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The American Journal of Managed Care December 2019
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Preventive/Office Visit Patient Knowledge and Their Insurance Information Gathering Perceptions
Evan K. Perrault, PhD; Katie J. Schmitz, BA; Grace M. Hildenbrand, MA; and Seth P. McCullock, MA
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Preventive/Office Visit Patient Knowledge and Their Insurance Information Gathering Perceptions

Evan K. Perrault, PhD; Katie J. Schmitz, BA; Grace M. Hildenbrand, MA; and Seth P. McCullock, MA
Patients have an incomplete understanding of what constitutes no-cost preventive care services. Ease of obtaining information from insurance companies can significantly affect whether patients are charged correctly.

Objectives: To better understand patients’ levels of health literacy regarding what constitutes no-cost preventive visits versus possibly costly office visits and their ease of obtaining information about coverage and costs from providers and health insurance companies.

Study Design: A cross-sectional online survey of 866 participants aged 18 to 82 years from 49 states.

Methods: Participants’ knowledge of preventive versus office visits was assessed through a series of true/false questions. Participants rated their ease of obtaining information from health insurance providers and doctors about costs and coverage. They also described phone calls with their health insurance companies via an open-ended question. Logistic regression was used to predict how the ease of obtaining information is related to being erroneously charged for a medical visit.

Results: About two-thirds of participants were unable to answer all knowledge questions correctly regarding the differences between preventive and office visits. Participants reporting a greater ease of obtaining information from health insurance providers were less likely to indicate being erroneously charged for medical visits. About 15% rated their calls with insurance companies as negative.

Conclusions: Many Americans have limited health literacy regarding what constitutes a preventive care visit. Support must continue to educate the population about preventive care visits and improve the ease of obtaining information from health insurance companies about preventive coverage.

Am J Manag Care. 2019;25(12):588-593
Takeaway Points

Despite the Affordable Care Act mandating no-cost preventive care services for many with insurance, utilization rates remain low. Limited health literacy regarding what constitutes preventive visits and difficulty obtaining information from insurance providers may be to blame.
  • Only about one-third of participants correctly answered all knowledge questions about preventive and office visits.
  • Increased ease of obtaining information from health insurance companies was related to a lower likelihood of being erroneously charged for a visit.
  • Continued efforts are needed to educate patients about what constitutes no-cost preventive visits and how to easily obtain coverage information from insurance providers.
When the Patient Protection and Affordable Care Act (ACA) was passed in 2010, preventive services became increasingly accessible for all insurance holders.1 For roughly 137 million privately insured people, these services are provided at no additional cost to them.2 However, years after the implementation of the ACA, many adults are still not receiving these no-cost preventive services.3 The CDC states that the utilization of preventive services is at only about half the recommended rate.4 Limited health literacy among the population, specifically regarding no-cost preventive services, may be partly to blame.

Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”5 The ability to understand health insurance coverage is a component of health literacy. When adults do not know how to understand or process their health insurance coverage, the quality of the care that they receive can be greatly affected. Adults with limited health literacy tend to have higher medical costs and greater numbers of emergency medical treatments6 and are less likely to receive preventive services, such as mammograms or flu shots.7

When consumers do not receive medical help until illness is present, healthcare costs rise. Each year, preventable hospitalizations account for an estimated $30.8 billion.8 When continuity of care is more consistent (eg, ensuring yearly prevention checkups), lower rates of preventable hospitalizations occur.9 Farley et al10 estimate that 50,000 to 100,000 lives could be saved each year through the use of preventive care services.

The purpose of this research is to identify patients’ degree of health literacy surrounding their knowledge of no-cost preventive services. It also sought to determine (1) how patients’ ease of obtaining information about their insurance is related to whether they are correctly billed for the services they obtain and (2) their general attitudes toward obtaining information from their health insurance providers.

Knowledge of Preventive Versus Office Visits

One of the key provisions of the ACA was the mandate that health insurance providers cover a set of preventive care services at no additional cost to patients (eg, cholesterol screenings, routine vaccinations, many cancer screenings, prenatal care). Although this policy was heralded by many as a way to improve overall population health by increasing access to evidence-based services,11 a knowledge gap persists regarding which services are included at no cost and which are not. For example, Eno et al12 found that of the insured people they surveyed who reported not using preventive services, more than half indicated that they did not know preventive services could have been covered at no cost. Sawyer et al13 also found that adults possessing less understanding of the services covered by the ACA were less likely to receive these no-cost services.

The overall goal of a preventive visit is to prevent future illnesses, whereas an office visit aims to address a current or specific health issue. Office visits include, for example, getting treatment, laboratory work, or x-rays for specific health concerns, conditions, or injuries.14 A patient’s difficulty in understanding the distinction between these potentially costly services and no-cost preventive services is likely a significant barrier to encouraging more patients to access the healthcare system. The distinction is further blurred by the fact that what initially begins as a no-cost preventive care visit may morph into an expensive office visit for the patient.

Modifier 25 is a diagnostic code used by many medical coders when preventive and office services are present within 1 visit; thus, the code is responsible for changing what was originally a fully covered preventive visit into an office visit with a charge.15 Without knowledge of the distinction between service types and when service types change, patients may become stuck with high, unexpected medical bills. Ultimately, these bills may deter patients from receiving future recommended health services and add to the reasons adults are not receiving preventive care services. Given the level of complexity present when patients try to receive no-cost preventive care services, the following research question is posed: How knowledgeable are people regarding the differences between preventive and office visits?

Impact of Patients’ Information-Seeking Ease on Correct Billing

As healthcare costs increase, patients are becoming increasingly involved in their medical decisions and expect physicians and health insurance providers to act transparently.16 A host of comparison and price tools now exist to help patients determine how much a care visit will cost and where they might get the best quality of care for the best price (eg, Castlight Health, Healthcare Bluebook,

However, just because information about quality and prices exists does not mean that this information is easy to digest. A newly enacted federal rule requiring hospitals to disclose their prices to the general public has generated significant confusion because of a lack of uniformity in how procedures and prices are described.17 This level of confusion and complexity is likely one reason that many patients simply decide to not engage in health information–seeking behaviors, such as contacting a physician or health insurance provider to clarify questions about their coverage before a visit. For example, only about 22% of patients report always inquiring about the cost of their medical visit prior to attending.18 It is for these reasons that we pose our second research question: What effect does ease of seeking information have on whether or not a patient is correctly charged for a visit?

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