Why do insurance companies cover pharmaceuticals and surgeries, but seldom cover non-invasive n

January 23, 2024  •  Leave a Comment

Oh please, come on now… we all know there is no profit in treating healthy individuals. No business by definition will operate at a loss, let alone a lesser profit when so much money is left sitting on the table. Companies cannot stay in business for too long if they do not continue to grow from existing and new customers. Often people with chronic ailments are customers of drugs for the duration of their life span. US healthcare (truly sick-care) is a profit-driven system where it benefits from people remaining sick enough to require daily meds, but well enough to function in society. This is blatantly obvious where every fall medical experts warn us of the impeding “flu season” and a need to get vaccinated once again. Why not suggest instead or addition to this, that people take better care of themselves, get more sunlight (vitamin D) and exercise more? This is the time of year when temps drop, people bundle-up and cover their exposed skin or stay indoors more and thereby become even more Vitamin D deficient than they are normally anyway. Poor diet choices help fuel this deficiency also. Any qualified medical expert knows this and also know that Vitamin D levels are directly relevant to the immune system’s ability to function properly.

Similarly, look how difficult it is to find insurance policies that cover hearing aids, eyeglasses or dental treatments, as if these are not major health issues that often dictate our everyday tasks and responsibilities. If you need to be able to see better, hear better or eat properly, the former are all basic health requirements. Insurance companies need not cover these because they know most people will spend their own money regardless of if they can afford such luxuries as glasses, hearing aids or healthy teeth and gums.

So, how does this relate to the insurance companies? Insurance coverage decisions are a reflection of the current healthcare system’s business strategy, that is often in a state of constant change and adjustment. In today’s US health climate, there is a strong emphasis on pharmaceutical interventions and surgery in lieu of lifestyle modifications. Insurance coverage decisions regarding treatments with pharmaceuticals and surgeries are influenced by various factors of claimed cost-effectiveness, clinical evidence, medical guidelines, and the choices of pharmacy benefit managers who quite often base decisions upon profit over treatment effectiveness. It is important to note that insurance coverage decisions may not always coincide with individual preferences or beliefs towards certain treatments.

Surgical procedures may be covered if are seen as necessary, while chiropractic or physical therapy coverage varies based on upon perceived effectiveness of the specific condition being treated. I have had firsthand experience with this exact situation on many occasions. Nasacort for allergies is $26-36 or Flonase $14-21 with insurance, both covered but also offered me side-effects of anxiety and jitteriness. Over time, my body became accustomed to these medications and were no longer effective, but the side-effects remained. Insurance doesn’t cover herbs or supplements which I found to be quite effective for managing seasonal allergies. The cost for a microdiscectomy on a herniated disc can range between $20,000 and $50,000 which would be covered, but rest for a few weeks followed by chiropractic treatments at about $100 per session – 5 total, were not. Yoga sessions at $20 a class for about 20 classes, not covered. Both of these methods worked for those that I knew could fare better from options other than surgery. An osteopathic surgeon looked at me and shook his head in bewilderment when I declined to have a covered knee surgery procedure ($5000-$30000) for something I was able to manage through appropriate exercise, free of cost other than time and effort on my part. Some sufferers have no option but to have surgery or use pharmaceuticals, especially if they have suffered some type of traumatic injury.

Most of us know that chiropractic and appropriate exercises such as stretching, yoga and others are viable and effective methods of managing chronic pains. We also mostly know that insurance companies will not be covering these treatments because they generate little or no profit to their bottom lines. We know this but go along with it (cognitive dissonance) because most of us feel that we are helpless (learned helplessness) against a system that favors profits over patients. However, there is hope as we all have the ability to make our own decisions regarding our own health and well-being. I have personally trained and/or helped many of my students over the years to better manage chronic issues with their knees, lower back, neck, shoulders, headaches, allergies, anxiety, depression, PTSD and other ailments, through appropriate exercise and lifestyle modifications. Anecdotal experiences and academic studies abound if one cares to do a bit of research. I encourage all to perform their due diligence when it comes to pursuing and treatment, whether pharmaceuticals, surgery, chiropractic, herbs, physical exercise or any other methods of healthcare/self-care.

Several factors influence insurance companies’ decisions on coverage, including but not limited to the following:

  1. Regulatory approval of pharmaceuticals and surgical procedures – specific medicines and surgeries should go through a rigorous approval process by regulatory agencies, which can hopefully offer credibility to their usage in medical treatment. However, there has been an erosion in public trust towards regulatory agencies in recent years, as it has been proven that many are actually paid to perform research by the same companies that fall under their regulation.
  2. Clinical evidence – pharmaceuticals and surgical procedures often have established clinical evidence demonstrating their effectiveness in treating certain conditions, however as stated previously some research studies are funded by pharmaceutical companies leading to a conflict of interest. Some companies seek out specific academic institutions or scientist that agree with their particular goals (Jureidini, 2022).
  3. Quick fixes or a pill for all our ills – pharmaceuticals and surgeries can often offer relatively quick relief from symptoms, which may be desirable to both patients and healthcare providers. Time-consuming and effort to modify one’s lifestyle can require more time in order to gain significant results.
  4. Patient compliance – a certain percentage of patients might find it difficult or challenging to commit to making and managing lifestyle changes. Consequently, this makes pharmaceuticals and/or surgeries more practical, reliable and seemingly better options for particular patients.

There does seem to be a small but growing acknowledgement of the importance of lifestyle choices and relative modifications, such as managing a more nutritious diet, regular and consistent exercise, and taking some preventative measures towards various health conditions. Particular insurance providers might cover preventive services or programs focused upon encouraging healthier lifestyles. As this field of preventive medicine continues to evolve, there may be some amount of increased emphasis on adding some lifestyle interventions into healthcare coverage. In the meantime, realize that we truly are the architects of our own health, happiness and well-being.

Reference:

https://www.forbes.com/sites/sallypipes/2023/10/16/this-healthcare-reform-could-finally-bring-democrats-and-republicans-together/?sh=2b4ceb5b43cb

Jureidini, J. (2022, March 16). The illusion of evidence based medicine. The BMJ. https://www.bmj.com/content/376/bmj.o702

________________________

I teach and offer lectures about holistic health, stress management, qigong, tai chi, baguazhang, meditation, phytotherapy (herbs), music for healing, self-massage, and Daoyin (yoga).

I look forward to further sharing more of my message by partnering with hospitals, wellness centers, VA centers, schools on all levels, businesses and individuals that see the value in building a stronger nation through building a healthier population. I also have hundreds of FREE education video classes, lectures and seminars available on my YouTube channel at:

https://www.youtube.com/c/MindandBodyExercises

www.MindAndBodyExercises.com

www.Amazon.com/author/jimmoltzan

Mind and Body Exercises on Google: https://posts.gle/aD47Qo

Jim Moltzan

407-234-0119


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