optimal health: functional medicine and nutritional genomics

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AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: USING PRINCIPLES OF FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS PART 2 2012 freestanding MRI clinics that would route a portion of any insurance reimbursement for a scan procedure back to the referring physician. Under these arrangements, if your handshake was weak, you needed an MRI. These deals were found to violate federal anti-kickback laws and Stark laws applicable to Medicare and Medicaid patients. Brownlee’s review of data from several sources indicates that if you include imaging tests billed to Medicare by radiologists and nonradiologists, the average Medicare patient undergoes 3 imaging tests per year. Let’s say the cost of these studies (MRI scans, CT scans, PET scans, ultrasounds, x-rays, and so on) averages $200. There are some 50 million covered Medicare patients, so that’s roughly $10 billion in imaging costs for Medicare annually. The question then becomes, what percentage of these imaging tests were medically necessary? For purposes of addressing this question, let’s define an imaging test as medically necessary if something significant and actionable was learned from the test. For example, when a doctor has historical and physical evidence to cause legitimate concern about the possibility of multiple sclerosis (MS), whatever the scan shows will be useful. It may detect brain plaque consistent with MS, which would prompt the creation of a disease management care plan. It might also disprove MS for now, removing it as a cause for concern but prompting a search for ways to better explain the patient’s clinical situation. Yet many tests are ordered to rule a medical condition in or out and the results accomplish neither task. The results fall into the category of true but useless information that is of no medical value. Based on several estimates, roughly one-third of medical procedures can be considered medically unnecessary or useless. Eliminating medically unnecessary imaging studies alone for Medicare patients would save Medicare roughly $30 billion dollars. The Henry J. Kaiser Family Foundation reports that Medicare benefit payments for 2010 totaled $509 billion. By these calculations, Medicare could reduce its total annual payout by six percent just by denying payment for medically unnecessary imaging tests. Yet it’s not easy to simply issue a policy and collect the savings. Medical necessity is notoriously tricky to pin down ahead of the clinical decision. It’s most often in retrospect that doctors realize that a test result didn’t seem to matter one way or the other. From a clinical standpoint, it is almost impossible to devise a rules-based algorithm for medical necessity when the task at hand involves setting up diagnosis and treatment plans for unique individuals whose chronic illnesses represent complex systems biology interactions. If clinicians are not allowed some flexibility to follow their hunches here and there, then it will feel to physicians that medical resources are being rationed by cost-reduction rules and that invisible third parties control clinical judgment. We need to clarify in advance the difference between a good clinical hunch and a profit-play. We’re not there yet—but we have reached the point where affordability must take precedence by necessity. We need wiser ways to go about reallocating health care resources. Health insurance companies, on the other hand, want more flexibility when it comes to defining the concept of medical necessity. Otherwise, they argue, doctors and hospitals are free to pee on their legs and call it medically necessary. Doctors who use a clinical systems biology approach to chronic illness lick their chops at the thought of competing on an ability to turn 198
AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: USING PRINCIPLES OF FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS PART 2 2012 evidence into better clinical outcomes at less cost. Nowhere is our health care system more dysfunctional than in how it approaches the care and prevention of chronic illness. These dysfunctions trace to an overly costly routine for assessing the patient that, despite many tests and visits to multiple doctors, fails to produce a coherent systems biology-based way of explaining the patient’s condition. The result is not an integrative care plan, but a conventional rubberstamped care plan for a diagnosis rather than a unique person. Chronic illness is a self-perpetuating loss of functional integrity. The reasons for lost health beg to be explained, not just diagnosed. Most diagnoses are illness labels, not explanations. Preventing or treating chronic illness poses a problem that differs for each patient in question. In the long run, the most cost-effective way solve problems is to understand their causes as fully as possible before moving ahead with a onedimensional care plan. Over 125 million Americans have one or more chronic illnesses. For many of them, overtreatment is a problem, but the deeper problem is under-evaluation—or too little evaluation based on a clinical systems biology approach to chronic illness. In this context, under-evaluation does not mean that conventional doctors are doing too little testing to properly manage or prevent chronic illness. We just covered that. The problem is an over-reliance on diagnostic testing that does too little to help explain the root causes of chronic health decline, and the failure to deeply explore the patient’s illness narrative. Doctors are not doing enough listening and history probing prior to making their diagnostic testing recommendations. A systems biology perspective will help make doctors more effective in their work with chronically ill patients. Insurers don’t’ get this fact because it is in their interests not to get it. They already have doctors over a barrel with their policies, their way of defining medical necessity, and the way they enforce an outmoded process for the coding and documentation of procedures, known as the Current Procedural Terminology, or CPT system. The American Medical Association (AMA) handed the CPT system to the insurance industry in 1966. Ever since, insurers have been exploiting the AMA’s rules for how doctors must allocate the time they spend with patients if they want to get reimbursed. These rules have not kept up with the growing complexity of the physician’s cognitive task. When using a clinical systems biology approach to the chronically ill, meeting standard coding and documentation requirements steals precious narrative construction and problem solving time from both the patient and the doctor. Insurers benefit by making doctors to jump through irrelevant documentation hoops in order to justify their time, whereas the systems biology perspective allocates every necessary minute to explaining the problem before jumping to its solution. Then there are the vague diagnoses that turn patients into medicine’s second-class citizens, like chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. These nametags create a false sense of precision when all they really do is confirm that your pattern of signs and symptoms meet experts’ simplified criteria for a diagnosis. If you’re chronically ill, a diagnosis is a place to start, but you’ll want help solving the underlying systems biology puzzle using best working explanations for your particular illness experience. Anyone who runs a solution shop of any kind, be it medicine or motorcycle repair, will tell you that the path toward a workable solution relies on a solid understanding of the problem. Underevaluation is harder to grasp than over-treatment, 199
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