Answer: When the insurance company decides it is not.
A Healthcare Puzzle
The definition of screening, from a health prevention viewpoint, seems pretty straight forward: “a strategy used in a population to identify an unrecognized disease in individuals without signs or symptoms.” Typically these services are covered at 100%. However, insurance companies avoid appropriate payments for their members by changing the coding of a preventive service (which is covered 100%) into a diagnostic procedure, which is paid based on whatever the patient’s coverage allows. This change in coverage occurs because a polyp is found during the exam, which is of course, the whole point of doing the procedure: Screening and removing a polyp so that it never becomes cancer. Patients with high deductibles suddenly owe several hundred dollars in unexpected healthcare bills for a procedure they were told was covered. This is ethical and appropriate corporate policy?
And I can’t help but mention that the insurance company fancying itself a “Healthcare” company, promoting health and well-being, is the worst offender.
Subsequent colonoscopies that must be done five years later for individuals with polyps, instead of ten years, can arguably be called diagnostic. But changing the definition of a procedure solely to avoid paying for an appropriate screening exam, is another example of non-transparency, regardless of how well you explain it in the patient’s policy description.
In our “more is better” culture it is hard for people to understand that more tests do not equal better health. Physicians feel it necessary to order tests for multiple reasons; defensive medicine, patient requests, belief that it will find early, more treatable disease. Good examples of the latter is the controversy over the PSA test and yearly mammograms. In our community it is common for people of all ages to get “Life Line Screening“(the most well-known) or screenings done by other companies. It is offered at health fairs, as a perk for employees and their spouses, and at many churches. In my experience, most of the individuals undergoing these tests have almost no risk factors for the tests being run and many are too young for them.
Recently a middle-aged patient of mine came in with the results of her community screening in hand, done by a company called Stroke Prevention Plus. The first thing that I noticed was extremely high systolic blood pressure readings done by a technician looking for peripheral artery disease. This patient is a normal-sized woman who works out regularly. She’s never had a systolic blood pressure over 120 in my office much less 160. On the day I saw her it was up a little–125.
The oddest thing about the results was a black and white “photo” stuck with a piece of scotch tape in the middle of the page. It was from an ultrasound. In the middle of the photo was an arrow pointing to the edge of a black shadow and in the upper left-hand corner were the letters “L thyroid”. There was no identification on the photo whatsoever. Among the sheets that were mailed to her was a non-specific “Jane Doe” letter about “incidental findings” that could occur with the testing she had undergone. Nothing was addressed specifically to her.
My interpretation, looking at the little photo and the arrow, is that the radiologist noticed a cyst on her left thyroid while interpreting the carotid ultrasound. I am speechless that she would be notified of a possible abnormality in such an impersonal and unprofessional manner. What if it is a cancer and she ignored it or wasn’t smart enough to understand the significance of that photo? What if she thought everyone got a photo like that attached to their result sheets?
Does the company, Stroke Prevention Plus, think that they did their “due diligence” and are absolved from further followup of these abnormalities by this notification? Since they’ve performed over seven million health screenings, and no doubt monetarily flourished in the process, do they feel it unnecessary to inform a patient in a CLEAR manner what they “incidentally” found? Do they feel that they have done the patient a favor because they could have ignored the results? What an odd decision on the company’s part! I’m thankful this patient is well-educated and understood that she should talk to me. I worry about other people who are not so capable.