Why is the insurance model broken?
Here are my top three reasons the insurance system is broken.
Did you know that the USA spends more on healthcare than any other developed nation in the world? From the Center for Medicaid and Medicare Services (CMS) "U.S. health care spending grew 9.7 percent in 2020, reaching $4.1 trillion or $12,530 per person. As a share of the nation's Gross Domestic Product, health spending accounted for 19.7 percent."
1. Protocol based medicine not individual based care
2. CYA - 'cover your ass' model, protocols help to prevent doctors from losing their medical license
3. Disease management vs. healthcare
Regular doctors (MDs and DOs) learn about pharmaceuticals and procedures as the primary means of treatment based on disease type. It doesn't matter what dis-ease you have, healing happens in the same way. Regular doctors don't learn how healing happens in the body.
Regular doctors will prescribe you all the medications. And I get it because when I was 17, I was taking 10 prescribed medications. Now at 31 I take no medications.
At 18 I lost my health insurance, Medicaid. This was prior to the Affordable Care Act in the US. In this seemingly unfortunate event, I had to boot strap my way to regain my health. I could no longer afford my name brand medications so I just stopped taking them. I do not recommend this and encourage you to work with a licensed practitioner to help you get off your medications safely.
I also started to pay out of pocket for doctors that I wanted to see. I didn't start to get well until I did this. I know my journey is mine and not necessarily yours, but those of us outside the insurance system see this often!
Diseased Based Healthcare
You get diagnosed with acid reflux you get a proton pump inhibitor like Protonix or Nexium, Gaviscon for inflammation and Pepto Bismuth which isn't the worst medication (because bismuth deficiency is associated with H. pylori overgrowth), and Zantac an H2 blocker. You're now taking four medications and still not feeling better.
The disease model assumes one thing - you are having stomach acid in the wrong spot. So the stomach acid is the issue. There isn't another set of questions then asking but why is the stomach acid going up instead of down. The disease model doesn't actually tell us what's wrong because it could be any number of causes. The most common is low stomach acid or hypochlorhydria.
Protocol Medicine
You get diagnosed with an autoimmune condition and you get prescribed Humaria, the number one selling drug in the world. You get some side effects and head back to your doctor 3 months later because there was a waiting list. You now have a different issue, a skin rash. A few months later you start having anxiety and depression and head to the psychiatrist...And before you know it you are on ten medications.
Protocols are there not only by the insurance company but also to protect the doctors that are prescribing, if they follow the rules laid out by the insurance company they will be protected. They were just following the algorithm.
How many of you had this experience?
You are prescribed a certain medication and without any side effects. A year later you head to your doctor for a refill and your doctor says, "Oh, this medication is no longer covered by your insurance"(which hasn't changed mind you) and you get switched another medication in the same drug family and start having issues with it. Often times people do better with one medication over another due to our individual differences.
Why do insurance companies change annually?
Because they are profit driven and often patent related. If the drug company that had a patent on a certain medication that expires, often times they will change a small aspect of the drug to get another patent to have a more profitable medication compared to the one that no longer has a patent.
What about physical exams and protocol medicine?
This one is my favorite thing an insurance company dictates with protocol medicine. Doctors are too dumb to do a good physical exam. For example if you hurt your knee and the doctor determines it's not broken, it's likely a sprain or strain. You need an MRI to look at the soft tissue, not an X-Ray. However, the insurance company dictates, "Nope, we need an X-Ray first to determine it's not broken." What's the point of having a doctor in this case anyway? The insurance company's goal is to save money.
Direct Primary Care (DPC)
DPC is a model of primary care outside of the insurance model that gives you access to cash pay prices and often same day services. A man was telling me a story about his wife that use the DPC clinic in Grand Junction, CO. She had fallen and hurt herself and she needed an X-Ray. She was able to get in that same day, Friday afternoon and the results of the X-Ray was read by Monday morning. The treatment plan was determined in a few days. As opposed to waiting around for the results, if the doctor's office even bothers to call you.
When you work with someone outside of the insurance system, you are making an investment into your health where you get individualized healthcare. I know you and your family, you are not patient number 49 I see.
When you are well you are much less profitable to the 'healthcare' system, but you have the freedom to do what's in your heart instead of play on the merry go round in the sick care system that is keeping you ill.