Health 411: No co-pay for preventive care, but there are loopholes

I went for a physical and was asked for a co-pay. I thought preventive care didn't require a co-pay under the new health law. The woman behind the desk at my doctor's office didn't seem like she knew. What's the answer? Co-pay or no co-pay?

It's not surprising that the woman you spoke with at your doctor's office wasn't familiar with details of the Affordable Care Act. Most people aren't aware of the changes to the healthcare delivery system under the law, says Dr. Tony Shih, executive vice president for programs at the Commonwealth Fund, a New York City-based private healthcare foundation.

A December public opinion poll conducted by Kaiser Family Foundation, based in Menlo Park, Calif., reported that 42% of Americans are unsure of how health reform will affect them and their families.

In any case, the new rules are confusing.

Generally, if your coverage went into effect after health reform passed on March 23, 2010, the full cost of preventive care — things like annual checkups, flu shots and cancer screenings, such as mammograms and colonoscopies — should be covered without you having to shell out a co-pay or co-insurance.

Just what's covered? Insurance companies are now required by law to pay for preventive services assigned a rating of A or B (on a scale of A through D) by the U.S. Preventive Services Task Force, a panel of medical experts that advises the government, says Jennifer Tolbert, director of State Health Reform at Kaiser Family Foundation. Patients don't have to share any of the cost for these, be it through deductibles (the amount you pay before insurance kicks in), co-pays (a fixed dollar amount for visits to the doctor) or co-insurance (a percentage of charges).

You can review the full list of preventive services covered by law at Healthcare.gov. (Once on the site, navigate to "The Health Care Law & You," then to "Key Features of the Law," "Rights & Protections" and finally to "Preventive Care.")

There are, however, health plans that are exempt from covering preventive care in full.

If your plan has made minimal changes to its benefit design since health reform took effect, it has a "grandfathered" status and is not required to comply with this provision of the health reform law.

What is considered "minimal"? Plans must not have cut benefits to diagnose or treat medical conditions or add new limits to what they'll pay. Also, there are restrictions on how much your costs can rise — the amount of co-insurance you pay, for example, has to stay at the same level it was when the law first took effect in March 2010 (if you pay 20% of the cost of your doctor visit, it can't shoot up to 30%).

Even if you've worked at the same job for a while and have seen your insurance company change from one year to the next, your plan may still be grandfathered as long as it covers the same benefits at the same costs as the previous insurer.

By next year, this special status is expected to apply to only 34% of small employers offering health plans to employees (those with 100 or fewer employees) and 55% of large employers, according to Health and Human Services estimates. Between 33% and 60% of health plans on the individual market are expected to lose their grandfathered status as well.

If your health plan is grandfathered, it is required by law to let you know this in any materials it sends you about your benefits, spelling out that it's exempt from certain aspects of the health reform law. You should have seen a statement, along with contact information for questions and complaints, included in the health plan enrollment materials you received in the fall.

Also keep in mind that only preventive services are covered in full — if you have a mammogram, for example, it will be paid for by your insurer, but if a mass is found that your doctor wants biopsied, the biopsy and all other follow-up care will be subject to co-pays, co-insurance and deductibles, as dictated by the rules of your plan.

Are you aware that some hospitals have hired someone (unknown to the patient) called a "hospitalist" to follow the patient during his or her stay? My belief is that if you have a patient who is sick enough to be hospitalized, they should not be dumped on a stranger so that the attending physician can get to his office and have more billing hours.

It's understandable that you would be alarmed by the thought of a doctor you don't know taking over your care once you enter the hospital.

"I totally empathize with the patient who chose their doctor carefully and now says, 'When I'm sick, I'm being taken care of by someone I don't know.' It's natural to feel that way," says Dr. Steven Z. Pantilat, director of the Palliative Care Program at UC San Francisco's School of Medicine.

But these days, your care is indeed more likely to be managed by a doctor specializing in hospital-based medicine (a hospitalist) than the primary care physician who treats you as an outpatient. In fact, according to the Society of Hospital Medicine, this is the fastest growing medical specialty in history, with more than 34,000 hospitalists currently practicing in approximately 3,700 facilities nationwide.

There are a number of reasons for the specialty's rapid-fire growth and for the increasing separation between inpatient and outpatient care.

For one, patients hospitalized today are generally much sicker than in years past, which makes caring for those in the hospital more complex. "They are awfully sick, with a lot of chronic medical issues," says Dr. Joseph Ming Wah Li, co-director of the Oncology Hospitalist Program at Beth Israel Deaconess Medical Center in Boston and president of the Society of Hospital Medicine.

In addition, he says, "the technology we have in the hospital today is much more advanced than what we had years ago. It's a lot to ask a generalist to practice in both the inpatient and outpatient setting and maintain competence in all of those things."

There's also a matter of efficiency. "We can respond to any situation immediately. We are [in the hospital] 24 hours a day, seven days a week and are the leader of the care for that patient," says Dr. Brent Drouin, co-chief of Hospital Medicine at San Diego-based Sharp Reese-Stealy Medical Group.

Drouin says that doctors specializing in hospital medicine understand better than primary care physicians — who may admit patients to hospitals only a few times a year — how each department and the overall hospital system functions. They've established working relationships with all the medical professionals involved in patient care, including nurses, lab technicians and radiologists.

"When you go to see the patient, you've already spoken with the consultant that they've seen, you've already spoken with the nurse and everyone is on the same page," Drouin says.

Doctors based at the hospital can also respond more quickly to a patient's needs. In the past, Li explains, a patient who suddenly became short of breath at 1 in the afternoon would prompt a nurse to contact the primary care doctor by phone and wait for orders and directions.

"Your primary care physician's option is then to drop what he's doing or ask some doctor who doesn't know you to come see you. They also aren't there at night," Li says.

Ideally, the hospitalist and your primary care doctor should work as a team that maintains close contact during your hospital stay to make sure your care is well coordinated as you move between inpatient and outpatient treatment. "There is a big upside here if people do what they are supposed to do, but it ain't perfect," Li acknowledges. "Like any system, you have to have the right operators, and it's subject to human error."

Still, there's evidence that using hospitalists improves inpatient care:

A 2009 study published in the Journal of American Geriatrics involving more than 3,600 hospitals found that teamwork across disciplines in the hospital, often coordinated by a hospitalist, reduced return visits to the hospital, as well as rates of disability and healthcare costs.

And a 2011 study published in the Journal of Hospital Medicine, examining nearly 8,300 hospital-based patient interactions, found that patients reported being just as satisfied with the care they receive from a hospitalist as they were from their own doctor.

Although it's increasingly rare for primary care physicians to follow their patients while in the hospital, it's important that people understand that the doctor isn't being shut out of the hospital, Pantilat says.

"This is voluntary," he says. "No doctor should be forced to give up hospital admitting rights and no patient is forced to use a hospitalist."

Zamosky has been writing about how to access and pay for healthcare for more than 10 years.

Got a healthcare dilemma? Email health411@latimes.com or write to Health 411, Los Angeles Times Health, 202 W. 1st St., Los Angeles, CA 90012.

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