Bizarre ObamaCare Incentives
Want a mammogram? No charge. But if you find a lump, you pay.
Here’s why:
A woman over 40 can have a free screening mammogram. But if she notices a breast lump and goes to her doctor to have it evaluated, she’ll pay for a diagnostic mammogram. That could cost $300. So the woman at lower risk for cancer — the one with no signs or symptoms of the disease — has an incentive to be tested, while the woman at higher risk — the one with the lump — faces a disincentive.
Source: The New York Times.
I doubt very much that most patients know or care to know the coding difference between “screening” and “diagnosis”. While I agree with Dr. Welch that there is a problem, editing labels attached to codes is not going to fix it.
The real take-away from his argument is that the system is designed to attract healthy people and not sick people to insurers. This antiselection will persist as long as Obamacare’s community rating and guaranteed issue exist.
What techniques can be used to attract the healthy people though?
Definitely not the crazy commercials the white house puts out
Those both frighten and make me uncomfortable.
As they should
If a woman finds a lump in her breast due to a self examination all she has to do is schedule their preventative screening, not mention her concern, have the test, let the diagnostician find the lump and Presto. No Charge. No disincentive.
Why? Because if you raise a concern the test becomes diagnostic and you will be charged for it. If you do not raise any concerns the test is a Screening meant to create early detection and treatment.
It will work the same with any Preventative Screening. People have to be taught how to access their care.
The article also mentions colonoscopies… in fact, I assume this applies to all basic screening procedures that would fall under preventative care recommended for a patient’s particular age/sex (such as pap smears, etc). Since these procedures can be expensive, it is important that people know what charges they might face before they incur them!
Right. Two family members recently had colonoscopies. One had a small polyp removed, so will probably be designated as screening, I think a $300 charge. The other one had a large lesion removed which turned out to be cancerous. The cost will be about $4000. Big difference.
Why such a vast difference though?
If polyp removed during screening, there should be no charge to patient, as described by Dr. Welch in his column.
I don’t know if you mean “it would be nice if it were the case” when you say “should be.” Or if you mean that is the law?
But it is not the case with Medicare. Under Medicare, for a colonoscopy that finds nothing, there is no charge to the Medicare beneficiary. (That’s the case as long as there has been five years or two years or whatever between screenings, depending on family history and what phase the moon is in and all the other government BS rules.) But if the doctor removes a polyp (you sign a form saying it’s ok to do that if he finds one), there is a 20% co-pay.
In fact, there are several problems with the test yourself method. Many doctors actually say women need just as many check ups.
As self checks yes. If you can afford it, it is highly recommended
I’m sure a woman would not care about the $300 if it saved her life.
I would hope not, that seems like a fair enough trade
Some people are crazy though
“But if you think the need for this fix is evidence that the Affordable Care Act should be repealed, think again.”
Swing and a miss.
We need to fix it though
Several years back it was brought to my attention that the way you requested an annual physical could impact how much you were charged. With an HSA, a physical every year was theoretically free. Of course, if you called your doctor and only wanted a physical, it could take longer to get an available appointment. But if you asked your doctor when you were already there, the billing code would be different than merely getting an annual physical.
The doctor would get a higher reimbursement and the insurer would have no idea that part of the exam qualified as a free preventive service. I suspect some of the same perverse incentives are also in Exchange health plans.
The insurer would not want to know that the physical should be “free” to the patient, nor should the insurer want the patient to know that!
It is in the insurer’s interest that the patient be misinformed and pay out of pocket. That way the insurer gets to “double dip”: The cost of the preventive care is included in the premium, but the patient also pays directly.
What confused me about Dr. Welch’s op-ed was that the insurer’s customer-service rep educated the beneficiary in a way that harmed the insurer financially.
I suppose insurers know that only a very small fraction of patients who pay directly learn that they have a chance at claiming the service was preventive rather than diagnostic, So, when those patients call, insurers respond positively, in order to reduce the chance of a dispute bubbling out into a wider audience, and risking more people learning about the situation.
We sorely need to euthanize the usage “So the woman at lower risk for cancer….” In English, one says, “at risk of,” “probability of,” and “chance of.” There is no “for” in the equation.