The documentation requirement on doctors has become so onerous that, instead of spending our time being doctors and practicing medicine, we are wasting time meeting the overwhelming requirements of MACRA. MACRA is the Medicare Access and CHIP Reauthorization Act. Part of its function is to streamline multiple quality programs under the Merit Based Incentive Payments System (MIPS). However, the amount of time required to complete documentation has doubled. The 2019 Medscape Physician Compensation Report showed that, in 2012, the majority of physicians had about four hours of paperwork per week. The majority now have over 10 hours per week, and more than a third have over 20 hours per week. To get all of that documentation done, you’re either working longer hours or you’re spending less time taking care of patients.
I had the pleasure to interview Dr. Michael Lowenstein, MD. Dr. Lowenstein is a leader in the field of treatment of opioid use disorder. Recognized as one of the pioneers of anesthesia-assisted rapid detoxification, he has also been an excellent source for the advancement of medical protocols for opioid drugs over the last 20 years. He is quadruple board certified in anesthesiology, pain medicine, addiction medicine, and anti-aging and regenerative medicine. Dr. Lowenstein serves as the medical director of Waismann Method® Advanced Treatment for Opioid Dependence, which has maintained the highest opioid detox success rate in the U.S. for over two decades.
Established in 1998, the world-renowned Waismann Method® detoxification center receives patients from all around the world at its sole location in Southern California. It continually maintains a reputation for excellent medical care and superior results. The Waismann Treatment™ includes individualized medical protocols for people suffering from opioid abuse, including rapid detox, medically assisted opioid detoxification, and inpatient medical alcohol detox.
Dr. Lowenstein is a member of numerous medical associations, including the American Society of Addiction Medicine, the American Society of Interventional Pain Practitioners and the American Academy of Pain Management. In addition to his four board certifications, Dr. Lowenstein is also a pain management specialist. He completed his degrees at University of California at Berkeley, his transitional internship at Santa Clara Valley Medical Center, and his anesthesiology residency at Loma Linda University Medical Center.
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
I wanted to be a surgeon forever. In residency, I fell in love with anesthesia, and part of that is pain management. I became an anesthesiologist. In my first job, I had an opportunity to help patients with chronic pain. I realized there was a need for treatment for patients suffering from opiate addiction being referred to me.
Treatments available at that time in 1993 had a meager success rate. I started looking into options, including rapid opiate detox. I met Clare Waismann, founder of Waismann Method® Advanced Treatment for Opiate Dependence, in 1997 and started doing rapid detox. Twenty years later, I’m still assisting patients with medical detoxification — not just for opioids but also for alcohol dependence — while still running a chronic pain unit.
The opioid epidemic makes the work more relevant now than it has ever been. As a medical doctor, there are two components to treating patients suffering from opioid use disorder: opiate dependence, which is the physiological component, and then the emotional component, which could be a result of a psychiatric, behavioral, or psychological condition. We begin by treating the physical dependence so that patients can better address emotional issues. If the underlying problems, such as depression and anxiety, were adequately treated, many of the serious addiction issues could be avoided.
Another issue is the urgent need for accurate information regarding prescription painkillers, not just for patients but also for prescribing doctors. In the mid-1990s, doctors faced punishment for inadequately treating pain, which they were calling the “fifth vital sign.” People were being told drugs like OxyContin were safe and the best option to manage pain. This false information led to a tremendous increase in opioid prescribing.
Can you share the most interesting story that happened to you since you began leading your company?
On a positive note, as the Waismann Method® medical director and a doctor, the most rewarding stories are when we hear back from patients years later saying, “You saved my life. Now I’m married with children, and opioid abuse is an issue from the past.” As often as I hear how so many of my patients’ lives improved and how fate took a radical turn for the best, every time I hear those words, it feels as good as the first time.
On another maybe not-so-positive note, just the other day, a patient came in for opioid detoxification. At his initial evaluation, we diagnosed a cardiac arrhythmia, which sadly led to the discovery of an unknown lung cancer.
