Is Functional Medicine Covered By Insurance?
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by Dr. Daniel
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Is Functional Medicine Covered by Insurance?
My clinic often receives calls from patients asking if functional medicine doctors are covered by insurance.
Chances are, if you are in a true functional medicine practice where your doctor is practicing in a functional medicine model of care (not a conventional model), the most likely answer is No, functional medicine is not covered by insurance.
But that doesn't mean you cannot use your insurance with functional medicine, it just depends.
Truth is, there is no comprehensive functional medicine health care insurance plan available.
Traditional insurance and what is covered, is largely based on the conventional medical model of care.
Conventional medicine is oriented toward acute care, the diagnosis and treatment of trauma or illness that is of short duration and in need of urgent care, such as appendicitis or a broken leg.
This means that only those tests, procedures and services commonly used in a conventional medical model (for acute and urgent care) will be covered.
It is also the reason why most conventional medical doctors never order tests that we typically need to identify the actual “cause of our health problems.”
Because traditional insurance (conventional medicine) isn't interested in prevention of disease or identifying the root cause of chronic health conditions, they only cover specific lab tests, procedures and services that allow for a potential diagnosis.
That diagnosis often leads to a prescription or medical procedure that is usually covered for urgent or acute care needs.
But if you're interested in a Functional Medicine approach to your healthcare problems – an approach that will ask “Why do I have a particular diagnosis?”, then most of the time coverage will be limited.
Is Functional Medicine Expensive?
Much of the perception about the cost of Functional Medicine is rooted in the illusion cast by our current sick-care, insurance-based, third-party-payer system.
Here's some perspective:
Today we face a tsunami of chronic diseases that will cost our global economy $47 trillion over the next twenty years and kill twice as many people around the world as infectious disease. [1]
Today, we spend more and more on healthcare, and yet we get less and less.
Today, the United States has worse health care outcomes and a lower life expectancy than almost every other developed nation.
Heart disease, diabetes, cancer, autoimmune diseases, digestive disorders, dementia, allergies, asthma, arthritis, depression, attention deficit disorder, autism, Parkinson’s disease, hormonal problems like early puberty and infertility – all cause endless suffering and are draining our financial resources.
Chronic disease now affects one in two Americans and accounts for 80 percent of our health care costs. [2]
Every year, for the past 75 years we have generated more research, created newer drugs and developed more medical procedures than ever before, yet the incidence of chronic disease continues to rise.
For example, Humira® – a popular drug used to manage autoimmune diseases such as rheumatoid arthritis and colitis – costs over $38,000 a year. [3]
And it’s price has gone up 100% since 2012. That’s expensive!!
Even more bonkers is the fact that many of our autoimmune patients can be successfully treated without these expensive immune suppressing medications.
Another example is getting the appropriate tests to understand what is happening in our body.
A comprehensive blood chemistry panel can range from $1500 – $2000 when billed to insurance.
Some insurance companies will cover parts of this test and others won't.
If you're insurance is really good, you'll have anywhere from 80-100% coverage.
This means that you could have an out-of-pocket expense, even using your insurance, of about $100 – $200 for comprehensive blood chemistry testing.
Now compare that to someone who doesn't have insurance, but wants to get the same exact comprehensive testing.
The out-of-pocket, private pay cost for the exact same testing is $400.
Let me repeat that… the exact same testing when done via private pay is $400, compared to billing insurance at $1500 – $2000. That's expensive!!
Considering monthly premiums and possible co-insurance, private pay testing for $400 is actually less expensive than having insurance!
Here's yet another example…
According to figures released by the Milliman Medical Index (MMI), the average cost of employer-sponsored PPO coverage for a family of four annually is now $26,944.00 compared to $14,500 in 2007. [4]
That’s an 86% increase in the last 11 years. Once again, pretty dang expensive!!
Then there’s the everyday stuff like surgeries, procedures and lifetime dependency on drugs – which are all incredibly expensive in terms of money, health, lost wages and lifestyle factors.
When you really begin to understand the economics of health, health delivery and the conventional medical system – you will also understand that Functional Medicine is downright affordable (and more effective) compared to the alternatives.
How Functional Medicine Saves Money
As healthcare costs become increasingly unsustainable, it's apparent the heart of the problem is conventional medical disease management versus Functional Medicine disease prevention and reversal.
Rather than identifying the root causes of underlying health problems, patients with chronic health conditions are often encouraged to follow costly, lifelong medication regimens and hope for occasional days of freedom from their symptoms.
Functional Medicine offers the potential for achieving unprecedented levels of health restoration and financial savings.
By uncovering and addressing the underlying causes of the common conditions that afflict a growing number of people – autoimmune diseases, diabetes, and digestive issues, to name a few – Functional Medicine brings the potential to liberate patients from their dependence on costly medications that are not designed to address the root causes of their disease.
In addition, Functional Medicine practitioners are not bound by insurance limitations of analysis. This means that functional medicine doctors are able to order the appropriate tests that will allow for the identification of health problems before they become full blown diseases.
Typically, a 15- to 17-year gap lies between scientific discovery and its implementation in the practice of medicine.
Functional Medicine practitioners dramatically reduce that gap by using solid scientific foundations to translate breakthroughs in scientific understanding into clinical practice in real-time.
As a result, Functional Medicine practitioners are early adopters of innovative knowledge and practices.
The combination of scientific rigor with patient-centered pragmatism achieves superior results in many cases.
A number of Functional Medicine patients have experienced resolution of illnesses that were thought to be untreatable in conventional practice.
How Much Does it Cost to Work with Dr. Daniel?
Functional Medicine Membership
First, Dr. Daniel offers a Functional Medicine membership that is highly affordable.
This membership includes all of your lab orders, lab interpretations, treatment planning, health coaching and consults for one low monthly fee.
Insurance/HSA/FSA
The membership doesn't include fees for lab testing, but he does utilize insurance, HSA and FSA accounts when appropriate.
In some cases, your HSA and FSA will cover the functional medicine membership.
Generally speaking, a comprehensive blood chemistry panel is needed to begin and 80-100% of that particular panel is covered by insurance.
If you don't have insurance, then Dr. Daniel contracts with local and national labs to get discounted rates on lab testing that ranges from $89 – $400 out of pocket.
Therapeutic Order of Care
Dr. Daniel follows a therapeutic order of care.
This is a concept in which the doctor always recommends the least expensive, least invasive course of action before moving on to more expensive, invasive measures.
Dr. Daniel also suggests and/or requires minimal follow up testing, if any.
Virtual Visits (Phone or Video)
All virtual visits are included in your membership. Some patients need to be seen more than others, but you are in charge of how often you want to have a consult.
The good news is that you don't pay extra for these visits because it's all included!
Treatment
Both cost and treatment are heavily dependent on the person.
Dr. Daniel and his team always opt for the most minimal, yet effective treatments, and his goal is to get you to a point where you no longer require treatment as quickly as possible.
Our care is consistently less expensive than the majority of functional medicine care.
This is because we don't have a goal of making money of testing or supplements.
Rather, we place special emphasis on reducing the costs of lab testing and ongoing treatment often found in other functional medicine environments.
References
- https://www.reuters.com/article/us-disease-chronic-costs/chronic-disease-to-cost-47-trillion-by-2030-wef-idUSTRE78H2IY20110918
- https://www.cdc.gov/chronicdisease/about/costs/index.htm
- https://www.nytimes.com/2018/01/06/business/humira-drug-prices.html
- http://www.milliman.com/uploadedFiles/insight/Periodicals/mmi/2017-milliman-medical-index.pdf
