Problems that arise when preventive medicine services waive co-pays

by Jeoffry B. Gordon, MD, MPH

Preventive medicine services will soon require no co-pays.

This is just another example of how complex and fouled up any health reform that depends on commercial insurance can be. In addition it demonstrates how pious morality infused into the democratic politics of health reform impairs the greater good.

So after all current insurance policies renew, according to Affordable Care Act, preventive services must be provided without co-pay — i.e. be free at the point of service.

Let’s look at three impending problems:

  1. Well women exams and pap smears are preventive medicine. If the visit then results in contraceptive advice or a birth control prescription does this become a medical service (and subject to copay)  even though no disease is treated? Who will decide this and how will it be done?
  2. Co-pays are now so substantial that they induce a significant number of patients to fore go medically needed care. So when a patient schedules a “preventive medicine visit” and then pours forth a bunch of significant symptoms, which obviously require care and attention, should the doc go back and see if a copay was made or even worse get into a possibly contentious discussion with the patient about requiring an (unexpected) copay? What does this do to the doctor patient relationship?
  3. Say I am a pediatrician and I see 20 patients a day, including 6 well child visits. If an average insurance copay is now $20, the new law means I will be foregoing $120 per day or $28,800 per year. This is a substantial amount. In this day and age when insurance companies are responding to a multitude of mandated cost accelerating mandates and are routinely squeezing physician reimbursements anyway, it is unlikely that they will be taking any initiative to raise any fees or payments to the doctor to make up for this forgone income. Thus the direct effect of this reform will be to make the patient’s incentive for preventive care an  expense to the providing physician. Most docs will not curtail preventive medical care because of this, but this is certainly demoralizing and certainly not an inducement for providers to expand preventive services.

Jeoffry B. Gordon is a family physician.

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  • WarmSocks

    1. That’s probably a question for your attorney or risk management service. Now. Before it comes up with a patient.

    2. I’ve talked to a number of people who did not know that a well-visit (“routine” checkup) precluded prescriptions or treatment. Actually, I’ve never talked to a patient who already knew this; only people who work in a doctor’s office know those types of details. It needs to become common knowledge. Post a sign in your waiting room, add the information to your practice’s website. Let us patients know what’s included in the different kinds of appointments. When someone phones to make an appointment for a checkup, the receptionist can have a little blurb she reads, akin to, “By definition, a well-exam requires the doctor to check specific things, and it also excludes disease management. If you have symptoms that need to be addressed, or need a prescription refill, I’d be happy to schedule a separate appointment for you to address those issues.” Some patients are happy to work within the system, but we have to know what it is.

    3. That’s not the way it works. Right now, my doctor charges $160 for a well-child visit, but he’s contracted with my insurer to accept $130. Of that $130, I pay a $20 copay and the insurer pays the remaining $110. The doctor gets the entire $130 he’s agreed to accept. Under the new rules, my insurer will pay the entire $130 and it won’t cost me anything out-of-pocket. That makes it easier to make a separate appointment to discuss symptoms because the patient won’t owe a second copay.

    • AnnR

      It’s designed to be time-wasting. If I have to take half a day off of work to go to a Dr. appointment two appointments on two different days is a full day of work.

      I’d much rather shell out the co-pay and have my problem addressed in one visit.

  • Emily Gibson

    My understanding of the new law is that insurance plans will be required to cover preventative services recommended by the United States Preventative Services Task Force as category A or B ratings (A = conclusive evidence and B = very strong evidence showing benefit of receiving the services).

    What is not clear, as Dr. Gordon points out, is how the health care provider and patient will mutually determine the nature of an encounter once sitting in the privacy of an exam room together.

    There really is no such thing as a “non-prevention” clinical encounter. Health care providers are constantly teaching, guiding and advising their patients how to avoid diseases they don’t have, detect diseases in their early stages through screening, and reduce the negative impact of established disease by restoring function and reducing disease-related complications. Sounds like primary, secondary and tertiary prevention to me.

    Sounds like everything I do every day with every patient.

  • IVF-MD

    History proves time and time again when attempts at societal improvement are initiated by coercive means rather than by natural voluntary incentives, the unintended consequences brought about by natural human motivations to game the system for ones own survival and benefit will end up resulting in the opposite of the desired outcome. In other words, if the goal of this coercive legislation was to IMPROVE the access to quality preventative medicine care, then the above theory states that things will overall get worse. It will be interesting how this plays out.

