What Goes Missing in Insurance-based Healthcare (And What To Do About It)

In the United States, we have traditionally look at insurance-based healthcare as the gold standard for receiving healthcare, relying on using our insurance to pay for outpatient visits with specialists and primary care providers. This has been evolving as insurance premiums continue to rise along with deductibles, where individuals and families are finding themselves having to spend more out of pocket for routine, essential care. But even with these changes, many people continue to utilize their insurance.

Using health insurance has its benefits. People are typically not paying the full cost of their medical visit. Upon meeting certain criteria, expensive new interventions such as transmagnetic stimulation (TMS), immunotherapy, and chemotherapy can be covered. This access can be life-saving.

Health insurance reimburses clinics and clinicians for the time spent and/or the complexity of the patient seen. The more time spend reviewing the chart the day they are meeting with the patient, meeting with the patient, and documenting the visit typically results in a higher reimbursement rate which amounts to more that either insurance or the patient is required to pay.

Not Reimbursing for Depth

People are complicated and often in mental health, have complex histories that are important to understand. Insurance does not pay clinicians for cognitive labor on its own though we can try to capture it for same-day billing by adding the time spent reviewing the case earlier that day.

When clinicians are working in more complex and integrative areas of medicine, it can be harder to capture the additional cognitive labor of synthesizing symptoms and histories while reviewing the existing research literature outside of the actual 30 minute visit. The health insurance payment model simply isn't designed to see it or value it. It was designed for discrete problems and not systems thinking which creates limitations that can negatively impact both patients and clinicians.

This is what makes practicing functional and integrative psychiatry so challenging to practice in an insurance-based system. The reality is that a significantly greater amount of cognitive labor and detective work is spent in trying to understand complex, interconnected chronic symptoms in this pratice approach. Treatment plans are often lengthy, complicated, and require high touch, high communication that simply is not able to be captured through insurance reimbursement. This is why you see so many functional and integrative medicine physicians practicing "out of network" and only accept cash or out of pocket pay rather than working in large systems, accepting insurance.

Diagnosis Inflation

We can also look more closely at diagnosis inflation, which is the idea that patients end up carrying more and more diagnoses over time and there is an expansion of who qualifies for a diagnosis. Diagnosis inflation is more prevalent in insurance based healthcare because diagnoses are the currency for health insurance. They are billable and therefore, incentivized. Diagnoses can serve important roles and guide not only treatment but research and communication as well. They can validate suffering people experience: this can be powerful. And, they can lead to the over-pathologizing of human experience, constaining people and putting unnecessary limits on what people think they are capable of in life due to having a certain diagnosis.

What This Means

What this means is that the health care system (and therefore, the health insurance system) rewards discrete and definable interventions. But complex patients require time, synthesis, and uncertainty. There is a mismatch and that helps explain why we see the shortcomings of conventional healthcare for individuals who have symptoms that involve multiple organ systems and are overlapping. People who don't always present with one clean diagnosis or one treatment. People who have hormonal and psychiatric overlap, chronic inflammatory states, neuropsychiatric symptoms, or medication sensitivities. The result is often multiple siloed diagnoses and fragmented care.

I think it can be incredibly frustrating for both patients and clinicians. We have to remember that there are significant structural limitations contributing. They systems do not give clinicians enough time or space to do this work well.

What Clinicians Can Do

1. You can leave the system and work outside of the insurance-based model. This gives you greatest autonomy but the trade-offs include being less accessible from a SES lens.

2. Contain the cognitive work: Use time-based billing to account for the time spent reviewing the chart that day and shift away from purely problem-based billing.

3. Name the limitation with patients. "This is important and deserves more time than we have today".

4. Be aware of why and when you are adding diagnoses to a patient's chart and the implications of these diagnoses to the patient.

5. Help build care pathways for complexity. This already exists for diabetes management, oncology, and primary care behavioral health integrated clinics. These models have team-based care rather than relying on 15-30 minute individual visits. They can successfully help prevent hospitalizations and improve patient outcomes. In psychiatry, we have opportunities to expand into more complex psychiatry tracks such as an advanced depression or a neuroimmune track. It's important for healthcare systems to recognize these models are more expensive at first but are cost-saving and make care cheaper over time.

6. Advocate for payment model innovation. This involves more health insurance paying for outcomes and the value provided rather than simply fee-for-service. We might see more healthcare systems use a hybrid payment model where more complex and integrative medicine-based care is optional and available in a cash model alongside using insurance for standard care. This is not necessarily equitable but also a reality that some healthcare systems are exploring.

I welcome your thoughts and comments!