Preventive Care May Be Free, but Follow-Up Diagnostic Tests Can Bring Big Bills

From access to care coordination, U.S. primary care lags far behind other  wealthy countries: report | Fierce Healthcare

Source: Kaiser Health News, by Michelle Andrews

When Cynthia Johnson learned she would owe $200 out-of-pocket for a diagnostic mammogram in Houston, she almost put off getting the test that told her she had breast cancer.

“I thought, ‘I really don’t have this to spend, and it’s probably nothing,’” said Johnson, who works in educational assessment at a university. But she decided to go forward with the test because she could put the copay on a credit card.

Johnson was 39 in 2018 when that mammogram confirmed that the lump she’d noticed in her left breast was cancer. Today, after a lumpectomy, chemotherapy, and radiation, she is disease-free.

Having to choose between paying rent and getting the testing they need can be a serious dilemma for some patients. Under the Affordable Care Act, many preventive services — such as breast and colorectal cancer screening — are covered at no cost. That means patients don’t have to pay the normal copayments, coinsurance, or deductible costs their plan requires. But if a screening returns an abnormal result and a health care provider orders more testing to figure out what’s wrong, patients may be on the hook for hundreds or even thousands of dollars for diagnostic services.

Many patient advocates and medical experts say no-cost coverage should be extended beyond an initial preventive test to imaging, biopsies, or other services necessary for diagnosing a problem.

“The billing distinction between screening and diagnostic testing is a technical one,” said Dr. A. Mark Fendrick, director of the University of Michigan’s Center for Value-Based Insurance Design. “The federal government should clarify that commercial plans and Medicare should fully cover all the required steps to diagnose cancer or another problem, not just the first screening test.”

A study that examined more than 6 million commercial insurance claims for screening mammograms from 2010 to 2017 found that 16% required additional imaging or other procedures. Half the women who got further imaging and a biopsy paid $152 or more in out-of-pocket costs for follow-up tests in 2017, according to the study by Fendrick and several colleagues and published by JAMA Network Open.

People who needed testing after other preventive cancer screenings also racked up charges: half paid $155 or more for a biopsy after a suspicious result on a cervical cancer test; $100 was the average bill for a colonoscopy after a stool-based colorectal cancer test; and $424, on average, was charged for follow-up tests after a CT scan to check for lung cancer, according to additional research by Fendrick and others.

Van Vorhis of Apple Valley, Minnesota, did an at-home stool test to screen for colorectal cancer two years ago. When the test came back positive, the 65-year-old retired lawyer needed a follow-up colonoscopy to determine whether anything serious was wrong.

The colonoscopy was unremarkable: It found a few benign polyps, or clusters of cells, that the physician snipped out during the procedure. But Vorhis was floored by the $7,000 he owed under his individual health plan. His first colonoscopy several years earlier hadn’t cost him a cent.

He contacted his doctor to complain that he hadn’t been warned about the potential financial consequences of choosing a stool-based test to screen for cancer. If Vorhis had chosen to have a screening colonoscopy in the first place, he wouldn’t have owed anything because the test would have been considered preventive. But after a positive stool test, “to them it was clearly diagnostic, and there’s no freebie for a diagnostic test,” Vorhis said.

He filed an appeal with his insurer but lost.

In a breakthrough for patients and their advocates, people who are commercially insured and, like Vorhis, need a colonoscopy after a positive stool test or a so-called direct visualization test like a CT colonography will no longer face out-of-pocket costs. According to federal rules for health plan years starting after May 31, the follow-up test is considered an integral part of the preventive screening, and patients can’t be charged anything for it by their health plan.

The new rule may encourage more people to get colorectal cancer screenings, cancer experts said, since people can do a stool-based test at home.

Nine states already required similar coverage in the plans they regulate. Arkansas, California, Illinois, Indiana, Kentucky, Maine, Oregon, Rhode Island, and Texas don’t allow patients to be charged for follow-up colonoscopies after a positive stool-based test, according to Fight Colorectal Cancer, an advocacy group. New York recently passed a bill that is expected to be signed into law soon, said Molly McDonnell, the organization’s director of advocacy.

