When free preventive screening tests aren’t really free

I recently spoke to a class of undergraduates about the benefits, harms and politics of screening smokers for lung cancer using low-dose CT scans. Afterwards, a student asked how I felt about the Affordable Care Act’s requirement that Medicare and private insurers cover U.S. Preventive Services Task Force “A” and “B” recommended screening tests and other preventive services without co-payments or deductibles, making them free at the point of care.

I admitted that I have mixed feelings. On one hand, some studies have found that even small out-of-pocket payments make patients less likely to receive recommended health screenings or counseling. On the other, it isn’t clear why this particular set of services for healthy people (which include contraceptives classified as “pregnancy prevention”) deserve to be valued more than medical interventions for people who actually suffer from chronic illnesses. The chance that a 50 year-old woman at average risk for breast cancer will have her life extended by a screening mammogram is around 1 in 1000; the chance that a 50 year-old woman with diabetes and high blood pressure will have her life extended by taking fitness classes and anti-hypertensive drugs is around 1 in 20. The healthy person receives a service for free; the ill person does not. And, as I wrote in a blog post shortly after the 2012 presidential election, that mammogram isn’t really free:

Thanks to the ACA / Congressional Democrats / President Obama, a typical political ad will say, women can now get free mammograms, Pap smears, cholesterol tests, and birth control pills! Isn’t that great? This kind of ad is misleading because none of the preventive health services defined by the bill have suddenly become free. In fact, some cost hundreds or even thousands of dollars. Instead, the costs of these services have just been shifted – into higher insurance premiums, on to an employer, or to the federal government (and therefore the individual taxpayer or an international investor that holds some portion of the U.S.’s $16 trillion national debt).

perceptive commentary in this week’s JAMA by Drs. Joann Elmore and Barry Kramer offered more reasons to doubt the wisdom of mandating that marginally beneficial preventive services be provided for free:

With the goal of improving access to preventive services and medical screening, the ACA offers free screening mammography to women. However, women often pay for the consequences of screening, even if the screening examination is free. Women bear not only financial charges but also important human costs. Screening mammography can trigger recalls for more testing, biopsies, mastectomies, radiation, systemic therapy, days off work, and debt related to health care costs. These byproducts of screening can lead to adverse financial consequences and personal harm.

Two years ago, I bought a color printer for under $50 (practically free!) for my home office. It printed pages excruciatingly slowly, had a tendency to jam and leak toner, and sets of replacement cartridges came to $75 every other month. Several weeks ago it quit printing any documents that required black ink. After spending hours trying unsuccessfully to troubleshoot the problem, I paid five times as much for a new printer, and so far it’s worked like a dream.

Do I provide mammograms and other USPSTF-recommended “free” screening tests to my patients? Of course I do. But I also caution them not to be deceived by the sticker prices for these services and exaggerated claims about their benefits, and to consider more than upfront costs in determining personal health values, as they would in making decisions about the value of any other service that costs money.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor

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  • Kristy Sokoloski

    What’s interesting about all this is that even if those screening exams such as Pap smears were really free and the result comes back abnormal then the other tests that need to be done to try and find the problem are not free. Copays and coinsurances as well as deductibles then come in to play. And if someone can’t afford the amount for the coinsurance or the deductible portion that goes toward that what are they going to do next? Because then if treatment becomes necessary for the problem found the cycle with regard to copays, coinsurance, and deductibles begins again unless you have maxed your out of pocket expenses for the year. But then when the new year starts come Jan the cycle begins all over again. And that cycle then causes the patient to worry yet again how they are going to be able to afford it even though they have insurance. Yes, even if it’s supposed to be very good insurance there is still the worry.

  • FriendlyJD

    I think rather than offering an annual physical and a battery of preventative tests that fall outside the deductible, insurance plans should offer, say, 3 or 4 doctor’s visits and a threshold budget, say $1,000, for tests (whether they be labs or mammograms or pap smears). All would be subject to the relevant coinsurance/copay, but this would allow patients to prioritize the threshold access they receive before their deductible becomes an issue.

