After moving to West Virginia last year, Steve Kuo signed up for a new insurance plan that would cost him $500 a month. But there was one upside: He knew he was entitled to a free preventive visit. He wanted to take advantage of it, so he made an appointment at a clinic near his new home.<\/p>\n
But then when he got there, they asked about his medical history and he mentioned prior kidney problems. When he received a bill a few weeks later, he had been charged twice for the same appointment: Once as that free preventive visit, once as an \u201coffice sick visit\u201d because of the kidney conversation. He was flummoxed \u2014 and very annoyed, as he shared<\/a> on social media. \u201cNo copayment means no copayment, exactly as stated in the insurance guidelines,\u201d Kuo told me over email. \u201cWhat is written and agreed upon should be honored.\u201d<\/p>\n He is far from alone. On Reddit, I easily<\/a> found<\/a> more than<\/a> a dozen<\/a> examples<\/a> in just the past year of people getting a surprise bill for what they thought was going to be a free visit.<\/p>\n One woman posted<\/a> a nearly $1,000 bill she\u2019d received for what she thought was going to be a preventive gynecology visit. Another woman said<\/a> that she ended up facing roughly $3,000 bills because she was given an ultrasound (which she said she didn\u2019t request) at a preventive visit, and then her blood draw was sent to an out-of-network lab. Another person lamented<\/a> that they had been billed $170 for an office visit because they had briefly mentioned back stiffness.<\/p>\n It\u2019s not supposed to be like this. Americans don\u2019t get much when it comes to our healthcare, but most of us are supposed to be entitled to at least one thing: Once every year, no matter your health insurance, you can go to the doctor with the goal of preventing future health problems by discussing important vaccinations, cancer screenings, and cardiovascular health screenings. The Affordable Care Act made that the law in 2010.<\/p>\n But more than 15 years later, people all over the country are walking into their doctor\u2019s office, thinking they\u2019re entitled to that one free visit every year, and walking out being billed for a sick visit, blood labs, and more. Researchers estimate<\/a> that Americans spend tens of millions, maybe hundreds of millions of dollars every year on services that are supposed to be free under the ACA.<\/p>\n Dr. Yalda Jabbarpour<\/a>, a family physician in the Washington, DC, area and medical director of the Robert Graham Center for Policy Studies, told me she still deals all the time with people\u2019s confusion about what a preventive visit really means.<\/p>\n \u201cEvery single time I\u2019m in the clinic, this issue comes up with a patient. And it\u2019s sad that it comes up,\u201d Jabbarpour told me. \u201cIn my mind, the blame is not to be put on the patient. The blame is not to be put on the physician. Really, this points to a bigger system issue that we need to solve.\u201d<\/p>\n How could a seemingly simple promise of one free annual doctor\u2019s visit result in a situation so convoluted that patients and doctors are still struggling with it nearly two decades later? And how might we fix it?<\/p>\n Patients are getting surprise bills from their doctors \u2014 and they\u2019re pissed off<\/p>\n The goal of the ACA was to expand coverage and make sure health insurance would be comprehensive to actually help people stay healthy. As part of that project, the authors of the law added a mandate for insurers to cover those services, including an annual wellness exam. The problem is, they did not define what the parameters of that preventive visit actually were, said Alex Hoagland<\/a>, a healthcare economist at the University of Toronto.<\/p>\n \u201cIt didn\u2019t establish a clear definition of\u2026all the diagnosis codes and procedure codes and how frequently you get that combination within a year,\u201d he said. \u201cThey don\u2019t define what actually is preventive care and what\u2019s not.\u201d<\/p>\n Do\u2019s and don\u2019t\u2019s for a preventive visit:<\/p>\n Topics that should be free to talk about: routine vaccinations, many cancer screenings, screenings for diabetes and cardiovascular health, contraception.Topics that could lead to you getting charged: chronic pain, prior medical problems, other physical and mental health symptoms (including depression).If you are a first-time visitor at a doctor\u2019s office, you may also be charged a \u201cnew patient\u201d fee.<\/p>\n That has left each insurer to define a preventive visit on their own \u2014 and that\u2019s where the perverse incentives that leave patients in a lurch begin. Preventive visits are supposed to be reserved strictly for screenings and talking about other preventive measures you can take to protect your long-term health, but you may get billed for an \u201coffice visit\u201d or a \u201csick visit\u201d if you talk about any specific symptom you\u2019re experiencing, the same as if you had come in because you had the flu.