In recent years, advocates have also pushed to eliminate cost sharing for breast cancer diagnostic services. A federal bill that would require health plans to cover diagnostic imaging for breast cancer without patient cost sharing — just as they do for preventive screening for the disease — has bipartisan support but hasn’t made headway.

In the meantime, a handful of states — Arkansas, Colorado, Illinois, Louisiana, New York, and Texas — have moved ahead on this issue, according to tracking by Susan G. Komen, an advocacy organization for breast cancer patients that works to get these laws passed.

This year, an additional 10 states introduced legislation similar to the federal bill, according to Komen. In two of them — Georgia and Oklahoma — the measures passed.

These state laws apply only to state-regulated health plans, however. Most people are covered by employer-sponsored, self-funded plans that are regulated by the federal government.

“The primary pushback we get comes from insurers,” said Molly Guthrie, vice president of policy and advocacy at Komen. “Their argument is cost.” But, she said, there are significant cost savings if breast cancer is identified and treated in its early stages.

study that analyzed claims data after a breast cancer diagnosis in 2010 found that the average overall costs for people diagnosed at stage 1 or 2 were just more than $82,000 in the year after diagnosis. When breast cancer was diagnosed at stage 3, the average costs jumped to nearly $130,000. For people with a stage 4 diagnosis, costs in the year afterward exceeded $134,000. Disease stages are determined based on tumor size and spread, among other factors.

When asked to provide health plans’ perspective on eliminating cost sharing for follow-up testing after an abnormal result, a spokesperson for a health insurance trade group declined to elaborate.

“Health plans design their benefits to optimize affordability and access to quality care,” David Allen, a spokesperson for AHIP, said in a statement. “When patients are diagnosed with medical conditions, their treatment is covered based on the plan they choose.”

In addition to cancer screenings, dozens of preventive services are recommended by the U.S. Preventive Services Task Force and must be covered without charging patients under the Affordable Care Act if they meet age or other screening criteria.

But if health plans are required to cover diagnostic cancer testing without charging patients, will eliminating cost sharing for follow-up testing after other types of preventive screenings — for abdominal aortic aneurysms, for example — be far behind?

Bring it on, said Fendrick. The health system could absorb those costs, he said, if some low-value preventive care that isn’t recommended, such as cervical cancer screening in most women older than 65, were discontinued.

“That is a slippery slope that I really want to ski down,” he said.

Millenials Underestimate the Cost of Care

Millennials (ages 18 to 36) are more likely than are non-millennials to underestimate the cost of an injury or illness, including medical, household, and out-of-pocket costs (66% versus 45%), according to a survey by Aflac. Sixty-five percent say they could afford less than $1,000 for an unexpected out-of-pocket expense. Millenials are more inclined to try unconventional ways to pay for out-of-pocket health care expenses, such as borrowing from friends or family and crowd sourcing. The online study surveyed 1,500 benefit decision-makers and 5,000 employees at small, medium, and large companies

Millennial Women Want Wellness Care

Millennial women see health as total well being − physical, mental, and spiritual in contrast to the traditional healthcare model that emphasizes disease management. They want to minimize their use of the healthcare system, according to a survey by Survey respondents are 22 to 36, hold college or post-graduate degrees, and are working professionals. Also, most are single.

Participants estimate that they spend 25% of their monthly income on preventative and integrative behaviors. Respondents are skeptical about doctors and pharmaceutical companies that are only concerned with prescriptive care. One participant said, “Why isn’t massage or acupuncture covered under insurance? I think the whole system is focused on procedures and not prevention; there needs to be a shift.”

The Costs of Denying Care for Transgender Surgery

The Obama administration is proposing rules that would prevent health care providers from discriminating against transgender patients. A survey by True Benefits finds that, when care is denied, there are important costs for insurers and the public. As a result of being denied coverage for transition-related care, 35% of respondents needed psychotherapy; 23% became unemployed; 15% attempted suicide; and 15% needed public assistance programs.

