Unnecessary Health Care Services




When President Clinton addressed Congress regarding universal health coverage, he focused on selling points such as security, simplicity, savings, choice, quality and responsibility. These were among the key words that I remember from watching his masterful performance. I was especially attuned to his mention of the twin concepts, of unnecessary service and medical fraud. These concepts have become increasingly important reference points in the past decade as private and public health insurance plans have quickly replaced our previous fee for service and combination public hospital and medical charity system.

I recall no great concern about unnecessary service and fraud in my previous 38 years since medical school graduation. Of course, like all doctors, I was aware of medical faddism and quackery and I saw heroic figures like Andrew Ivy and Wilhelm Reich go down ignominiously for that which they sincerely believed but couldn't quite prove. Despite the relatively few cases that we heard about, it seems that quackery laws became quite formalized, particularly where cancer treatment is concerned.

In California the state Medical Association sponsored a Cancer Quackery law about 20 years ago, which makes it illegal for anyone to make claims of benefits or to treat cancer using vitamins or herbs, such as red clover and apricot pits, which contain laetrile. I know of a few physicians who were disciplined by the state board or expelled from hospital staff privileges because they offered vitamin C therapy, particularly intravenous treatments, even though it was for general health benefits without claims of cure.

Nutrient therapy has long been construed as a form of quackery. It does not surprise me that private insurance companies and government programs, such as Medicare, do not cover nutrition or prevention. Nor do they cover alternative methods in general. The key word for covered services is "prevailing." If a treatment is considered to be prevailing, i.e. accepted by the medical establishment then it is likely to be covered. So far, nutrition is not a prevailing form of therapy. That may come as an unpleasant surprise to you.

Sometimes a doctor's life brings pleasant surprises. I had treated an elderly man for his Parkinson's tremor about 10 years ago and his renewed ability to participate in everyday life made such a favorable impression on his family, that I eventually consulted his wife, his daughter, his granddaughter and his infant great-grandson. The granddaughter and her infant son were both chronically ill with recurrent infections and doing so poorly that her mother arranged for them to visit San Francisco especially to consult me.

All went well, but then for the past 6 years I had no contact with this family. I felt a little uneasy about their absence until recently the daughter, Shirley, returned with questions about menopausal symptoms. I had almost forgotten about her own daughter's few visits and so I was startled when she credited my treatment with having saved Nancy, her daughter's life. Encouraged by that news I reviewed the case records. If the results were so good, how could I have such a hazy memory of the case?

The answer was very simple: I had only seen Nancy for three visits and a follow-up telephone consultation. She had recovered. No news can be good news and it is often that way in medicine: patients don't call back when they are feeling well. It takes a crisis to force us to call the doctor. For that reason alternative medical service is unlikely ever to be a major burden on the health insurance system: it is aimed at prevention and chronic disease, not (yet) at acute care.

On the other hand, my correspondence with her health insurance company was more extensive than my work-up for her medical problems. And the issue that stood out was "unnecessary service." Was it necessary that I treat this patient at all? On that question rides a good part of the future of medical practice in the United States. Who decides what is necessary when it comes to health services? The doctor? The patient? The insurance company? The government? In this case, I'll ask you to decide.

Nancy was 22 years old at the time, had a 2-year-old son and had been sickly since her son was about six months old. For the eight months before consulting me she had episodes of sore throat, 103º fever and bronchitis. Antibiotics had been prescribed for three of these episodes and were required almost half the time just to curb her fever and cough. But she was feeling more and more tired and weak and she had persistent sore throat and cough. Lately she got a new symptom, vaginal yeast infection, possibly as a complication of antibiotics, or more likely due to weakened immunity.

As practicing Scientologist, she was attempting to be "Clear" and therefore she scrutinized herself for psychological causes, which she believed must play a role. Her self-confidence was badly shaken. She followed a low fat diet and took vitamins at the advice of Scientology practitioners but had lost 15 pounds in weight and was beginning to look obviously emaciated and sickly.

On physical examination she was 5'5" tall but weighed only 99 pounds. She was not febrile but her heart rate was 84 beats per minute (normal is 60 to 78). There was an exudate of pus on her swollen right tonsil and her right eardrum was slightly inflamed. The lymph nodes under her jaw were tender and swollen but the laboratory results were not alarming. The white blood cells numbered 6200 (normal range is 5 to 10 thousand) and were of normal cell distribution. The multiple chemistry panel was entirely normal. Stool analysis was free of parasites and yeasts and showed no sign of malabsorption. Blood levels of vitamins were sub-optimal for fat-soluble vitamin A but not carotene or vitamin E. The blood mineral panel was low in manganese, zinc and magnesium. Amino acids were high in leucine and valine and low in threonine and histidine, a pattern often seen with infection. Early phase antibodies (IgM type) to Candida Albican yeasts were present in her blood.

