Preventive care may be free, but subsequent diagnostic tests can be costly

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When Cynthia Johnson learned that she owed $ 200 out of pocket for a diagnostic mammogram in Houston, she almost postponed taking a test that indicated she had breast cancer.

Johnson, who works at the university’s education assessment department, said, “I didn’t really spend it and I thought it was nothing.” However, he decided to take the test because he could not afford a credit card.

Johnson was 39 years old in 2018, and that mammogram confirmed that he had a tumor found in his left breast. Today, after lumpectomy, chemotherapy, and radiation, she is still recovering.

Choosing between paying the rent and getting the tests they need can be a serious dilemma for some patients. Under the Affordable Care Act, many preventative services, such as breast and colon cancer screening, are included at no cost. This means that patients are not required to pay the usual additional payments, additional insurance or accrued expenses required by the plan. However, if the screening results are abnormal and the health care provider conducts another test to determine what is wrong, patients may charge hundreds or even thousands of dollars for diagnostic services.

Many patient advocates and medical experts say that cost-effective coverage should be expanded to include imaging, biopsies, or other services needed to diagnose the problem, in addition to the initial prophylactic test.

“The accounting difference between screening and diagnostic testing is technical,” the doctor said. А. Mark Fendrick is director of the Center for Value-Based Insurance Design at the University of Michigan. “The federal government should clarify that commercial plans and Medicare should include all the necessary steps to diagnose cancer or another problem, not just the first screening test.”

A study of more than 6 million commercial insurance claims for mammogram testing between 2010 and 2017 found that 16% required additional imaging or other procedures. According to a study published by Fendrick and several colleagues, half of the women who received further imaging and biopsies in 2017 paid $ 152 or more out of pocket for subsequent tests in 2017. JAMA Network Open.

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

Van Warchis, a resident of Apple Valley, Minnesota, underwent a home-based stool test for bowel cancer screening two years ago. When the test is positive, the 65-year-old retired lawyer needs a follow-up colonoscopy to determine if something is seriously wrong.

The colonoscopy went unnoticed: the doctor found several benign polyps or clusters of cells during the procedure. But Warchis owed $ 7,000 for his personal health plan. His first colonoscopy did not cost him a penny a few years ago.

He contacted his doctor to complain that he had not been warned about the possible financial consequences of choosing a stool-based test for cancer screening. If Vorhis had decided to have a colonoscopy screening in the first place, he would not have owed anything, because the test would have been preventive. But after a positive stool test, “it was an accurate diagnostic for them and there was no free” diagnostic test, “Waris said.

He appealed to the insurer, but lost.

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 direct visualization test like a CT colonography, will no longer have to pay out of pocket. Under federal regulations for health plans that begin after May 31, follow-up screening is an integral part of preventive screening and nothing can be taken from patients under a health plan.

The new rule could encourage more people to get screened for gastrointestinal cancer, and cancer experts say people can have a blood-based test at home.

Nine states have already requested such coverage in the plans they regulate. Arkansas, California, Illinois, Indiana, Kentucky, Maine, Oregon, Rhode Island and Texas, Fight Colorectal Cancer, said the advocacy group does not allow patients to pay for a colonoscopy after a positive stool-based test. New York recently passed a bill that is expected to be signed soon, said Molly McDonnell, the organization’s director of advocacy.

In recent years, advocates have called for the abolition of the distribution of costs for breast cancer diagnostic services. A federal bill that requires a health plan should include a diagnostic picture for breast cancer without sharing the patient’s costs – it’s like screening for disease prevention – with mutual support, but without success.

At the same time, several states – Arkansas, Colorado, Illinois, Louisiana, New York and Texas – have made progress on this issue, says Susan G. Comen, Breast Cancer Awareness Organization. these laws were passed.

Comen said an additional 10 states have introduced similar laws in the federal bill this year. Events were held in two of them – Georgia and Oklahoma.

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

“Our main insurers are coming back,” said Molly Gutri, Comen’s vice president for politics and advocacy. “Their argument is cost.” However, she said that if breast cancer is detected and treated at an early stage, there will be significant savings.

A study that analyzed data on claims after a diagnosis of breast cancer in 2010 found that the average total cost of people diagnosed with stage 1 or 2 exceeded $ 82,000 in the year after diagnosis. When diagnosed with stage 3 breast cancer, the average cost jumped to almost $ 130,000. For people with a stage 4 diagnosis, the cost exceeded $ 134,000 the following year. The stages of the disease depend on the size and spread of the tumor, among other factors.

When asked to comment on the elimination of the distribution of costs for subsequent testing of health plans after an abnormal result, a representative of the trade group for health insurance declined to elaborate.

“Health plans develop benefits to optimize access to affordable and quality care,” said David Allen, AHIP spokesman. “Once medical conditions are identified for patients, their treatment is based on a plan of their choice.”

In addition to cancer screening, dozens of preventative services are provided by the U.S. Preventive Services Group and must be provided free of charge under the Affordable Care Act if patients meet age or other screening criteria.

But if health plans require patients to close a cancer diagnostic test without recharging, will this eliminate the cost allocation for subsequent testing after other types of prophylactic screening – such as for an abdominal aortic aneurysm – to be left behind?

“Come on,” said Fendrick. According to her, the health care system will cover these costs if some of the preventive measures, such as cervical cancer screening, are discontinued in the majority of women over 65 years of age.

“It’s slippery, I really want to ski,” he said.


If free cancer screening reveals a potential problem, subsequent costs may be added


2022 Kaiser Health News.
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