Many preventive screening services are covered at no cost to patients—but when they produce an abnormal result, patients are often responsible for subsequent, expensive diagnostic tests, leading to financial burdens.

New guidelines nearly double the number of Americans eligible for no-cost lung cancer screenings

Patients often face a large financial burden after initial screening

Under the Affordable Care Act, many preventive services, including breast and colorectal cancer (CRC) screening, are covered at no cost to patients, meaning they do not have to pay the copayments, coinsurance, or deductible costs their health plan typically requires.

However, when a screening produces an abnormal result, patients are often met with expensive diagnostic tests that can cost hundreds or even thousands of dollars.

"Health plans design their benefits to optimize affordability and access to quality care," said David Allen, a spokesperson for AHIP. "When patients are diagnosed with medical conditions, their treatment is covered based on the plan they choose."

In a study published in JAMA Network Open, A. Mark Fendrick, director of the University of Michigan's Center for Value-Based Insurance Design, and his colleagues analyzed over 6 million commercial insurance claims for screening mammograms between 2010 and 2017. They found that 16% of tests required additional imaging or other procedures following the initial screening. Of those, roughly 50% of patients paid at least $152 in out-of-pocket costs for follow-up tests in 2017.

In addition, those who needed testing after other preventive cancer screenings were also met with expensive diagnostic tests. On average:

• 50% of patients paid $155 or more for a biopsy following a suspicious result on a cervical cancer test
• Patients paid $100 for a colonoscopy after a stool-based CRC test
• Patients paid $424 for follow-up tests following a CT scan to check for lung cancer

Two years ago, 65-year-old Van Vorhis took an at-home stool test to screen for CRC. When the test came back positive, he needed to have a follow-up colonoscopy to determine whether he had any serious problems.

While the colonoscopy only found a few benign polyps that were removed by the physician during the procedure, Vorhis was shocked when he learned that he owed $7,000 under his individual health plan—especially since his first colonoscopy several years earlier had not cost him anything.

If Vorhis had opted to have a screening colonoscopy initially, the test would have been considered preventive and cost him nothing. However, since he already had a positive stool test, "to them it was clearly diagnostic, and there's no freebie for a diagnostic test," Vorhis said.

Similarly, 59-year-old Elizabeth Melville believed that her colonoscopy would be a zero-cost procedure. However, she was billed $10,329 for the procedure, anesthesiologist, and gastroenterologist. Her health insurer's negotiated rate was $4,144, and her portion was $2,185.

When Melville spoke with representatives from both the health system that performed the procedure and her health insurer, the health system staffer "was very firm with the decision that once a polyp is found, the whole procedure changes from screening to diagnostic," Melville said.

Should no-cost coverage be extended to follow-up tests?

Many patient advocates and medical experts have argued that no-cost coverage should be extended beyond initial preventive testing to include additional imaging, biopsies, or other services required to diagnose a condition.

"The billing distinction between screening and diagnostic testing is a technical one," Fendrick said. "The federal government should clarify that commercial plans and Medicare should fully cover all the required steps to diagnose cancer or another problem, not just the first screening test."

Under new federal rules, those who are commercially insured will no longer be met with out-of-pocket costs when they need a colonoscopy after receiving a positive stool test. The new rules, which apply to health plan years starting after May 31, classify follow-up tests as an integral part of preventive screening, which means that patients will not be charged by their health plan.

According to Kaiser Health News, many cancer experts believe the rules may encourage more people to get CRC screenings since they will be able to do them at home. In fact, one study of more than 1.2 million people ages 45 to 64 living in Oregon, Kentucky, and nearby states, found that the elimination of cost-sharing for patients who had a noninvasive CRC screening and needed a follow-up colonoscopy was associated with a 6% greater likelihood that patients would get the CRC screening.

However, the researchers only found that result in Oregon; a similar policy in Kentucky saw no increase in likelihood of patients receiving the CRC screening. According to the researchers, these findings suggest "that the enactment of policies that remove financial barriers is merely one of many elements (e.g., health literacy, outreach, transportation, access to care) that may help to achieve desired cancer screening outcomes."

"Even with positive pre-colonoscopic testing indicating a potential risk of active cancer, patients will oftentimes not follow up with the necessary procedures to address the findings," said Allen Kamrava, from Cedars-Sinai Medical Center, who was not involved in the study. "Though not the unitary factor, costs are definitely a factor—something that I have seen oftentimes myself, anecdotally, in my practice."

Advocates have also pushed to eliminate cost sharing for breast cancer diagnostic services, and some states are moving ahead on the issue.

And if health plans are required to cover diagnostic cancer testing without charging patients, some experts have wondered whether cost sharing for follow-up testing after other types of preventive screenings could also be eliminated.

According to Fendrick, health systems could absorb those costs if some low-value preventive care services are discontinued. "That is a slippery slope that I really want to ski down," he said. (Andrews, Kaiser Health News, 6/14; Andrews, "Shots," NPR, 5/31; Hamza, MedPage Today, 6/14)