A regimen of therapeutic nutrients designed to correct her deficiencies was quite successful. Potassium iodide applied to her tonsil cleared away the purulent exudate immediately. She reported a 90% improvement within two weeks; however the white blood cell count increased, up to 8500, and vitamin A decreased by over 15%, despite supplementation with 120,000 units daily for two weeks. This is a paradox, a decrease of blood levels in the face of megadose intake and it dramatizes the fact that she was actually more deficient in vitamin A than it appeared at the initial testing.

I prescribed an additional two weeks of vitamin A supplementation. And this time her serum level increased by 35% over the initial level and her white blood cell count returned to normal (5300). She was well enough to return to her home state, where she continued taking carotene but not vitamin A (I had warned her about the danger of fetal damage from vitamin A if she were to become pregnant.) She called a month later with a sore throat but this cleared without antibiotics after another 10 days on vitamin A and self-application of iodide. Because I feared she might have chronic infection locked into tissues beneath the tonsil, I referred her to an Ear-Nose-Throat specialist and a tonsillectomy was performed. End of case history: a speedy and complete recovery, in which targeted nutrient therapy prepared the patient for successful surgery.

The surgery coats were paid by her health insurance company. No problem. Nutrition did not fare so well. Here is a section of the letter that Nancy received from her health insurance company when they denied payment on 95% of her medical expenses with me: "It appears that your expenses were for vitamin therapy. Vitamin therapy is considered preventative care. Under the exclusions and limitations section of your policy, it is stated that covered expenses will not include, and no benefits will be paid for any charges incurred for routine preventative care, including physical examinations. Therefore, there are no benefits payable on the aforementioned expenses."

I responded to the insurance company: "It is inconceivable to me that any responsible medical authority would consider the treatment of documented vitamin and mineral deficiency to be merely "preventive". They ultimately paid token additional benefits, far less than the case deserved.

Unnecessary services are a critical cost-control factor. By excluding services, administrators can selectively cut costs of their insurance plan and, indeed, this is what has happened, not only to preventive and nutrition-related services but also to a number of other promising therapies: electrotherapy, chelation, acupuncture, hypnosis and herbalism. None of these is usually covered by insurance

Health care already costs an average of $3000 per capita in this country. The lifetime medical costs of all Americans come to $225,000! The health care budget consumes almost a trillion dollars annually. I am certainly not arguing against economies and controls. As you will see, I am arguing for medical freedom—for both doctor and patient. The best predictor of what is to come is reflected in the present policies of Medicare.

I received a letter from a Medicare Special Investigations Unit. Their computers detected a variance in my practice and they wished to remind me that Medicare does not pay for nutrition-related or preventive services. It is not clear whether the government wants me to stop providing these services. If so, I must either fight the government or possibly retire from practice. In either case my patients lose access to those nutrition and prevention-related services that are called "orthomolecular." This is a loss of personal freedom to all concerned.

I am not recommending that the government should have to pay for all medical services. I am only making a case for the doctor-patient relationship as the best means of deciding upon the treatment and the fee. Unfortunately medical freedom was left out of the bill of rights. Dr. Benjamin Rush, one of the founding fathers, had lobbied vigorously for such an amendment, but it lost. The right to privacy, a constitutionally guaranteed right, ought to protect the doctor and patient, just like any other competent, consenting adults engaged in any licit activity.

Read the following two paragraphs from a letter that I have received from my Medicare "special investigator" and see if you still feel comfortable about medical freedom in America.

"Federal Medicare law specifically excludes from coverage items and services which are not medically reasonable and necessary for the diagnosis or treatment of illness or injury... a coverage determination is based upon treatment/procedure's general acceptance, by the professional medical community, as an effective and proven treatment for the condition for which it is being used. Medicare will make payment only when a service is accepted as effective and proven."

.."Fraud and Abuse under the Medicare Program defines fraud as: knowingly and willfully making or causing or to be made any false statement or representation of a material fact, in an application for a Medicare benefit or payment, or for use in determining the right to any such benefit or payment; … or to receive benefit when none is due."

Penalties for violating the rules run as high as $25,000 and 5 years in federal prison. Luckily for the public, penalties apply only to the physician, not the patient. My concern is that a physician might be charged with fraud and be subject to criminal penalties when he or she was merely practicing good medicine according to his best knowledge and conscience. By billing a service as medical, one is subject to an investigator's opinion that the service was not medical but nutritional or preventive, and therefore ineligible for Medicare payment and therefore subject to penalties as Medicare Fraud.

As far as I know the rules have not yet been put to the test. You can bet that the first case will be highly publicized and, if the physician loses, he will be publicly humiliated, fined and possibly jailed. Even if he wins, he will probably be bitter and bankrupt from the legal expense. Not exactly a win-win situation for anyone. Ben Franklin summed up his view of political zealots in his magazine, Poor Richard's Almanac, 200 years ago:

"There's many men forget their proper station
And still meddling with the administration
Of government; that's wrong and this is right,
And such a law is out of reason quite;
Thus, spending too much thoughts on state affairs,
The business is neglected, which is theirs.
So some fond traveler gazing at the stars,"

©2007 Richard A. Kunin, M.D.