry, our movement is never present at these meetings. None of the organizations representing either the natural products and nutrition industries or the holistic medical professionals are spending the time and money to get in front of the nation’s CEOs and its insurance managers. The holistic health and natural living movement has always been about individual empowerment, self-care, healthy choices and personal health responsibility. But we’re not represented at the Big Table, where the healthcare UberWonks—who are sudden champions of “empowerment”—are hashing out the future of healthcare.
Many health policy folks put great faith in the potential of “Health Savings Accounts” as tools for changing healthcare. These accounts allow people to put tax-exempt dollars aside for use on healthcare expenses, and are usually packaged with a low-premium, high-deductible insurance plan. While definitely not widespread, they are increasingly popular.
It is ironic, given all the HSA rhetoric about personal responsibility and freedom of choice, that people cannot use their HSAs to pay for nutritional supplements or holistic practitioner services. These are not, according to the law, legitimate expenditures. Even more surprising is the fact that our industry is doing nothing to change this.
I wonder why we consistently fail to stand up and make our voices heard? Is it simply shortsightedness? Lack of awareness? Failure to recognize that our industry is, and rightfully should be part of healthcare? Is it fear of the “suits” (as if our industry is not totally corporate at this point). Or is it a crisis of confidence, that perhaps these products don’t really deliver what we’d like to believe they can? If that’s the case, then regulators are right to challenge the industry’s marketing claims.
But if our approach to healthcare, and the products that support it, really do help people stay healthy—and I believe that on the whole, they do—then we need to stand up and say it. The nation’s corporate leaders are desperate for help on the healthcare front, and in principle, they’re asking for what the best in this industry, this movement, has to offer. There’s tremendous potential for synergy and growth by getting involved in the broader effort to solve the healthcare crisis.
Still, the question remains whether greater insurance involvement will help or hinder holistic medicine.
Greater Insurance Involvement:
A Blessing or a Curse?
Few physicians are better qualified to speak on this topic than Elson Haas, MD, director of the Preventive Medicine Center of Marin, a comprehensive, multidisciplinary holistic center north of San Francisco, CA. In his more than 30 years of holistic family practice, Dr. Haas has worked in nearly every type of business structure and setting outside of academia. He’s seen patients on a fee-for-service basis; he’s been paid by the hour; he has tried the “Barefoot Doctor” model, a sort of early-concierge plan in which patients paid a yearly “membership” fee; he has participated in conventional preferred-provider organizations (PPOs). His Preventive Medicine Center does take insurance.
He says it is possible to provide good holistic care within the constraints of insurance, provided you’ve got a strong team on the clinical side, an equally strong support staff, and lots of group activities for patients.
All the payment models have their advantages and disadvantages. But according to Dr. Haas, the economic model is secondary. The real key is for doctors to figure out their core practice philosophies, and their personal strengths and tendencies, and then do what they can to craft practice models that best support them. Insurance, he says, is neither inherently evil nor inherently benevolent. “Our core mission is this,” he says, “Let us serve as many patients as possible, with the best quality healthcare. In everything we do, we ask ourselves, ‘Are we serving people better by doing this?’”
Dr. Haas decided to take insurance simply because many of his patients could not afford to continue paying out of pocket. He acknowledged that insurance-based medicine tends to shorten office visits. Dr. Haas says he offsets this by making extensive use of patient education handouts, drawn from his years of research and his popular books, including “Staying Healthy With the Seasons.” “The reason we can do more in less time is that I have plenty of informational support tools I can give our patients. We don’t have to spend time repeating the same things day in, day out.”
Teamwork is also key. The Preventive Medicine Center of Marin brings together a well-integrated team of MDs, DOs, nurse practitioners, physician assistants, a chiropractor, a naturopathic physician, as well as practitioners of specific techniques like psychotherapy, nutrition counseling, massage and stress management. Though they have very diverse backgrounds, the practitioners are able to work well together because they all share the stated values of the clinic, and they are all willing to respect each other’s strengths and skills.
The other key time-saver for Dr. Haas is the Group Visit model, which allows Dr. Haas or one of his colleagues to teach important self-care skills to many patients at once. For example, Dr. Haas runs “Detox Groups” for patients undergoing cleansing protocols. This allows him to work with 20-30 patients at a time in a series of regular group meetings. The groups also provide participants with friendly peer support, and a forum for sharing their struggles and triumphs.
“We can help many more patients this way than if we were working with them individually, and they support each other through the process. It is very transformative.”
But Dr. Haas emphasizes that insurance-based medicine will only work for natural born multitaskers with a predilection for moving and speaking quickly. He stresses that doctors who really prefer a hands-on approach, who want to do everything themselves, and who like to spend a lot of time schmoozing with patients, will suffer under the constraints of insurance.
Grace Keenan, MD, an internist who directs the NOVA Medical Group, a four-site interdisciplinary practice in Loudoun County, VA, says that holistic doctors who want to take insurance had better be really good at coding and book-keeping, or be willing to hire people who are. Without a thorough knowledge of coding and meticulous record-keeping, insurance-based practice can be a losing proposition for doctors, not only from a fiscal viewpoint, but from a quality of care perspective, too.
NOVA Medical Group offers everything from walk-in emergency care, to medical spa services. NOVA also offers acupuncture, nutrition, stress management, and many other services, part of Dr. Keenan’s desire to give patients a one-stop health center. NOVA even has a gym, so people can implement the exercise plans their doctors and fitness counselors recommend.
She says she’s found it essential to create multiple revenue streams, some from insurance plans, others from the out-of-pocket, fee-for-service sector. The fee-for-service segments help to offset the time and cost-intensive holistic medical services and the discounted fees paid by the insurance plans. But again, the greater the variety of services a medical practice offers, the greater the demand put on the physicians in terms of management skill.
It is very early in the game to determine how insurance will ultimately affect holistic healthcare and natural medicine. But the issue will only increase in importance over time, as insurers and employers look for ways to stem the tide of disease and disability. It is my hope—a fool’s hope, perhaps—that the best and brightest from the natural products industry will get involved in the policy-making process, so that the core values of prevention, personal freedom and humanistic healthcare do not get lost in the bureaucratic shuffle.NW
Holistic Primary Care is holding its first conference, “Heal Thy Practice: Transforming Primary Care,” on October 31 through November 2, 2008, at the Westin La Paloma Resort in Tucson, AZ. The subject of insurance in holistic medicine is among the topics to be explored. Drs. Grace Keenan and Elson Haas are among the conference faculty. For more information about Holistic Primary Care or the “Heal Thy Practice” conference, visit www.holisticprimarycare.net or e-mail erik@holisticprimarycare.net.