Because we treat patients in a full-service hospital, we don’t just provide an opioid detoxification, we actually succeed in significantly improving their physical health. In some cases, we even save their lives from unrealized medical conditions masked by the opioids. At a traditional addiction treatment program, those serious conditions would have gone undiagnosed, which not only could lead to a dangerous detoxification, but a continued decline in health. It’s extremely rewarding when we can save people’s lives as we treat opioid dependence. It’s more than a drug treatment; it’s giving people their health and peace of mind back.
Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?
I can’t think of a mistake or a funny mistake, but I can share something we learned. We realized early on that once patients complete a medical detoxification, there is a crucial need for additional professional support. After discharge from the hospital, patients embark on an adjustment period that, for some, can be challenging. We saw a need to provide more support throughout the adjustment period.
We also understood that helping patients determine how to address the underlying physical and emotional issues they still faced gave them a much higher chance of success, which led Clare Waismann to create Domus Retreat.
Domus is a safe and supportive environment where people can recover and have an opportunity to identify what the best next move will be for them. It’s a place where people are seen as individuals, with no pre-existing rules and no cookie-cutter approach. With each patient, we learn from experience so we can do even better.
What do you think makes your company stand out? Can you share a story?
What makes us different is that we have replaced archaic and judgmental methods of treating people suffering from opioid addiction with effective medical science. Also, instead of focusing on the condition of addiction, we treat the human being behind it. We provide the most comfortable, respectable and effective option to overcome the physical component of opioid use disorder, which gives patients the freedom and clarity to work on their emotional issues.
I guess you can say we have been ahead of our time — a lone ranger. We did not give in to the pressures of the addiction treatment community, which often believes in labeling people, grouping them as “addicts,” or worse, allowing people to suffer so they can “learn” a lesson. That’s a cruel and ineffective form of treating people suffering from drug addiction. Suffering does not help people. Instead, it keeps them from receiving the help they so desperately need.
What advice would you give to other healthcare leaders to help their team to thrive?
Coming from a pain management and addiction space, pain is huge, even for primary care offices. The CDC reported in 2018 that 50 million Americans — that’s over 20% of the adult population — suffer from chronic pain. About 20 million of them have high-impact chronic pain that is so severe they can’t work regularly.
You really have to listen to people. How much of the pain is an actual physical issue and how much is emotional pain manifested as physical issues? You have to make sure you are not medicating physical distress caused by underlying anxiety, depression or bipolar conditions.
Furthermore, if you’re a prescribing physician, you need to clearly understand the risk of opiates. The opioid epidemic has forced many doctors to learn more about the long-term consequences and rethink their treatment plans. The issue is not just prescribing medication, however. It’s providing healthy alternatives, such as encouraging proper diet, physical therapy, meditation, acupuncture and other beneficial therapies. Doctors need to see and treat the whole person, not just the symptoms.
Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the U.S. healthcare system is ranked as the worst among high-income nations. This seems shocking. Can you share with us 3–5 reasons why you think the U.S. is ranked so poorly?
The cost of everything is high. If you look at our population, you have an enormous number of people who still can’t afford the healthcare they need. Our drug costs are high. Doctors don’t get reimbursed for various things by insurance companies. We’re very cutting-edge with some cancer treatments, for example, but they can cost millions of dollars. Above all, we need to start using better preventive and primary care earlier on. We also need to provide accessible mental healthcare and more public education regarding medical and emotional conditions.
You are a “healthcare insider.” If you had the power to make a change, can you share 5 changes that need to be made to improve the overall U.S. healthcare system? Please share a story or example for each.
1. We need to continue to move away from a “disease care” system to a “health care” system that promotes preventive and regenerative medicine and technology. It has started in some medical schools and needs to continue to be a focus. Preventive medicine, mental healthcare, nutrition, exercise, avoiding environmental toxins, and improving gut health are essential. Gut health affects the autoimmune system, and the majority of serotonin is made in your gut. Low levels of serotonin can cause depression, which can lead to numerous other issues.
