The Problem with Free Health Screening

screeningThere was an interesting opinion piece in yesterday’s New York Times by Dartmouth professor H. Gilbert Welch, who argues that the Affordable Care Act’s incentives for free preventive care may actually work against one of the law’s stated goals of helping Americans become healthier.

Welch, a professor of medicine, says the ACA’s requirement that insurance plans include free screenings, such as mammograms, serve as an incentive for Americans to undergo screening yet do nothing to ensure they’ll follow up should those screenings uncover abnormalities that could be signs of disease. In other words, he writes, the law makes a distinction between screening and diagnosis that means people have an incentive to undergo screening while facing a disincentive to pursue additional tests and treatment should the screening uncover any abnormalities:

So the woman at lower risk for cancer — the one with no signs or symptoms of the disease — has an incentive to be tested, while the woman at higher risk — the one with the lump — faces a disincentive.

In many cases, this leads healthcare providers to, essentially, commit fraud by relabeling diagnostic tests as screening tests so patients don’t have to pay for services that can, in many cases, be quite expensive, writes Welch. Additionally, when screening tests are free, patients are less likely to consider the potential downsides of screening — false alarms, over-diagnosis and the “potential for a lot of out-of-pocket costs down the line.”

Welch suggests a fix: Eliminate the “mismatch between screening and diagnosis” by having patients share the cost of screening and diagnosis:

We need people to consider medical care carefully, and that’s what cost sharing is all about. Patients already share costs on what is arguably the most important preventive service, treatment for really high blood pressure, and for procedures as necessary for setting a broken leg. Why would we treat a much closer call — screening — any different?