A sick system not a health system

Photo by Richard Catabay on Unsplash

Many people have unhealthy behaviors such as smoking, overeating, or lack of exercise that lead to chronic health conditions. Patients may want to make positive changes for their health and seek the advice of their doctor. But our insurance payment system works against supporting people when they want to act in a healthy way. Some of these payment decisions seem rooted in prejudices against those suffering from certain conditions. 

Smoking cessation seems like something insurance companies would support. Fewer smokers means less heart attacks, strokes and cancers. How can you not support people quitting smoking? But – insurance companies do not pay for smoking cessation efforts in any meaningful way. In 2014 the Affordable Care Act mandated coverage for smoking cessation but the payment is roughly $20 and there are limited visits per year. So you cannot see a patient only for smoking cessation – you need to have another reason to code to get paid for the visit. In my practice I have a healthy young patient who wants to quit and is interested in varenicline or bupropion. This would take multiple office visits for management and counseling but unless I can find another code to use insurance will not pay more than $20. Insurers also have varying coverage of nicotine replacement products and prescriptions for helping curb smoking. The out-of-pocket cost for these products is substantial and is itself a barrier to people quitting. This is a clear example of not thinking of the big picture. Insurers are paying for the COPD or cancer from the smoking but not for the treatments to prevent the disease. It is a sick-system not a health-system. 

Obesity is another major health issue. Around ⅓ of children are overweight or obese. Helping a family change their lifestyle and make healthier choices takes time. Yet – I cannot bill just for obesity as a code for an office visit and get paid. Insurers will pay for asthma, allergies, a laceration, even an ingrown toenail, but not obesity. Nutrition counseling is covered to a variable degree and often limited in sessions. Some insurers require an additional health issue like diabetes before covering nutritionist visits. No insurer that I know of covers visits to a exercise physiologist or trainer. At best an insurer might give a slight discount on a gym membership. There is absolutely no support given to people trying to lose weight. A sick-system not a health system.  

Opioid addiction – another huge issue. Medication assisted treatment (MAT) is the evidence proven best method to get people off of drugs. Most major insurers have prior authorization requirements for MAT and limit coverage of these expensive medications. Patients can get oxycodone or morphine without a prior authorization but a patient trying to obtain Suboxone to quit a heroin habit will encounter a number  of roadblocks. Choosing to quit drug abuse is hard enough without having to fight your insurer for coverage. Substance use disorder is a disease and merits treatment as such. Treating substance use disorder properly with MAT reduces costs to both the health insurer and society at large. The system is set-up to maintain addiction not treat it. Again, a sick-system not a health system.  

To me it seems to some extent stigma about certain conditions and prejudiced beliefs about those struggling with the conditions are involved. Some people feel those who are obese or who smoke or who abuse drugs are responsible for their own problems and lack self-control or self-will. Some feel they deserve any consequences that result. I do not share this view. I feel everyone is equally worthy of respect and dignity and if someone is working to change for the better they should be given a hand up in a compassionate and open-minded manner. 

In all I see the insurance reimbursement system as more of a sick-system then a health-system. It promotes the status quo rather than health change. It also reflects the same biases and prejudices that society at large fosters. Wholesale reform to our system to focus on health and wellbeing is going to require a wholesale change to how we fund our healthcare. There may be other solutions but single payer is one such a solution. A single payer system would see the benefits to reducing unhealthy behaviors as costs would go down in the long term. Another option is a system where health systems and doctors were paid per member to keep them healthy and not a fee-for-service model. There are multiple options for reform that would be useful but a fee-for-service sick-oriented model is not working. 

Previously appeared in Doximity and KevinMD.

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