Health care reform aims to encourage more cancer screenings

The federal health care reform law is designed to encourage people to get preventive care by making screenings and other measures effectively free to consumers.

But the law's complexities mean consumers shouldn't assume their screenings will, in fact, be free.

Cancer screening tests are important for public health because they can save lives by identifying cancer in its early, more treatable stages.

Just ask Jeff Smedsrud.

An avid runner and basketball player, Smedsrud avoided the doctor's office for years. Seven years ago, at age 43, he decided it was time for a routine physical. He also got a colonoscopy, and it was then Smedsrud said he got his wake-up call.

"In the midst of the colonoscopy procedure, they said, 'Well, you have cancer,'" Smedsrud said. "It was stage 2 colon cancer. If left untreated, it certainly would've ended up as a stage 4 colon cancer and the survival rates are not very good."

Surgeons later removed Smedrud's cancer, and he's been cancer free since then. Undetected, the cancer could have killed him. But two years after the surgery, he ran a marathon -- in Antarctica.

Smedsrud is also the CEO of IHC Solutions, a health insurance group. He said prevention screenings make financial sense for insurance companies.

"You pay far less for people at the front end than you do in the late stages of any type of illness, so I think it's one of the good things that's come out of health care reform," he said.

In principle, the health care law requires insurers to cover preventive care -- including colonoscopies, mammograms and immunizations at no cost to the patient -- no co-pays, no deductibles.

Medicare will begin covering these tests 100 percent on January 1, but for other plans there are myriad exceptions. For people who get their insurance through their employer, just when they can take advantage of these benefits varies. Some may still be on the hook for co-pays and there are exemptions under the new law for health plans that were in place before health reform took effect.

VARIATIONS IN PLANS

Jennifer Tolbert, a health care analyst at the Kaiser Foundation, said there will be a lot of variation in whether plans have to offer free screenings.

"The advice to the consumer would be to talk to the H.R. department if they have any questions," Tolbert said. "If they've purchased a plan directly through the individual market, talk to the broker or directly to the insurer they purchased the plan from."

There's also a question about whether patients will be liable for co-pays if screenings effectively become more involved. The American Cancer Society's David Woodmansee said, for example, during colonoscopies, the doctor may remove potentially cancerous polyps, and the patient may be billed for that cost.

"What happens is that when the polyps are removed, the insurers are then coding it as a diagnostic test instead of a screening test, and that exposes the patient to much more out-of-pocket costs than obviously if it was coded as a screening test," Woodmansee said.

Robert Zirkelbach of America's Health Insurance Plans or AHIP, the national trade group for the health insurance industry, said for some of these issues, it's "not black and white." He said health providers can also trigger out-of-pocket costs by the way they bill for these procedures and said the issue is a big gray zone.

"I think there is some question about where services go from being strictly preventive to being diagnostic, where you're treating the particular condition such as removing the cancer," Zirkelbach said.

Consumer advocates say patients shouldn't assume they'll enjoy these new benefits right away, but should first check with their doctors and their insurer.

Update: On February 20, 2013, the federal government said insurance plans may not impose out-of-pocket costs (co-pays, deductibles) on patients for colorectal cancer screenings -- even when the procedure includes removal of potentially cancerous growths. Annual preventive services such as colonoscopies are free under the health care law. But there was uncertainty over whether colonoscopies remained free to patients if surgeons discovered polyps and removed them during the procedure. Some insurers argued that once surgeons removed the polyps, the colonoscopy became treatment and therefore patients were liable for some of the cost. The federal government disagrees. It says polyp removal is an integral part of a colonoscopy as a screening procedure, and accordingly a health plan may not impose a cost on patients.