Health Care Costs Reducing Preventive Care

Health Care Costs Reducing Preventive Care

Despite the mandate in the recently upheld federal health law requiring new plans to cover preventive care costs like colonoscopies at 100 percent, patient advocates say some people still end up paying hundreds of dollars or more out of pocket.

“You can’t have anything wrong with you or it’ll get sent into the sick [diagnostic] path and then you have a big bill,” says Mary Kesel, the president of Benefit Advocates in Winston-Salem, who charges an initial rate of $100 hourly to help individuals with medical billing issues.

Research shows requiring even minimal cost-sharing, such as a copay, reduces the likelihood people will seek preventive care, and as the number of people with high deductible plans grows, cost-sharing increasingly means footing the entire bill.

The American College of Gastroenterology, whose physician members perform colonoscopies, also raised red flags, noting that the requirement insurers fully cover colonoscopies doesn’t always apply when the provider removes a polyp.

“It’s a coding issue we flagged very early on,” says Susan Pisano, spokeswoman for America’s Health Insurance Plans, a trade association. In the two years since the colorectal cancer screening coverage mandate took effect, she says insurers have expanded coverage so they still reimburse doctors extra for removing a polyp but now don’t require patients to pay out of pocket.

Governmental estimates project the federal preventive services mandate could improve prevention coverage for up to 88 million insured individuals by 2013, while many of the roughly 98 million people in “grandfathered” group health plans not bound by the mandate, including self-insured ones, also receive free preventive benefits. But Medicare still doesn’t fully cover polyp removal, considered therapeutic treatment.

Colonoscopies start at $1,129 locally, including doctor’s and facility fees but not anesthesiology, according to Healthcare Blue Book’s fair price estimates, representing what providers typically accept from insurers as full payment. Experts say they can exceed $2,000.

The confusion extends beyond colonoscopies, too. Highly rated Dr. Brian Devine of highly rated Lakeside Family Physicians in Charlotte says sometimes what starts as a routine annual checkup to screen blood pressure and other vitals can evolve into a full-fledged diagnostic workup, such as when a patient complains of chest pain or a bowel issue. “From a family physician standpoint, you never know what you’re going to get into in any given visit,” Devine says.

Symptoms that prompt medical care typically require patient cost-sharing, even if broached during a preventive visit. For example, a patient discovering a lump would likely pay at least some money out-of-pocket for a diagnostic mammogram, which differs from fully covered screening mammograms. “It’s a great example of something you should discuss ahead of time,” says Lew Borman, a spokesman for highly rated Blue Cross and Blue Shield of North Carolina. Ask your insurer what’s required for a visit to qualify as preventive, keep abreast of U.S. Preventive Services Task Force recommendations, which drive coverage requirements, and, experts say, appeal charges that don’t match up, but accept some cost-sharing as a trade-off for optimal care.

“It’s a lot easier to correct something if you find it ahead of time,” says Charlotte member Cathy Bossi, echoing medical providers. Bossi takes full advantage of covered preventive services under her plan, such as Pap smears testing for cervical cancer, but still pays $225 to $250 for uncovered calcium scans to gauge her heart health, given her family’s history of heart attacks. Bill or no, she says the peace of mind pays her back.


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