<\/p>\n Health insurers have an incentive to keep the definition of preventive care as narrow as possible, so they have to pay fewer claims without any contribution from the patient. At the same time, doctors want to be paid for the actual services that they are providing. If somebody does bring up a bigger health problem during a preventive visit, then the doctor reasonably wants to be paid accordingly.<\/p>\n \u201cI know, particularly in the healthcare space, it\u2019s really popular to blame one party or another, and here I don\u2019t think it\u2019s a matter of corporate greed or physician incompetence or whatever,\u201d Hoagland said. \u201cIt\u2019s just a natural mismatch of incentives.\u201d<\/p>\n So the reality is that \u201cone free doctor\u2019s visit\u201d sounds straightforward, but, in practice, it\u2019s much more complicated. You as the patient might think of it as one visit, but in our fee-for-service healthcare system, where providers bill based on each specific thing they do, it\u2019s not. The conversation about your vaccination may be free \u2014 but asking about your back pain is not. If you get blood tests ordered, that\u2019s another line item. The list goes on. \u201cIt\u2019s not like you walk into a doctor\u2019s office and it\u2019s just one thing that happens, right?\u201d said Sabrina Corlette<\/a>, co-director of the Center on Health Insurance Reforms at Georgetown University. \u201cIt\u2019s multiple different things that are happening when you go into a doctor\u2019s office.\u201d<\/p>\n Part of the problem may be that it\u2019s one free visit. We Americans are consumers at heart: Tell us we\u2019re going to get something for free and we want to take advantage of it. But having just one free visit may also lead to people bringing a laundry list of questions to that preventive visit, because they think of it as their only chance to ask everything of their doctor.<\/p>\n That makes it easy for the discussion to tip over into a sick visit \u2014 and not only does that lead to a surprise bill, it can also crowd out the conversation about prevention that the visit is supposed to be focused on.<\/p>\n \u201cWhat ends up happening a lot\u2026is that a patient comes in for their annual visit, and in their mind, that is their time to bring up every single thing that\u2019s been happening during the year, because they see it as the free visit to bring up everything that\u2019s happened during the year. For some patients, that takes up the entire visit,\u201d Jabbarpour told me. \u201cThey leave, and it\u2019s like, \u2018Oh my god, we forgot to do all the screening things: the vaccinations, the cancer screenings, and the cardiovascular risk screening.\u2019 And then something happens down the line because you never address those screenings.\u201d<\/p>\n A 2021 study<\/a> by Hoagland and Paul Shafer, both of Boston University at the time, estimated that Americans with employer-sponsored insurance had in 2018 alone paid between $75 million and $219 million in medical bills that should have been free. They were more likely to be charged for things like contraception or cholesterol and diabetes screenings, with individuals sometimes paying hundreds of dollars for those services.<\/p>\n Hoagland told me he had been billed for preventive visits because he has type 1 diabetes and the system automatically categorized his appointment as a diabetic visit. Earlier this year, he co-authored a study that found people with chronic conditions were more likely to be charged for preventive care<\/a>. Corlette said that she too had recently been charged for what was supposed to be a preventive visit after she mentioned an issue as an aside. And these are folks who study health care for a living.<\/p>\n \u201cIt was literally maybe a 10-second conversation where I would ask the doctor a question about something,\u201d she said. \u201cAnd that triggered it.\u201d<\/p>\n Colonoscopies are another dramatic example of how this issue plays out in real life; Corlette told me the procedure was one of the first services where this fuzzy line between prevention and treatment under the ACA became obvious. People go under for what is supposed to be a preventive colonoscopy. But then their doctor finds a polyp and decides to remove it \u2014 good clinical practice, but as a result, their patient could end up being charged thousands of dollars because the colonoscopy was no longer preventive once that polyp was snipped.<\/p>\n \u201cAll of a sudden, that would trigger what the patient thought was a preventive service into a cost-sharing obligation,\u201d Corlette said. \u201cColonoscopies can be thousands of dollars. That was when we were first like, \u2018Oh, yeah, this is a more complicated area than I think the lawmakers that drafted this provision originally envisioned.\u2019\u201d<\/p>\n How the US could fix our preventive visit headaches<\/p>\n The ACA\u2019s preventive visit promise was clearly well-intentioned and it\u2019s worth remembering that, if you look in the aggregate, more Americans are getting more free preventive care than they did before the law was passed. The problem, as much as anything, is expectations: People think they\u2019re entitled to a free visit and are understandably frustrated when they get billed for it.<\/p>\n \u201cThe difference is before the Affordable Care Act, maybe they anticipated some kind of cost-sharing,\u201d Hoagland said. \u201cBut after, they expect it to be free.