Annual physical exams, blood tests, routine cancer screenings and other preventive health care services will soon be less costly for many Mainers.
New federal rules set to take effect over the next several months will eliminate preventive care co-pays and deductibles for people covered by Medicare and new private insurance plans.
Not everyone will benefit from the changes, which are part of the federal health care reform law passed in March. But it’s a trend that should keep patients healthier and health care costs lower, according to Maine health care providers.
“If we can detect and find things early, you’re definitely going to prevent the expensive downstream costs,” said Betsy Johnson, a physician and medical director at Portland-based Martin’s Point Health Care.
Seniors who have Medicare coverage currently have to pay the entire cost of annual physicals and as much as 20 percent of the cost for periodic tests, such as mammograms and colonoscopies. As of Jan. 1, Medicare will pay 100 percent of those costs, as well as fully covering some other services.
Some privately insured patients will see similar changes starting this year.
Beginning Sept. 23, all new private health insurance plans will cover 100 percent of the costs of breast and colon cancer tests, as well as checkups for children and pregnant women, and other services.
However, people covered under private health plans that existed before March 23 — including the vast majority of those covered through their jobs — will continue to pay their existing out-of-pocket costs until they or their employers change to new plans. Plans that predate the Affordable Care Act are considered exempt, or grandfathered, as long as they don’t significantly reduce benefits or increase employee premiums.
The phase-in is one of the first pieces of the federal reform law to take effect and is part of the larger transition toward a new health insurance market that advocates hope will reduce the runaway cost of health care.
In the private market, an estimated 41 million Americans should benefit from the new policy this year and a total of 88 million should benefit by 2013, according to the U.S. Department of Health and Human Services. About 98 million people are covered by health plans that are grandfathered and would not be affected.
The expansion of coverage benefits could increase insurance premiums by 1.5 percent on average, according to the department.
On the other hand, encouraging better preventive care will ultimately save both lives and money by catching illnesses early and avoiding expensive surgery and critical care, advocates said.
“I think we’ll see more people availing themselves of these tests because they don’t have the financial burden,” said Carol Rancourt, a Medicare expert with the Southern Maine Area Agency on Aging. “In the early days, of course you’re not going to have the costs savings. But once you’ve intervened with enough people and you see you’re having less colon cancer surgeries and less mastectomies (there will be savings). When you think about it, it can be substantial.”
Seniors covered by Medicare can potentially save hundreds of dollars a year for preventive care services. An annual physical exam may cost $100 to $200 and is not now covered by the government insurance plan.
Dan McCormack, chief executive of South Portland-based Intermed, said he expects an increase in calls for physicals early next year, although the network of medical practices has not yet seen any impact.
“To the extent that people can have access to preventive care more readily or in a more affordable way, that’s a good thing,” he said.
“If you have to pay $25 to have a Pap test (for cervical cancer), you’re not going to get the Pap test, or at least a lot of people won’t,” said Robert McAfee, a retired surgeon from Portland and former president of the American Medical Association.
Although the insurance industry historically did not encourage preventive services, that is now changing, he said,
Maine’s DirigoChoice program fully covers preventive care and “several of the (private) companies have started selling in Maine.”
Health care providers said patients are still learning about the changes, or how they will be affected.
“We are not seeing any reaction from patients about it,” said Andrea Maker, vice president of corporate affairs for Martin’s Point Health Care. “It’s hard to know what applies to you and when it’s going to apply.”
Johnson, medical director at Martin’s Point, said the out-of-pocket costs for annual physical exams and tests was clearly keeping some patients away. And the experts say annual visits can have a big impact on health care costs because it gives patients and physicians a chance to talk about healthy habits and behaviors.
“I just think there’s a lot of value in having that annual visit,” she said.
And the coverage of additional lab tests also will clearly pay off over time, she said. A simple blood test that finds elevated sugar levels, for example, can identify someone at risk of diabetes before it’s too late.
“If you detect that early (you) can give them education about preventing diabetes as opposed to having them coming in with full-blown diabetes — that’s more costly in the long run,” she said.
Staff Writer John Richardson can be contacted at 791-6324 or at:
jrichardson@pressherald.com
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