Just over a decade ago, the passage of the Affordable Care Act (ACA, or Obamacare) made many common cancer screenings free. But a pair of new studies caution that when those free tests turn up signs of trouble, important follow-up tests may be too pricey for some patients.
The bigger concern: Some patients may forgo these expensive tests, even when they may prove lifesaving.
"With the Affordable Care Act provisions, any United States Preventative Services Task Force [USPSTF] Grade A or B recommendations are covered at no cost," explained Dr. Tina Tailor, lead author on one of the studies. "This includes a number of things, but some example of screening tests would include mammography, colon cancer screening, lung cancer screening and cervical cancer screening."
And the move towards cost-free screening "is a fundamental step in enabling access to preventive care," said Tailor, who is an assistant professor of radiology at the Duke University Medical Center in Durham, N.C.
Her study honed in on the cost of lung cancer follow-up tests and was published recently in the Journal of the American College of Radiology.
"Specifically, this refers to various types of biopsies, including surgery," Tailor explained. "A minority of patients would need these types of follow-ups. In the population studied in our investigation, approximately 7%.
"We found that individuals requiring downstream invasive testing after their [free] screening examination paid anywhere between $0 to approximately $7,500 out of pocket," she noted.
Four in 10 patients who underwent a post-lung cancer screening procedure didn't pay anything for their follow-up; the other 60% had to cough up cash to do so.
The second study, published recently in the journal Obstetrics & Gynecology, focused on the costs of a follow-up exam following concerning results from a Pap smear, HPV test or routine cervical exam.
Called a colposcopy, this type of exam may include a biopsy and a range of other gynecologic procedures.
Led by University of Michigan internal medicine professor Dr. A. Mark Fendrick and ob-gyn assistant professor Dr. Michelle Moniz, the investigation found that women undergoing a colposcopy had to fork out an average of $112 for the procedure alone.
If cells were extracted for further analysis, that figure rose to $155, the team found. And when a further analysis ended up involving a biopsy, the additional financial hit to patients could be as high as $1,000, based on 2019 figures.
"Costs much lower than these have been shown to prevent women from obtaining recommended health care," Moniz said in a university news release. "So it is high time we consider eliminating financial barriers to recommended care to prevent cancer."
What can be done? "We need to think about innovative insurance design and health policies that go beyond no-cost provisions for the initial screening test," said Tailor, who called ensuring for adequate coverage for all follow-up testing and procedures, given their critical and often lifesaving roles.
That call was seconded by Katie Keith, a research faculty member with the Center on Health Insurance Reforms at Georgetown University, who also runs Keith Policy Solutions in Washington, D.C. She stressed that the concerns stem from the way insurance companies currently process reimbursements.
"I would not call [this] a failure of the Affordable Care Act, which has dramatically increased access to preventive care and screenings," Keith said. "But additional clarity is likely needed as plans, insurers and providers draw distinctions between 'preventive' and 'diagnostic' care."
This is because "when the care is categorized or coded as 'preventive,' it must be provided without cost-sharing," Keith noted. "But when it is considered 'diagnostic' to, say, confirm prior test results or rule out an abnormal initial screening, patients can be asked to pay cost-sharing."
On that front, there has been some movement, she noted. "For instance, the Biden administration recently issued guidance to confirm that the full scope of [HIV prevention] PrEP-related services -- including certain follow-up care -- must be covered without cost-sharing, not just the medication itself.
"But in the absence of such explicit guidance, plans and insurers have some flexibility in how to define when a service qualifies as preventive, Keith noted. That means that in the end, any "comprehensive solution may require additional congressional action, to ensure the availability of follow-up tests without cost-sharing."
There's more on rules mandating free screenings at U.S. Centers for Medicare and Medicaid Services.
SOURCES: Tina Tailor, MD, assistant professor, radiology, department of radiology, Duke University Medical Center, Durham, N.C.; Katie Keith, J.D., M.P.H.. research faculty, Center on Health Insurance Reforms, Georgetown University, and principal, Keith Policy Solutions LLC, Washington, D.C.; University of Michigan, news release, Sept. 30, 2021; Journal of the American College of Radiology, Sept. 30, 2021; Obstetrics & Gynecology, Sept. 29, 2021