Preventive Medicine Blog Series - Part II: Insurance Perspectives

by Emily Podmore, June 25, 2013

The Affordable Care Act has been a source of heated debate on the national political scene since its inception. Supporters herald its provision of universal care and stricter regulations for insurance companies, while critics argue that it goes against the flow of the free market and will cause healthcare costs to rise. Regardless of the polarized political stances on the issue, there are provisions in the healthcare act that mirror the growing trend of preventive medicine. One such provision is that certain preventive services are available without co-pays, co-insurance, or deductibles for patients.

So that yearly check-up, screening for high blood pressure and diabetes, and standard immunization is probably as much in your insurance company's best interest as it is in your own. If you visit your own health insurance provider's website, you will probably see a page on preventive medicine encouraging members to take advantage of the cost-share free preventive opportunities. When insurance companies provide co-pay-free preventive care, they are keeping their members healthy and reducing overall costs.

That all being said, an article in the New England Journal of Medicine has noted that "sweeping statements about the cost-saving potential of prevention, however, are overreaching." It goes on to elaborate: the cost of widespread preventive screenings far outweighs the savings from avoided treatment that will occur in only a very small fraction of the population.

Angelina Jolie made headlines recently for her preventive double mastectomy, a procedure that most insurance companies do not cover at all. In many cases, it doesn't make sense for an insurance company to provide coverage for a preventive procedure such as this one because the costs incurred far outweigh the savings in the long-run.

As preventive care expands through the introduction of new practices, more widespread use, and more advanced technology, it is understandable that health insurance companies are unlikely to provide coverage for some of the more specific and rare preventive procedures. But we're seeing these companies cutting the corner on even the most basic preventive care.

What the provision in the Affordable Care Act doesn't do is draw a clear line between preventive and diagnostic doctor visits. Insurance companies are still finding loopholes and new ways to charge you. One of the most common sources of confusion and complaint is a colonoscopy. This preventive scan recommended for older adults is covered under the preventive medicine provision of the act. That is, insurance companies should not charge co-pay, deductible, or anything for the screening. However, many patients find themselves with a bill nonetheless. This is because if anything is found during the screening and is removed, the procedure is no longer preventive and the insurance company bills them.

Colonoscopies aren't the only problem area. It isn't made clear exactly what is covered when it comes to helping smokers quit their habit either. Stop smoking campaigns are considered preventive measures, but does that cover medication, counseling, or simply warning a smoker of the associated health risks? The list goes on, and patients are as confused as ever.

So what does this mean for the future of preventive medicine from an insurance company's perspective? As was the case with the Affordable Care Act, policy makers have an opportunity to influence the future of preventive medicine and its insurance coverage. This isn't to say that policy makers necessarily have the ability to force insurance companies to cover various preventive measures. However, as further cost-benefit analyses come to light regarding preventive medicine and procedures, the government may see fit to add to its list of preventive services covered under the Affordable Care Act.

On the other hand, insurance companies may see that it is in their best interest to cover additional preventive measures to avoid costs later on. Or, to the accolade of ObamaCare's opponents, the Affordable Care Act is repealed and preventive care is only free from cost-share when the insurance companies deem it "cost-efficient."

(For additional trends in Preventive Medicine see: Here)