Thyroid Patients: Why You May Need a Cash Practice Doctor

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Thyroid patients may need to consider going out of their HMO or health insurance to see a cash practice doctor, in order to get better diagnosis and treatment.. clipart.com

Thyroid patients often contact me in frustration, looking for the right doctor to diagnose and/or treat their thyroid condition. Usually, these patients are already well-informed, and want more than a thyroid stimulating hormone (TSH) test and a levothyroxine prescription to diagnose and treat hypothyroidism.

They often have already seen a primary care doctor, or even an endocrinologist, and feel like they have reached an impasse.

In some cases, they have elevated Hashimoto's antibodies, and symptoms, but so-called "normal" thyroid levels means the doctor will not treat them. Or they've been diagnosed with hypothyroidism, given levothyroxine, and are still not feeling well, despite that so-called "normal" TSH test result.

Some patients ask what they can do? "How can I make my endocrinologist run Free T4, Free T3 and Reverse T3 tests?" "How can I get my doctor to prescribe T3 or natural desiccated thyroid, when all he wants to give me is levothyroxine?" "Why does my doctor spend five minutes, have me run the same TSH test, hand me another levothyroxine prescription, and tell me to come back in six months, even though I don't feel well?"

There is no easy answer.

One of the realities of our health care system is that doctor who participate in insurance, or who work with Health Maintenance Organizations (HMOs), often work within very strict constraints -- very limited and prescribed procedures for diagnosis and treatment that they must follow in order to continue working with the HMO, or in order to continue being reimbursed by a particular insurance company.

Some would say that these processes are almost "cookie-cutter." For example, the "standard of care" for many thyroid issues means that some doctors are essentially limited to testing only your TSH, and if it falls within the normal range (i.e., .3 to 4.0/5.0) then thyroid disease is excluded, and your exploration is complete.

Free T3, Free T4, Reverse T3, and antibodies tests are not part of any follow-up, and are not encouraged. In some cases, these tests are not even permitted without a bureaucratic approval process, or are not reimbursable.

Even then, when tests, if your TSH is between 5.0 and 10.0 - you may be told you are "subclinically hypothyroid," and told that your TSH will be checked again in six months, or a year, and that "we will treat you when it goes over 10." In some cases, if your TSH is above 5.0, you will be treated, but with a conservative dose of levothyroxine, and told to return in six months or a year for a recheck. Again, case closed.

As a patient, you have to realize that you have two options.

The first option is to advocate for yourself, within your insurance or HMO. This is no small job. It can mean insisting on the additional tests, in writing. (One tip is that HMOs may schedule more appointment time, and insurance companies will sometimes reimburse for a longer visit, and both may be willing to approve more extensive thyroid tests if you are having an official "annual physical" versus a regular office visit.)

You may also have to insist on discussion of additional treatments. You may have to have your doctor -- if willing -- write an explanation to the insurance company that defends the need for the additional testing or, for example, coverage for adding a T3 drug or natural desiccated thyroid. (For help: Here is an article on fighting your health insurer, and another on coping with difficult doctors.)

The problem is, doctors who are reimbursed by insurance, or who work with HMOs, often have only a few minutes per patient for a visit. And as far as going to bat for you, few doctors have the time or inclination to go to these lengths to help you with tests and treatments outside the realm of the traditional, approved approaches. They don't want the extra paperwork and bureaucracy, nor do they want to be labeled as a physician who is doing things that are "outside the box" or that expose them to scrutiny from their colleagues.

If you are with an HMO, you may be able to appeal to the HMO's ombudsman or patient liaison for assistance. Don't hold your breath, though. As we know, HMOs tend to be fairly monolithic and bureaucratic, and a great deal of their effort is expended in discouraging tests or treatments that cost extra -- especially when they are not considered the standard of care.

The second option is to opt out of the system. Many integrative doctors, holistic doctors, hormone experts, and those working with thyroid, adrenal and hormone imbalances have been forced to opt out of the system. They cannot practice an integrative approach to hormone balance within most HMO restrictions, so you rarely will find these doctors working with HMOs. And since insurance has very specific limits on reimbursement for time, many of these doctors can't spend the time they know they need to thoroughly evaluate you when they know they will get $40 reimbursement, for example, from the insurance company for the visit, no matter how long it takes. They know that it takes more than 5 to 7 minutes to do a thorough clinical examination, talk to you about your medical history, make a diagnosis, and discuss treatment options. They also know that insurance often will not cover the various tests they need in order to make a diagnosis or medications to optimize your treatment.

This is why many of the physicians who specialize in hormone balance have chosen to not work with HMOs, refuse insurance, and go to a cash practice (This refers to a practice or doctor who does not take insurance, or participate in an HMO. Payment is due at the time of the visit.) Some doctors go to aconcierge-style practice, where a limited number of patients pay an annual fee for remain a patient and have access to the doctor, in addition to fees for visits and tests. These doctors want to be able to schedule longer, more in-depth visits, and want the freedom to order the tests they feel you need, and prescribe the treatments they feel with safely work best for you.

I know that the option to opt out is not one that everyone can afford. And for that reason, thyroid patient advocates, including me, are working to help change the standards of care, and to encourage HMOs, insurers and physicians to broaden the scope of standard thyroid tests, as well as the range of reimbursable treatment options. But it's a slow road -- especially when we come up against the juggernaut of the medical establishment, thinking that TSH tests and levothyroxine are sufficient, and insurers and HMOs who want to keep drug costs to a minimum, and drug companies with a financial interest in keeping patients from switching to other medications.

It's profoundly unfair that even when you pay for an HMO or health insurance, there are times when you still may need to pay out of pocket to see a cash practice doctor who is out of your network, in order to get properly diagnosed and treated. Or when you have to pay out-of-pocket for your T3, natural thyroid, or compounded thyroid medication because it is not covered. But when the alternative is to suffer a lifetime of ill health and sub-par care for your thyroid condition, it may be money well spent.

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