2. I deal with a lot of workers’ comp patients. The pendulum swings back and forth in terms of who makes the medical decisions. In the work comp setting, it’s the government making those decisions because they adopted guidelines for treatment. I believe in putting the decision-making back into the hands of physicians. We (doctors) treat individual patients. However, now we (the healthcare system) are treating patients based on insurance company rules and guidelines that don’t necessarily reflect state-of-the-art care.
In some ways, it has become more challenging to provide care to patients. For example, the utilization review process and determining whether insurance will authorize a particular treatment make it difficult to provide quality care. One example is that, in some cases, it can be easier to prescribe medication than to get an epidural injection approved. Also, it can take a great deal of time to request approval and appeal decisions, which, sadly, can delay treatment. I think the whole process needs to be revised.
3. Evidence-based guidelines are written by various government panels and professional societies. They are designed to help allocate resources and measure quality. The problem is that we need a better system for keeping these guidelines up to date and based on the latest, validated research and technology. Outdated guidelines hinder everyone’s ability to make the best decisions possible for patient care.
4. The documentation requirement on doctors has become so onerous that, instead of spending our time being doctors and practicing medicine, we are wasting time meeting the overwhelming requirements of MACRA. MACRA is the Medicare Access and CHIP Reauthorization Act. Part of its function is to streamline multiple quality programs under the Merit Based Incentive Payments System (MIPS). However, the amount of time required to complete documentation has doubled.
The 2019 Medscape Physician Compensation Report showed that, in 2012, the majority of physicians had about four hours of paperwork per week. The majority now have over 10 hours per week, and more than a third have over 20 hours per week. To get all of that documentation done, you’re either working longer hours or you’re spending less time taking care of patients.
5. In this country, we’re bearing a lot of the cost to develop medications. They’re paying a lot less in other countries for the same drugs. However, it also has to be profitable for the drug companies to continue to produce new medications. The cost of prescription medication in this country is an issue that needs to be addressed. We need to make it possible for drug companies to do necessary research and development while also keeping medications affordable.
Ok, it’s very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?
Individuals would need to be more vocal and persistent in raising concerns about access to affordable care. They also would need to seek out preventive care earlier on. Individuals who are struggling financially and facing medical issues are at a disadvantage, however. The responsibility is not on them alone.
Communities, healthcare professionals and others would need to focus on providing answers for these healthcare problems from two angles: 1. Create more avenues for individuals to access the preventive and medical care they need. 2. Advocate on behalf of individuals and themselves to elicit change from the government. These entities have the potential to leverage their influence to a higher degree.
Leaders in the government, healthcare industry and pharmaceutical industry are at a crossroads. Sweeping changes to opioid prescription laws have backfired to an extent in terms of negatively impacting chronic pain patients. Access to necessary pain medications is being cut off or dramatically reduced out of fear of being charged with unnecessary overprescribing. The latest directive to titrate people off opioids slowly instead of stopping opioid use suddenly — which can have grave consequences — is better but still doesn’t address everyone’s needs. Instead of making sweeping changes, these entities need to work with doctors to end the opioid crisis without hurting people already suffering from chronic pain.
We also need to focus on the real crisis: emotional distress. The lack of mental healthcare causes a plethora of physical, emotional and social issues. When people are suffering from emotional pain, they have more medical issues and more addiction issues. We need to concentrate on preventing the numerous consequences of untreated mental conditions by allocating our precious resources responsibly and appropriately.
Lack of good and accessible mental health resources is the principle reason for addiction, mass shootings and homelessness. If we provide access to good, all-around healthcare, we may be able to waste fewer resources, prevent significant societal harm, and best of all, improve the quality of our lives.
As a mental health professional myself, I’m particularly interested in the interplay between the general healthcare system and the mental health system. Right now we have two parallel tracks, mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?
The status quo is insufficient. First, physicians need to be better trained to identify emotional issues that can manifest as physical complaints. As pain management physicians or primary care doctors, people come to us for their pain. Physicians need to identify and treat underlying issues that can cause the pain they’re describing. Take, for example, someone who has untreated depression and anxiety. Say they get an unrelated medical procedure done and are prescribed opiates. The opiates make them feel much better overall. When their prescription runs out, they still have the underlying depression and anxiety to deal with. Those symptoms often surface in full force. They become hypersensitive to discomfort, including the emotional kind. They become so overwhelmed, it becomes hard to differentiate the source of distress. All they know is that pain is present.