    This year, for example, I chose to get the Nexplanon birth control arm implant. My OB/GYN mentioned it, it seemed easy, and the $800 was fully covered under my plan. I switched for convenience, but my $11/month birth control was working just fine. When I needed a CT scan, however, I had to pay $790 out of pocket. Given the choice, I would have stuck with the pill and allocated that money for the CT scan.

    • Lisa

      I think your idea is a pretty good one.

  • betsynicoletti

    Of course, the tests aren’t “free.” But, any test with an A or B rating from the USPSTF has first dollar coverage, so insurance pays for it without a patient due amount. No co-pay or deductible. No one would argue that screening colonoscopy should be deferred. Or, many other screening and preventive services.
    But, it’s difficult for Medicare or private payers to remove tests (like mammography or PSA) when evidence shows they might not now get an A or B rating: cries of rationing prevent their removal. So, Medicare still covers a pap smear in women over 65 every two years, for low risk patients. I believe most physicians counsel their patients about the rational need for this, but should Medicare suggest it wouldn’t be covered—the cries of outrage would be loud and long.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Many years ago King Gillette came up with an idea: give people free razors, so they can become lifetime customers for razor blades. It worked amazingly well…..
    Of course, they are giving free stuff to healthy people. The sick ones are already customers. With a little bit of luck, and a little bit of planning, every person will be diagnosed with something during these free physicals….

  • Lisa

    Men know that testing for prostate cancer causes much more harm than good. And there is not an equivalent organization to Komen to raise money for prostate cancer research.

  • Lisa

    First of all, mammograms do absolutely nothing to prevent breast cancer. Secondly, they detect some breast cancers but miss others. I was diagnosed with breast cancer – only one area of in situ cancer was detected via mammogram. One area with another in situ cancer and two invasive tumors were not seen on a mammogram. But the real problem with mammogram is that find early breast cancers do reduce the mortality rate from breast cancer that much. Mammograms do lead to a lot of biopsies and treatment for cancers that would never spread beyond the breast and would never be life threatening. The harms of mammograms are real and should not be discounted.

    If you are going to have a screening mammogram (as opposed to a diagnostic mammogram after finding a lump) you should understand the benefits and harms. You should understand your risk of developing breast cancer.

  • JPedersenB

    Are there really people out there who are so naive that they don’t realize that this “free” care has been paid for with insurance premiums, lower wages or taxes?

  • Lisa

    I think the reason breast cancer survival is higher is due to improved, targeted treatments. Tamoxifen and Herceptin both are game changes with regard to breast cancer.

    You are right about a needing a crystal ball. I do find it disturbing the number of women who won’t admit that, but who claim early detection saved their lives. That makes it impossible to discuss the benefits versus harms of screening mammograms.

    I won’t ever have another mammogram, as I had a bilateral mastectomy. My husband will not have PSA testing, as he understands the harm is greater than benefit. Interestingly enough his brother had prostate surgery and has had many problems. Perhaps my husbands position is similar to yours as they are both based on observations . . .

    • Linda

      Lisa, you are obviously a learned, insightful woman who speaks from a personal experience. I think it’s wonderful to have these reasonable, thought-provoking discussions. I will certainly think more about these subjects, as I’m sure you will, as more information becomes available. Thank you for a productive conversation.

    • querywoman

      The whole mammogram controversy has an inflammatory effect on me. I believe they are overdone, while other women’s health issues are neglected.
      I have a friend who had a bilateral mastectomy and reconstructions who still has mammograms.
      I vote for better treatments as having lengthened breast cancer survival rates.

  • querywoman

    Preventive medicine is not on the chopping block, at least not for many decades. It’s too popular and profitable in current American medical thinking.
    Yet everybody still gets sick and dies!

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