The blurred line between preventive care and treatment


Preventive care is often overlooked in the U.S. healthcare system as a valuable tool to help patients avoid chronic conditions and save the industry dollars. The health reform law meant to compel patients and doctors to take advantage of various preventive care and screening services by requiring health insurers to fully cover them. But there are two obstacles thwarting the law's ability to achieve its goal--preventive care hasn't yet increased and there is confusion about when preventive care and treatment overlap.  

Despite the full coverage of preventive care and services, many patients don't use them. In fact, less than half of adults over 50 are up to date on their colon-cancer screening, just half of eligible women get an annual mammogram, and only 28 percent of smokers are counseled on how to quit. 

Also, an important caveat in the reform law left a gaping hole between preventive care and treatment because federal lawmakers didn't specify who must pay for treatment required as a result of preventive care. Depending on how preventive services are billed, insurers aren't required to cover everything. For example, if the preventive service is billed separately (e.g., a cholesterol screening), then a health plan can impose cost-sharing requirements with respect to the related office visit. If the preventive service is not billed separately from an office visit and the primary purpose of the visit is delivering preventive care, then the plan must cover the whole visit. 

Likewise, if doctors find and remove a polyp during a colonoscopy, some insurers require the patient to pay for the polyp surgery, which is considered treatment, even though they covered the colonoscopy, which is preventive care. Because of this loophole, it remains unclear how insurers and doctors are supposed to handle patient cost sharing for preventive checkups that turn up medical findings like a skin lesion or breast lump needing a biopsy or excision during that visit. "Should this be a preventive visit with a modifying code, should it be considered only therapeutic, or should the patient be brought back for the needed care? It will take some clarification and time to work this through," says Dr. Roland Goertz, president of the American Academy of Family Physicians. 

Preventing healthcare problems is an essential part of overall wellness and more people will likely undergo vital preventive tests, saving themselves from enduring the pain from a variety of diseases and illnesses because the reform law now covers it.

But patients won't be able to take advantage of these services if federal lawmakers don't clear up the confusion surrounding preventive care and treatment. I think doctors may be hesitant to recommend preventive services if there's confusion about payment; I think patients will be less likely to undergo preventive services if there's a chance they have to pay out of pocket. Hopefully, we will see some clarification on this issue in the near future so that preventive services are better integrated into our healthcare system. - Dina

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