  • ClinicalPosters

    I wonder how this will affect HSAs, which in premise, offer lower premiums and moderately high copays with a high deductible in exchange for lower monthly premiums. (i.e. copay regular doctor visit: $90; annual colonoscopy: $200)

  • Dr. Z

    “Most docs will not curtail preventive medical care because of this, … and certainly not an inducement for providers to expand preventive services.”

    1. Why not? It’s business.

    2. What is the long term wellness product of not just no expansion in prevantative services … but retraction?

    There is no value in free.

  • stargirl65

    I run into this problem every day. Patients think a physical exam includes assessing their chest pain, ear pain, and knee pain in addition to adjusting their diabetes and blood pressure meds. And while you are at it all the vaccines are also included, right? This is in addition to the actual physical exam. Now there is no copay and the insurers are paying rock bottom prices for performing the annual physical. I take a very forward approach to this and when patient start asking about other things I directly tell them in the exam room that THIS IS NOT INCLUDED IN YOUR PHYSICAL AND EXTRA FEES WILL APPLY. They are not happy and some have left my practice over this. They have a high deductible health plan and basically wanted everything for free.

    BTW, I have been charging this way for years and it was not a problem until the no copay physical and high deductible health plans became vogue.

  • John martinez

    I’ve looked through a bunch of summaries of the health care law and I think you may be misunderstanding the effect of the “no co-pay” for preventative care portion of the law. That part of the law is aimed at the insurance companies, not physician offices.

    Patient co-pays are the portion of the fee schedule that the patient is responsible for. if a patient has $20 co-pay, the insurance company deducts that co-pay from the fee schedule they pay the physician. It’s not an extra $20 on top of what the fee schedule is for that visit. If a patient has a $0 co-pay, then the insurance company would be paying 100% of the contracted fee schedule for that visit, so the total amount paid should still be the same.

    One valid argument would be that office practices would have less money coming in on the day of service with less co-pays and would have to wait the 14 to 30 days it takes for the insurance companies to send their checks. The (small) upside – less cash at the front desk to worry about going missing, and less credit card fees to pay.

    Regarding the “preventative” vs “sick visit” charges – that’s already a tough one. Many of the insurance companies I deal with already won’t pay for a “preventative exam” and a “sick visit” on the same day of service, so also not sure how the “no co-pay” would change what the insurance companies are already doing to us.

    • BladeDoc

      Do you people not understand economics? Or math even? Look, using the $130 as an example — that money comes from somewhere. Either the insurance company pays the $130 and raises your insurance policy $20 per person (remember EVERYONE is supposed to get preventative care every year) or you split it $110/$20 or the insurance company tells the doctor to lump it and now take only $110 for the visit (and saying that insurance companies cannot do this without renegotiating is disingenuous as anyone who has actually been party to these “negotiations” could tell you).

      The most likely outcome is some combination of lower office visit payments AND higher insurance costs. When you lower the office visit by ~5% you will most likely see physicians attempt to make it up in volume or add PA/NPs to do this kind of work.

      It cracks me up to see article after article about how we need more PCPs followed by policy after policy that makes primary care practice miserable and poorly remunerative. This goes under the heading of “revealed preferences.”

  • r watkins

    I don’t see these as new problems.

    In reference to 1 and 2, you should already be coding for an E&M code in addition to the preventative service. For most patients, this already means a higher payment, due to deductibles, HSAs, etc.

    In reference to 3, the insurer will still be responsible for the contracted fee and will have to pick up the co-pay. They can’t lower their payment unless you negotiate a new fee schedule.

  • anonymous

    When I switched billing companies several years ago, my new biller told me I was supposed to be collecting two copays if I was billing an E&M at the same time as a preventive service. Of course, patients always balked at this, but my biller was very good at explaining all the insurance rules (and emphasizing these were rules made up by the AMA and the insurance companies, not by us).
    I eventually found it was easiest to just avoid the problem. Now, before I start on the actual physical exam or any preventive education, I always ask the patient if he or she has any other questions or concerns for the day. If the discussion is more complicated than “that’s a suspicious mole, I’m sending you to the dermatologist”, then I tell them I want to address their chest pain (or GERD, back pain, depression, anxiety, etc.) and we will have to postpone the physical to the next visit. It is rare that a physical exam finding requires a long discussion afterwards, or a patient doesn’t mention the chest pain until AFTER I am done with the physical.
    In my opinion, though, it would be best to just scrap the whole E&M system and charge by time. I am dropping insurances one by one and offering this for patients who continue seeing me out-of-network. They are charged by time, but their superbill (for insurance reimbursements still have the codes.

