Free Preventive Health Care Is Not Free

Friday, June, 15 2012

While everyone wants something for nothing, that something is never free. In order to encourage the use of preventative health screenings such as annual well-health physicals, check-ups, and exams many organizations provided such coverage with no or reduced out-of-pocket co-pays, co-insurance, and/or waived the deductibles. As applied to preventive screening, most health care professionals would argue that when appropriate, both children and adults should be screened for those illnesses for which they are at risk. This includes vaccinations as well as screenings.

Under the Patient Protection and Affordable Care Act (PPACA), preventative screenings listed as class “A” or “B” by the U.S. Preventive Services Task Force (USPSTF), an agency of the U.S. Department of Health & Human Services, are to be provided at no out-of-pocket cost to most insured members. In a periodic publication of nearly 300 pages, the USPSTF reviews and recommends or discourages the use of various medical procedures designed to provide “preventive” health care for adults and children. While individual physicians are not mandated to follow such guidelines, they frequently do unless the member’s age, gender, personal medical history or other factors indicate a deviation should occur. Prior to PPACA, most health insurance plans covered preventive services recommended by the USPSTF when considered “medical appropriate” but usually imposed an out-of-pocket co-payment, co-insurance, and/or deductible.

The theory behind providing for preventive services is simple; it is cheaper to prevent an illness than to cure it. Unfortunately, not all physicians agree on the use or frequency of all preventive screenings. One example is mammograms. The National Cancer Institute suggests that women age 40 and above should have a mammogram every 1 to 2 years. However, the USPSTF’s 2009 recommendation for females younger than age 50 is,”Clinicians may provide this service to selected patients depending on individual circumstances. However, for most individuals without signs or symptoms there is likely to be only a small benefit from this service.” Another example is the Prostate-Specific Antigen (PSA) test, used to identify males with highs levels of PSA as a possible indicator of prostate cancer or other prostate disorders. The American Cancer Society recommends men as young as age 40 should be screened for prostate cancer based on ethnicity, personal and family history. Men with an elevated PSA level should be screened every two years. However, in its October 2011 update, the USPSTF concluded, “that many men are harmed as a result of prostate cancer screening and few, if any, benefit.”

The theory of out-of-pocket cost-sharing arrangements such as member co-payments, co-insurance, and deductibles is to provide “skin in the game” for covered members by requiring those who actually use the services to pay a portion of their costs. This is true for auto, home owners, as well as for health insurance. Under a “fee-for-service” payment method, when out-of-pocket cost-sharing arrangements are removed, unnecessary service utilization increases which increases overall premium costs for all insurance members. A $20, $30 or $50 co-payment may seem insignificant, until it is considered that hundreds to thousands of those co-payments must be absorbed by members who never use the covered services. Finally, without some form of control, excessive utilization will without a doubt be seen in next year’s rate increases.