Thirty-seven percent of those who were denied care turned to drugs and/or alcohol, and 36% developed other physical symptoms. John Hodson, president of True Benefit said, “Insurers and policymakers have had an antiquated list of exclusions that haven’t evolved for several decades. The thought was that denying transgender medical care saved policy holders money. This report shows that it’s not true. There are important costs to insurers and the public associated with denying care to transgender individuals, including the costs of therapy, public assistance, unemployment, and care for new physical symptoms.”

An insurance industry professional, Hudson became interested in the issue when his own daughter was denied coverage just weeks before a gender-reassignment operation was planned two years earlier. She eventually became the first person covered by a new Connecticut mandate in 2014.

The survey of 355 transgender individuals, among the first to focus on denial of health care, was conducted by TrueChild in May, 2015. Their average age was 35. Eighty-five percent were living full-time in a gender other than their birth sex, but only 54% had completed all or part of their physical transitions.

What Doctors Want You to Consider Before Choosing a Health Plan

As open enrollment for 2015 exchange plans gets underway, the American Medical Association (AMA) urges patients to review the plans they are considering in order to prevent interruptions in care and higher out-of-pocket costs. Whether it’s a new plan or a renewal, patients should consider deductibles, co-pays, drug costs, which physicians and facilities are covered, and the cost of out-of-network treatment. Patients should ask whether their physicians are participating in plans they are considering. AMA President Robert Wah, MD said, “It is very important that patients look beyond the big print, color-coded plan designations and price of insurance plans and check the small print details before making their selection.” AMA asks patients to consider the following:

1) Are your family’s doctors in the plan? If not, what will you have to pay out-of-pocket for office visits or other services your doctor prescribes? Is the plan’s directory of participating physicians up-to-date and accurate? Are there physicians on the list who are still accepting new patients?

2) What does the plan cover? What percentage of your health care costs will you have to cover? If so, how much and can you afford it? How much will you have to pay out of pocket for the medicines your family needs? Will you be able to use hospitals, labs and other facilities that are convenient to where you live or work? Does the plan provide access to a sufficient number of specialists that you need?

3) Does your primary care physician have to get permission from the insurance company to refer you to a specialist? Does that rule include specialists you see regularly for a chronic condition? Does the insurer use penalties or incentives to induce physicians in the plan to limit referrals in any way?

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Uninsured May Have Better Access to Care than Medicaid Patients

About 47% of providers surveyed by the American Physicians and Surgeons (AAPS) said say that it is harder to get an appointment with a primary-care physician if you are a Medicaid patient than if you are an uninsured patient. For specialist appointments, 44% say uninsured patients were better off; and 32% say Medicaid patients were better off. Only 2% say that Medicaid patients have no problem getting an appointment with a specialist.

Forty-eight percent say it can be extremely difficult for a Medicaid beneficiary to get drugs, medical equipment, or diagnostic tests; 27% say it can be moderately difficult at times; and only 13% say it’s no problem.

Providers’ comments were overwhelmingly negative about Medicaid. Rural patients who can’t drive or travel may have no access to care except through charity. Some areas have no hand surgeons, endocrinologists, dentists, or rheumatologists who accept Medicaid. Many cardiology tests are questioned or denied, even echocardiograms for inpatients. Many drugs, even common generics, are not available without jumping through bureaucratic hoops. Treatment for chronic pain is especially difficult. It may be very challenging to get non-emergency surgery approved, no matter how necessary.

One physician writes called Medicaid simply a jobs program for administrators and quasi-medical professionals with little money going to the health care part of the equation. Another said that t poor customer service and excessive paperwork a commonplace with Medicaid. It can cost more to file a Medicaid claim than a physician can ever hope to collect. In fact, a physician may lose less money by just seeing the patient for free. One physician said that, since denials for appropriate treatment are much more common than approvals, it is insane to expand “such a horrendous program.” For more information, visit

Last Updated 08/10/2022

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