\u201d<\/p>\n Sign up for the Good Medicine newsletter<\/p>\n Our political wellness landscape has shifted: new leaders, shady science, contradictory advice, broken trust, and overwhelming systems. How is anyone supposed to make sense of it all? Vox\u2019s senior correspondent Dylan Scott<\/a> has been on the health beat for a long time, and every week, he\u2019ll wade into sticky debates, answer fair questions, and contextualize what\u2019s happening in American health care policy. Sign up here<\/a>.<\/p>\n It doesn\u2019t have to be this way. Corlette\u2019s team at Georgetown University recently released a proposal that Americans be entitled to three primary care and two urgent care visits<\/a> every year with no cost-sharing. This approach has two virtues, she told me: It will help people feel like they are actually getting value from their insurance \u2014 the very complaint that Steve Kuo raised \u2014 and, because we know primary care helps prevent problems down the road, it should also improve people\u2019s health in the long term. Take the pressure off that one free visit and let people see the doctor a few times a year without worrying about being charged.<\/p>\n \u201cIn employer-based insurance, a lot of people feel like, \u2018What the hell am I getting for my premium each month?\u2019\u201d Corlette said. \u201cWe wanted people to feel like they\u2019re getting good value, and we wanted to get to better population health.\u201d<\/p>\n Hoagland also endorsed the idea of at least one free physician\u2019s visit every year, no matter what\u2019s discussed. In the long term, Jabbarpour said she\u2019d like to see copays eliminated entirely for primary care.<\/p>\n But any payment reforms are not going to happen immediately. What can we do right now?<\/p>\n For one, doctor offices could make an effort to be as transparent as possible. Jabbarpour\u2019s MedStar system has started calling people a couple of days before their appointment with a brief script that tells the patient that they could be charged if the conversation with their doctor touches on additional medical problems. If your doctor\u2019s office doesn\u2019t proactively bring it up, ask when you schedule your appointment or when they call you to confirm it. Worst-case scenario, ask your provider what they consider preventive care when your visit begins. You might also want to educate yourself on what services are generally considered preventive and should be available for free: Your insurer may make that information available on their website, or KFF has a database you can peruse<\/a>.<\/p>\n It\u2019s not a perfect solution. \u201cWhat ends up happening is patients come in, and they say, \u2018I know I\u2019m not supposed to talk to you about anything else, so I\u2019m not going to tell you about anything else.\u2019 And you don\u2019t want that to happen,\u201d Jabbarpour said. You should ask your doctor directly: What do you consider to be preventive care? Establish boundaries at the start. That way, you can at least be aware if you are going to get charged because the conversation crossed the line to discussing an active health problem.<\/p>\n And if you want to see the underlying laws change, start organizing. Contact your state and federal reps and ask them what they are doing to ensure this stops happening. Things could be different: Jabbarpour said she hopes to one day work in a health system where the cost of a single primary care visit isn\u2019t so high-stakes, where doctors and their patients can manage their health according to their particular needs, rather than worry about how to bill for one specific conversation that covers the whole range of somebody\u2019s health \u2014 like primary care is supposed to do.<\/p>\n \u201cI think some patients can be managed by seeing us once every year, once every two years, and some patients need to see us monthly,\u201d Jabbarpour told me. \u201cTo put all patients in the same box and say you can only see your primary care physician once a year if you want it paid for, it makes zero sense.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"After moving to West Virginia last year, Steve Kuo signed up for a new insurance plan that would…\n","protected":false},"author":2,"featured_media":870594,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[59],"tags":[191309,97,252,253,1343,5599,166767],"class_list":["post-870593","post","type-post","status-publish","format-standard","has-post-thumbnail","category-health-care","tag-good-medicine","tag-health","tag-health-care","tag-healthcare","tag-policy","tag-public-health","tag-the-highlight"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/870593","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/comments?post=870593"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/870593\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media\/870594"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media?parent=870593"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/categories?post=870593"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/tags?post=870593"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}