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Our Health System Is a Sick System

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Unhealthy behaviors such as smoking, overeating, or lack of exercise lead to chronic health conditions, and many patients wanting to make positive changes to their health may seek the advice of their doctor to do so. But our insurance payment system works against supporting people when they want to act in a healthy way, and 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? Yet 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 the number of visits is limited 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. For example, 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 levels of nicotine replacement products and prescriptions for curbing smoking. The out-of-pocket costs for these products are substantial and in themselves are 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. This is a sick system, not a health system.

Obesity is another major health issue. Over one-third 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 visits. Some insurers require an additional health issue such as 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. Again, a sick system, not a health system.

Opioid addiction — another huge issue. Medication-assisted treatment (MAT) is the best evidence-backed 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 for both the health insurer and society at large. The system is set up to maintain addiction not treat it. Once more, a sick system not a health system.

To me it seems that stigmas around certain conditions and prejudiced beliefs about those struggling with these 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 willpower. They feel they deserve any consequences that result. I do not share this view. Everyone is equally worthy of respect and dignity, and, if someone is working to change for the better, they should be given a hand in a compassionate and open-minded manner.

Ultimately, 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 as a whole 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. Single-payer is one such a solution, though there may be others. A single-payer system would see reducing unhealthy behaviors as a way to reduce costs in the longer term. Another option is a system where health systems and doctors were paid per member to keep them healthy, as opposed not a fee-for-service model. There are multiple options for reform that would be useful, but, at the end of the day, the system we have is not working.

Heather Finlay-Morreale, MD, is a board-certified primary care pediatrician working for Nashaway Pediatrics, a practice run by UMass Memorial in Sterling, Massachusetts. Her interests include mental health, mindfulness, and general well-being.

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