I have shared my opinions a few times when it comes to alternative and complimentary health care (CAM). My major gripe with them is calling something a treatment or cure with no supporting evidence (or worse, lying about the evidence). But, CAM has done a much better job in creating a empathic relationship with the patient than evidence-based medicine.
I want to pivot and speak about one area of concern in evidence-based medicine or what some call “western medicine.” Again, this is one single critique point, not any type of comprehensive examination of the whole enterprise. While I’ve had my own challenges with my healthcare, this is really not about me personally.
I am a story teller. But I try very hard to be honest and to tell the truth. I do cherry pick stories, often the worst of the worst, just to illustrate a point. That’s precisely what I will do here.
In my previous life, I was a headache specialist and for a while, owned my own headache specialty clinic. In many regards, the clinic was very successful, full schedules every day, drawing patients from six states and four countries. We had had praise from our patients and I think we gave them excellent care.
Business Side of Medicine
While I was not naïve when it came to the medical-business side of healthcare, it became a real eye-opener as an owner. We were successful as a clinic, we were a complete failure as a business. For the last six months of business, I took no salary, and came close to losing my house. The reason? We could not get paid for the services we rendered.
There were several ways that we failed to collect fees. We had some patients who gave us false insurance information (that’s another story) and ran up huge bills and never paid a penny. But the real crux was the low payments by insurance companies.
When I opened the door, I wanted to see all patients. Soon, I learned the hard lesson that Medicaid, and some situations Medicare paid below the cost of seeing a patient. For example, I figured my hourly cost for running the practice, not including my own salary, was about $120 per hour. This included the salary of my employees, rent, insurance, and etc. Medicaid paid us at a rate of about $40 per hour and Medicare, about $60-100. So you can see right away, this business model doesn’t work. Also, medical business are far more expensive than a normal business like a hardware store. We worked in a very lean way, yet, it took two full time employees to manage the paper work of insurance companies. We had to pay $20K per year in malpractice premiums and then there are many other expenses.
But then comes the way that commercial insurances reimburse for services. We are far removed from the days when a medical practice could roll in the dough with minimal effort. Insurance companies have turned the screws tighter and tighter, requiring more and more paperwork to prove you did the work (which adds the cost of the employees) and then pays less and less.
The poor headache patient has been discriminated from day one. It is for two big reasons. First, it is a disease that affects women twice as often as men. Secondly, it is invisible except for the expressions and stories of the patients, and now with some very complex imaging research. It is easy for insurance companies and providers to dismiss a disease that you can’t see, especially a disease that mostly affects women. Now I will give one of two stories to illustrate this point with commercial insurances.
The Montana Martyr
I had a patient once, a really nice man, who his family drove him 700 miles from Montana for care at our clinic. He had already been seen at about 20 clinics, including several headache clinics and the Mayo Clinic, where I used to work. Yet, he suffered from a very complex headache disorder that kept this hard working farmer in bed as an invalid for over 10 years.
I studied his chart, about 400 pages of it, in advance and knew we needed to set aside 90 minutes for the visit. When he arrived, his sons almost had to carry him into my office. They had three large boxes of files, which I had not seen. To make a long story short, I spent over two hours with him, and he needed every second of the time. I was trying to find something to change his life. He was to the point of committing suicide so my intervention was to be a life-saving measure.
After seeing him and documenting everything we did and the very high level of planning for his care, especially knowing he lived so far away, I billed the insurance company, based on time, for 2 hours. This was 30 minutes less than what I actually spent.
