Thursday, May 1, 2014

Free Means Free

This is another profound disconnect between what is free under the Affordable Care Act and what that means with regards to treatment and more importantly diagnosis

The editorial below does the job for you. There are some aspects of free that mystify me. One is that birth control is free but of course that is under debate and then the whole abortion issue is another.

I don't have a problem with birth control and that it should be affordable and accessible. Frankly a small fee or charge for whatever kind of birth control one chooses should be just that a choice. By making any and all free those costs will be passed on to those who neither need, want or choose birth control. Is Viagra free? God forbid.

What is the problem is that the second you sign up for one there is the other. Bait and switch is essential in the medical industrial complex. So take that free colon screening and yep that positive means positively more money to be fully sure that positive was not cancer.

We have already had the debate over Mammograms and now the new pap screen seems a way to circumvent what worked and in turn costs less in the long run. Bet this new one will have a lot of "positives" to require further testing. Oh wait you said paps were free under the screening law. Well pick the old one. Like many drugs, treatments and options the old seems to have worked fine until they didn't. And that didn't mean they weren't working, they just werent' making enough money for big pharma.

The Problem With Free Health Care
APRIL 30, 2014

HANOVER, N.H. — NOW that it’s clear that Obamacare is here to stay, its supporters should focus on making the program better. Fixes are not a sign of weakness. They are a sign of responsiveness and of good management. And the Affordable Care Act does have its flaws. Here’s a big one: It favors screening over diagnosis.

While the distinction may seem arcane, it has real-world implications. Screening is what we offer to the well; it’s the effort to find abnormalities in those who do not have signs or symptoms of disease. Because screening is considered part of preventive care under the Affordable Care Act, it is provided at no charge.

Diagnosis is what we offer to those who do have signs or symptoms of disease. Because diagnosis is not preventive care, it is subject to deductibles and co-payments.

In other words: 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.

Does that make any sense? No. But it could encourage women with breast lumps not to report their symptoms.
Just how crazy this is became apparent to me when a friend enrolled on the New Hampshire exchange. Melissa is a 50-something self-employed author. She chose to be screened for colon cancer using the test doctors are most certain lowers colon cancer mortality — annual fecal occult blood testing.

Melissa’s screening test was free under the Affordable Care Act. It was also positive — she had blood in her stool, meaning she was at higher risk to actually have colon cancer. Everyone agreed about the next step: a diagnostic colonoscopy, to figure out where the blood was coming from. That’s not free; it’s real money, thousands of dollars. But had she chosen the colonoscopy as her first screening test, it would have been free.

Melissa contacted her insurer, and a representative suggested she ask her gastroenterologist to resubmit the colonoscopy claim as preventive. Pressure on doctors to recode diagnostic tests as screening tests is the inevitable result of this “incentive mismatch” between screening and diagnosis. But it’s also fraud, and Melissa knew it was wrong.

The gastroenterologists already got one fix in the Affordable Care Act. At first, screening colonoscopy was free, but if the test found a polyp, it was correctly reclassified as a diagnostic procedure, and was subject to cost sharing. In February 2013, regulators fixed the problem, saying insurance companies must also make polyp removal during screening free, noting, “polyp removal is an integral part of a colonoscopy.”

It’s true: Subsequent interventions are an integral part of all screening. Were I a mammographer, I’d happily argue that additional mammographic views, ultrasounds, M.R.I.s and breast biopsies are all part of screening.
But if you notice a new breast lump, you pay.

I wish money wasn’t such a powerful incentive in medical care. But the economists are right: Incentives matter. Right now they favor lower risk patients (those being screened) over higher risk ones (those with signs and symptoms).

They also encourage a feeding frenzy among providers to recategorize diagnostic testing as screening. Free screenings were seen as a way to get people through the door and ideally to find and address problems before they become more dangerous and expensive.

But in practice, it may not work this way. Some hospitals offer free screening knowing full well that the costs will be more than made up for by all the subsequent services required. More testing, false alarms and overdiagnosis are all part of screening. And if you make it free, patients are less likely to give proper consideration to these potential harms — not to mention the potential for a lot of out-of-pocket costs down the line.

Here’s the fix: Eliminate the incentive mismatch between screening and diagnosis. Treat them equally. Melissa would share in the cost of her fecal occult blood test. (But at around $10 to $20, it’s still roughly one one-hundredth of the cost of a colonoscopy.)

We need people to consider medical care carefully, and that’s what cost sharing is all about. Patients already share costs on what is arguably the most important preventive service, treatment for really high blood pressure, and for procedures as necessary as setting a broken leg. Why would we treat a much closer call — screening — any different?
But if you think the need for this fix is evidence that the Affordable Care Act should be repealed, think again.

Melissa had a mammogram at age 29 because her doctor thought she felt a lump. It was just fibrous tissue, but as a result, insurance companies put a rider on her policy disqualifying her from coverage for breast cancer. That’s right: Before the Affordable Care Act, if she developed the cancer that leads to the most deaths among nonsmoking women, she would not have been covered. No one wants to go back there.

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