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    Laurence Kinzler, MBA, FACMPE, FHFMA
    Functional medicine is a medical discipline that promotes a customized and patient-centered approach so that patients and practitioners can work together to address the underlying causes of disease and promote optimal wellness.

    Functional medicine practitioners attempt to address the root cause of disease rather than concentrating on treating the symptoms. This concept manifests itself in management of chronic conditions, such as diabetes, kidney disease, fibromyalgia or lupus. Chronic diseases are responsible for seven of 10 deaths in the United States each year, and treating people with chronic diseases accounts for most of our nation’s healthcare costs.

    Functional medicine is distinguished from the conventional medical model that identifies a specific disease state and applies a standard list of treatment modalities or options. Traditional, Western medicine focuses on curative measures to treat an existing problem. Functional medicine prescribes that rather than attempting to suppress symptoms, appropriate management of the symptoms serves to address the underlying causes.

    For example, a patient has high cholesterol. The provider will prescribe a statin that generally reduces the patient’s cholesterol level. Functional medicine practitioners endeavor to identify the root cause of the patient’s high cholesterol and promote options such as diet and other modalities to fix the high cholesterol rather than suppressing it. Functional medicine does not necessarily ignore common diagnosis and treatment plans, but may also prescribe a broader range of therapies, such as dietary interventions, supplements, lifestyle changes and stress management.

    Functional medicine providers must adapt to the differences from traditional medical care delivery to be reimbursed properly for their services. The current insurance paradigm ignores the fact that chronic diseases are often driven by genetics, hormonal balance, environmental exposures, nutrition, lifestyle and other factors, all of which are not easily subjected to a specific diagnosis and a specific treatment protocol that is compensated by insurance as payment for a specific service provided.

    The functional medicine focus is on prevention: discovering the root cause rather than treating the symptom(s), and helping the body to heal itself. This creates a mental shift — it changes the diagnosis and treatment paradigm. Functional medicine focuses on individualized, science-based care that addresses the cause of complex, chronic disease. It’s based on the premise that chronic disease is almost always preceded by a period of declining function in one or more body systems. Functional medicine promotes the concept that restoring health requires reversing, to the extent possible, the specific dysfunctions that have contributed to the disease state.

    Functional medicine also provides an interdisciplinary approach to managing the patient. Various nonphysician providers, such as chiropractors, nurse practitioners, physician assistants and dieticians may also be certified by the Institute of Functional Medicine (IFM) as functional medicine practitioners, though this certification is not sanctioned by the American Board of Medical Specialties (ABMS). Medical doctors and osteopaths may be boarded in an ABMS discipline and pursue IFM certification.

    A significant challenge for adopting functional medicine is that its practice does not lend itself well to fee-for-service reimbursement. Insurance products, including federally funded programs such as Medicare and Medicaid, have been slow to reimburse for lifestyle medicine and expanded preventive strategies. Even if the functional medicine provider prepares claims to insurance companies for covered services, generally the time spent and additional protocols related to functional medicine are not reimbursed.

    The Cleveland Clinic adopted the concept and uses providers trained in functional medicine to provide better coordination of medical specialties and encourage treatment of the “total person” rather than depend on the fee-for-service payer system that maximizes the income-based volume production model. The clinic introduced a patient-focused institute that combines medical and surgical departments organized by specific diseases or body systems rather than by specialty disciplines. In this manner, data mining can be structured to eliminate duplication of services and provide a clinically consistent approach to managing a disease rather than fixing a problem.

    Clinical compliance with the functional medicine program design is imperative for patient well-being. Generally, financial models will necessitate a significant commitment by patients as many of the treatment modalities are not covered by insurance.

    The financial and operational options available to medical doctor practitioners of functional medicine are as follows:

    Insurance-based models: Functional medicine medical doctor practitioners may set up their practice in the same manner as other physicians, including becoming credentialed with a variety of insurance carriers; utilizing an appropriate billing system and EHR; and filing claims on a fee-for-service basis utilizing standard CPT codes and diagnosis codes (ICD-10) with payment received through traditional insurance fee structures. Physician offices will collect standard patient copays and deductible amounts based on the patient’s insurance coverage. Practitioners may also offer functional medicine modalities in which patients support and accept this type of treatment program. Generally, the additional functional medicine modalities will not be covered by insurance and will be subject to additional cash payments by the patient for services not otherwise covered by insurance. In addition, the standard, traditional, insurance-funded exams will likely be significantly longer, thereby limiting the number of patient visits by the practitioner. Functional medicine providers may charge a membership fee in addition to billing insurance. This may be accomplished by a fixed annual fee or by an upfront fee to cover the cost of the initial exam and a monthly fee for ongoing services.

    Private pay models: Private pay models are funded entirely by payments from patients/clients. Providers are not expected to file claims with insurance companies. This limits the patient base for the provider; however, it is likely that clients will be dedicated to the concept and practice, and highly compliant with care recommendations. Payment can be designed as an annual membership fee or an upfront fee with monthly payments. This does not preclude the patient from visiting another physician for primary care or specialist services covered by insurance. It is important that the patient carefully coordinates the care provided by the insurance-based physicians and the functional medicine provider.

    In this situation, it is probably less important that the functional medicine provider be a licensed medical doctor, as several non-MD provider specialists may be trained effectively and credentialed in functional medicine.

    Academic medical centers: Major academic medical centers are approaching functional medicine in their care delivery by creating departments based on disease structure rather than medical specialties. This offers a much greater level of coordination of appropriate patient care, whereby the focus is patient-centered, depending on the clinical needs of the patient rather than having to transfer and transport the patient to different clinical areas, such as medical, surgical, x-ray and laboratory. This promotes a continuum of services that treats the patient’s specific disease state and limits the possibility of duplication of services. As accountable care organizations and the patient-centered medical home concept become prevalent, more major academic centers and healthcare organizations may adopt this approach.

    Low-income and underserved populations: The functional medicine concept, with its approach to managing chronic diseases, presents effective opportunities for managing care in group settings for lower socioeconomic populations or those who may otherwise not be able to easily access care. The functional medicine approach encourages providers to identify the most effective approach for treating disease. Such providers may be able to creatively offer alternative protocols. They may conduct group visits for patient education sessions. This approach has many challenges regarding compensation. The functional medicine provider may be able to organize this approach to deliver care through nonprofit or philanthropic organizations interested in promoting identification and treatment of chronic illness to offset the inevitable potential for acute illnesses that would necessitate high-cost medical care on an urgent or emergent basis.

    The functional medicine approach provides alternative clinical options, especially for managing and treating chronic diseases. As the scope and cost of chronic disease care continues to rise, functional medicine offers the opportunity to provide better outcomes and achieve cost savings for both patients and the healthcare system in the long term. However, functional medicine does not replace the need for traditional medical intervention when needed.

     

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