Interest in functional medicine is on the rise, but many are unsure of quite what it is or what it offers. One thing many do understand is that it may involve out-of-pocket costs, so most inquiries to my office initially center on just that: “What will it cost? And does insurance cover it?” And the discussion ensues, partly about medical concerns, but mostly about money. The real questions may be “Why even consider out-of-pocket expense, especially if you are already paying good money for insurance? Why aren’t these costs typically covered?”

First, why pay? What makes functional medicine worth putting out additional money beyond insurance costs?

1 – Extended, non-rushed office visits

2 – Extensive, in-depth, comprehensive lab testing

3 – Patient education to enable one to understand one’s health

4 – A variety of different tests not offered (or covered) traditionally, including food sensitivities, the microbiome, nutrient testing, testing for toxins, etc.

5 – Seeking and treating the underlying cause of symptoms/illness, rather than controlling or suppressing with medication

6 – Reducing or eliminating medications and their many side effects, substituting with diet, supplements, and lifestyle change

7 – Treating and eliminating symptoms in situations where traditional medicine has not come up with adequate solutions

8 – Proactively pursuing long-term, optimal wellness rather than focusing chiefly or only on current symptoms or medical issues

9 – Developing a more personal and interactive relationship with your practitioner and working with them closely as a “team”

10 – Still able to utilize all resources available through traditional medicine and coordinate them (testing, specialty consults, pharmaceuticals, surgery, physical therapy) as needed and indicated

The downside?

1 – Out-of-pocket costs, not only for visits for some, but also including tests, supplements, and potentially, a better grade of food that is healthy and even therapeutic but more costly

2 – More effort/a more active role on the part of the patient

3 – Sometimes changes happen slowly over time compared to pharmaceutical quicker fixes

Why aren’t the functional tests and visits covered? That is hard to explain. Visits are in fact covered by out-of-network benefits for those who have them as part of their insurance, and so are in-depth panels sent to such labs as Quest or LabCorp, who are nearly always in-network. But why do functional providers work out-of-network in the first place? The reality is that their long visits and extensive testing would almost inevitably be considered hyper-utilization by insurance companies, and any network affiliation would therefore quickly be terminated by the insurance company; it would be a poor fit.

And why are out-of-network/functional tests not covered? This is strictly a cost-saving device on the part of the insurance companies, as these tests are all very much lab/science-based, relying on chemistry and microscopic examination, just like all covered medical tests. Coverage is denied simply because it can be; no real reason exists.

Why aren’t nutrients and supplements supported by insurance? Or intravenous vitamins, or chelation of heavy metals, all powerful medical tools? Why is the preventive approach dismissed in favor of symptom/disease control? That is an issue at a much higher level of economics and politics than this simple article would even venture to address. But one that is infinitely worth considering and addressing, to be sure.

Getting inquiries from people who have medical concerns that would clearly benefit from a functional workup and discovering that finances may prevent proper and important diagnostics and treatment is tremendously disheartening to any good functional provider. Anyone who has gone into this field as a provider will tell you just how disheartening it is to hear from a patient who needs this alternative approach and will not be able to pursue it properly for financial reasons.

But, in honesty, patients who cannot afford the non-covered tests will likely be in little position to buy supplements not covered by insurance, to buy medications custom-compounded by specialized pharmacies, even to buy protein, fruits, and vegetables as may be called for, to do intravenous therapies, massage, colon hydrotherapy, etc.  In short, they may well not be able to implement the programs they are given, and their initial efforts and expense may well have been wasted.

So, what in fact is the answer? It is a very personal and individual choice for each person, based on situational need, medical philosophy, finance, willingness to put in effort, and how highly one prioritizes health. There is no right or wrong, and it is often not an easy choice to make. But, if the health benefits listed above seem important enough, it is a choice at least worth some very serious thought.

Robin Ellen Leder, M.D., has dedicated her career to the treatment of patients using the functional medicine approach for many years, since being introduced to it working side by side with Robert Atkins of “the Atkins Diet” fame. She has treated literally thousands of patients with all variety of conditions, always investigating the root causes of problems, be they physical, emotional or spiritual, and prioritizing treatment with diet, natural supplements, and lifestyle change.