Prevention vs Profit: How Health Insurance Shapes the Care You Get

Dr. Rose says insurance is a good fit for straightforward needs, like a medication you have a prescription benefit for, and for emergency care such as an accident or an ER visit. It also covers certain built-in preventive screenings like mammograms and colonoscopies when you meet the age or other criteria. She also wants patients to keep a primary care doctor for the things those offices do well.

She explains that the model is built around disease management and short visits rather than personalized, preventive care. In Maine and New Hampshire there is also a shortage of primary care providers, so access is limited and appointments are brief. Many patients feel dismissed when deeper testing is denied or when a single normal result is used to tell them they are fine.

A lab's normal reference range is based on the statistical norm for a population, so it reflects average rather than ideal. In functional medicine the target windows are often narrower, for example a tighter TSH range or higher optimal vitamin D and ferritin levels. Dr. Rose notes that someone can fall inside the normal range and still have symptoms that point to a real problem.

Insurance companies often cover only certain medications, frequently the least expensive option, so a patient's care can be shaped by their specific plan. Getting a different medication or imaging like an MRI or CT scan approved can require extra documentation, and if the patient does not meet specific criteria the request may be denied. High-quality supplements, botanicals, and lifestyle recommendations are generally not reimbursable at all.

Leaky gut refers to increased permeability in the small intestine, where the cells that should stay tightly joined begin to separate, which can trigger inflammation that shows up in the brain, joints, or skin. Dr. Rose says contributors include an inflammatory diet, a history of antibiotics, and long-term use of medications like proton pump inhibitors. She lowers inflammation, helps appropriate patients reduce those medications, and uses peptides, botanicals, and nutraceuticals to support healing over time.

Polypharmacy simply means being on many medications, often after one prescription is added to manage the side effects of another over many years. Dr. Rose says individualized care, lifestyle changes, and addressing root causes can sometimes lower doses or reduce the overall list. She describes a patient who, through gradual changes, came off a proton pump inhibitor, dropped to one blood pressure medication, and lowered his statin dose.