I got a letter from the insurance company a month later. It was a very harsh letter. They were going to pay $0 for the visit because I had bill an outrageous time, of 2 hours, for something as simple as a headache. I will remind you that I clearly documented all the prior treatments and the severity of the disease. I had submitted my own records, which were about 10 pages. But not only were they not going to pay me for my time and the visit, they had turned our clinic over to the state to be investigated for fraud. This cost me many nights of sleep and we had to spend many more hours on his case just to not being fined for fraud. The insurance commissioner finally let it go because of our good documentation, however, the insurance company never paid us for that visit or his follow up visits (via telemedicine). While this story might be cherry picked, a less severe but same type of problem, happened with most of our patients. The insurance companies pressured us to spend no more than 15 minutes with a patient, no matter how severe and complex their headaches were. The do this by a payment fee schedule that drops for each additional 15 minutes you spend. While the first 15 minutes is paid at A, then 30 minutes isn’t paid at 2 x A, but more like 1 1/2 x A. And then 1 hour is not paid at 4 x A but maybe 2xA. This is one reason that the five great headache clinics that were here when I moved out 16 years ago, all folded but one. It is due to low reimbursement for this disease.
I lobbied the insurance companies in behalf of my patients. I met with the Vice President of what was then Group Health. He had been a doctor in a previous life. After I presented how terrible of a disease headache can be, he had the audacity to say, “Headache, isn’t that what Excedrin is for?” Then he gave me this horrible, and heartless grin. Group Health’s failure to pay for over 100 visits was the death nail to our clinic.
One Compromise Medicine Makes
Now, I want to tell another story, one to illustrate, not more bad things about insurance companies, but how western medicine has, sadly, reacted to this toxic environment.
As my clinic started to struggle during its fourth year, I began grasping at straws for ideas to save it. I loved my patients and wanted to do everything I could. But like I mentioned, I had already stop taking any salary, so I was working 60+ hours for free. It was an unsustainable situation. I sometimes wonder if that period of extreme stress was what bred the cancer in my marrow. I started to see a mental health professional to help me.
It was so painful and stressful that the following day, after I closed my clinic, I flew to Malta alone and lived in a cave for a month. Seriously. Denise joined me after two weeks. It was 10 feet from the Mediterranean and a great coffee shop. A great place to decompress . . . and to finish my (not so well written book, due to the circumstances) Butterflies in the Belfry. But, to my good favor, I was able to connect with N.T. Wright (Anglican Bishop), who was also on “holiday” but in France. He was very kind to read my manuscript in two days, and his wife did as well. He gave me some pointers for clarification. I was lucky because he said he had such requests daily but never had the time. But I digress.
Now to my next story. It is extreme, but true. It is to illustrated this point of the bad choices some practitioners make to survive in this new insurance environment.
First do No Harm . . . Unless it is Lucrative
A few months before I closed my clinic, I heard about a nurse practitioner who also owned a headache clinic in another part of the country. The two of us were the only non-physicians in the country, who owned headache clinics. However, she was much more successful than me and I wanted to know how she did it.
She told me these “tricks” to survival. “Mike” she asked, “how many procedures do you do in a day?” (In headache work, a procedure are things like nerve blocks or Botox treatments.)
“Uh, maybe two.”
“There’s your problem. I do twenty.”
“Wait a minute, how do you do twenty procedures per day?”
“Well, I see thirty patients, 10-15 minutes each, and I do a procedure on most of them. I have two MAs that help me.”
“What kind of procedures?”
“Mostly nerve blocks.”
“But I don’t have that many patients that could benefit from such a procedure. The research is iffy about the long-term benefits and could cause more harm.”
“Doesn’t matter. This is about survival for our clinics. I couldn’t care less if they need a procedure, but I’m telling you that it doesn’t cost any more for you to do a procedure, but an insurance company will pay you double.”
Now don’t get me wrong. Don’t think that everything you doctor wants to do for you is about him or her getting the most money. I think that is an uncommon motive. But I also heard this same message (about doing procedures whether the patient needs it or not) based on the money you will get when I attended procedure workshops at national conferences. But this is the dark side of medicine. I have talked to headache providers during conferences in Europe who work under national healthcare systems, and thought such things, as doing procedures based on reimbursement was absurd and immoral. I agree.