  • Steven Reznick MD FACP

    Since when is $20 total a prohibitive amount of money to pay for a major and annual preventive service or exam?

    • Jeoffry B. Gordon, MD

      You must live on a different planet. I have a general family practice in San Diego which is not a deprived area and at least once a week a Medicare patient or a fully insured commercial patient will not make a sickness visit appointment and when I contact them they tell me that the copay(which may be up to $40 per visit now) is too much to afford or their gas expense is prohibitive. Really!

  • ErnieG

    I think the idea that preventive services for patients be free is misguided. One of the difficulties with medical care is that much of the cost for a patient not budgetable- you don’t know when you are going to get sick and need to pay medical bills. Health misfortunes can lead to bankruptcy from high costs of medical care. That is except for preventive services. These costs are easy to identify in advance and therefore easy to budget— when you turn 50, get screened for colon cancer; if you are a woman between 40-50 years old considering getting screened for breast cancer; get cholesterol checked every so often, etc, etc. Getting a third party payer involved in these services directly increases the overall cost of these services by about 10-20% as the money takes a longer route through the insurance company. Direct patient coverage of these services will lower the costs as they become transparent to patients, and cash flow is instant without need for administrative red tape from the insurance company. It may seem like a good idea that preventive services get “covered” by insurances, but I have always thought this was short sighted thinking. This only lead sto expansion of administrative costs for services that are easily to budget; the patient eventually pays more though higher premiums. Insurance should be to spread financial risk so that medical bankruptcy is an unlikely outcome from health misfortunes, not to pay for what is easy to foresee.

  • maribel

    When the “free” exam results in the need for further tests and follow-up appointments be prepared for noncompliance or unpaid bills. Oh, and good luck collecting because unlike the electric/phone co. or the landlord you can’t disconnect them or threaten to put them out. Why don’t they consider human nature when they come up with these things?

  • Bob

    Until the health system stops getting to the point where one sickness or incident can make you go bankrupt for the rest of your life, this problem will never be solved. Transparency pricing and billing practices (menu board style) will become the norm. Healthcare is the only place no one can tell me how much it will cost until I’m done. Lack of preventative health maintenance can cost the system much more at the end, so there needs to be impetus for people to get these services at a predictable/manageable cost.

    • Chris

      There are physician groups – one is a 250 PCP group in Dallas, that offer a web menu of costs. This is for the benefit of those who do not have insurance, so they can see what the prices are – reduced to the lowest levels of commercial reimbursements, i.e., those least able should not pay the most. The reason is as you say, because holding back on visits to the doctir can end up costing a lot more.

  • Vox Rusticus

    Interesting. By definition, a preventive service precludes a chief complaint. If you have a complaint, then evaluation and management naturally follow. So there is no value to history, either, since a history reveals changes, and changes possible progression of . . . a complaint, or a disease.

    • family practitioner

      I agree; yet one more example of how the deck is stacked against us in primary care.

      If we do a good review of systems, or if the patient comes to their physical armed with “a list” (which is usually the case), we will find things that may need exploring. However, we are then deviating from the preventive services format and doing extra work for free. I know, you can bill for both with modifier -25 but frequently that gets denied, then you have to appeal, then it gets denied again, then you send the notes from the visit, then the payor goes over your documentation and more often than not concludes there is not sufficient evidence to pay for both an E & M service and a preventive code on the same DOS. We still lose.

  • SarahW

    Never did a healthcare initiative need scrapping and starting over again more.

    • gzuckier

      That’s because never have we had a healthcare initiative.

  • Jo

    As you know, peventive measures have different CPT codes than regular visit level 1-5 E&M codes, since most of our patients always bring up other medical problems at annual physicals or their labs or Review of Systems also brings up other medical problems that require ICD-9 coding in the Assessment and Plan, the preventative code and the appropriate level of regular E&M visit are always billed together on same visit. If a procedure such as freezing wart is also done that is billed as well.

    Our “protocol’ built by us in the EHR include all CPTs for preventative test ordering, education, etc, then each diagnosis code that is covered during the visit is also brought down and noted as acute/new or follow up for each then the appropriate E&M code is billed for that follow up/acute visit. If a procedure such as freezing a wart is also done that is billed for as well as a different, distinct problem. All are billed with appropriate modifiers to the insurance companies, we get paid what ever is contracted for from all from insurance companies except one that will only pay half for the regular E&M visit at time of physical. Procedures such as SVNs, Injections, vaccines, etc are always paid for seperately.

    We always have and always will charge what is owed including co-pays up front before visit and will refund if needed on the way out, but currently with our complicated patient base that would be rare.

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