If people become desperate enough, they might try to obtain drugs on the street. If doctors spend time listening to the patient, reviewing their history and complaints, then they can create a responsible plan for treatment that would provide a much better quality of life. If doctors are also trained to do a better job identifying emotional issues, opioid use and abuse can be greatly reduced.
We also have to be more systematically efficient in treating the physical dependence issues first because they get in the way of effective long-term treatment for emotional conditions. Medical detoxification is exceptionally successful in this regard because it reduces the duration and discomfort of acute withdrawal, decreasing the chances of immediate relapse. This inpatient medical treatment — and aftercare provided by professionals — gives people a dramatically higher chance of successfully completing detoxification and pursuing any emotional or psychiatric care needed.
Education is also a key factor in improving the future of healthcare. People need to be better educated about their treatment options for physical and emotional issues. Doctors also need to have a clear understanding of the risks and benefits of each drug, including the potential for addiction and harmful drug interactions. Leaders in government need to be more careful about making uneducated decisions that directly impact patient care and medical professionals.
How would you define an “excellent healthcare provider?”
An excellent healthcare provider is one who treats the patient and not the symptom. One who will listen carefully to what is said and what is not said. A physician who treats the patient comprehensively. When doctors only focus on symptoms or diseases, they can overlook critical details about the person which could greatly improve treatment and outcomes. When doctors only treat one aspect of a person’s medical or mental health issues, they potentially miss the real cause of the problem they’re managing.
Doctors need to not only communicate effectively with patients but we also need to communicate with each other. In doing so, we can potentially improve diagnosis accuracy, treatment and patient care. We also can avoid preventable problems, such as prescribing drugs that don’t interact well together or that create new medical issues.
Can you please give us your favorite “life lesson quote?” Can you share how that was relevant to you in your life?
My favorite quote of my own is, “People do drugs for a reason.” Unless you identify the real reason they’re doing drugs, you’re never going to be able to offer the right treatment option. Until you identify the real reason — pain, anxiety, depression, emotional abuse, trauma — you’ll never make the patient better or effectively treat their condition.
My favorite quote from someone else is Einstein’s definition of insanity: “The definition of insanity is doing the same thing over and over again but expecting different results.” This idea applies to doctors now. What we’re doing isn’t working, so we need to change what we’re doing. Medicine, in general, needs to change. We’re losing the battle against the opioid crisis. We spend more money than anyone else on healthcare but we’re not №1 in the world. So we need to make modifications in the healthcare system and in how we deal with addiction.
Are you working on any exciting new projects now? How do you think that will help people?
We’re trying to evolve detox treatment to create the safest and most effective procedure that can be applied to the largest number of people. Currently, I’m looking at more regenerative technology like the use of stem cells that can be applied to treatment.
Over the years, we’ve made significant advances in our field to increase the level of patient care we can provide. We celebrate with our patients that we have maintained the highest opioid detox success rate in the U.S. for over 20 years. We look forward to helping more people every day.
What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?
I love to read the latest research and developments covered in various medical journals related to my fields. I would love to read more than I have time to.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger.
We need a movement of empathy and compassion. There is too much judgment and stigma around opioid use disorder, addiction, and people seeking treatment for pain and mental health issues. That kind of prejudice gets in the way of progress.
At Waismann Method® and Domus Retreat, for example, we never refer to people as addicts, and we never ask them to label themselves that way either. Piling that kind of unnecessary shame on top of the issues that a person is already dealing with is counterproductive.
That prejudice seeps into policy, too. Policymakers, people writing guidelines and others of influence need to remember the people who are impacted by their directives. We’re not simply working to end the opioid crisis — this problem without a face — we’re working to save individual people’s lives. It could be your own brother, spouse or friend. These people need comprehensive care for their overall health.
How can our readers follow you on social media?
Thank you so much for these insights! This was so inspiring!