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From the Editorial Board: Anne K. Gauthier, MS

The American Journal of Managed CareDecember 2019
Volume 25
Issue 12

Ensuring that everyone gets appropriate preventive care is not controversial. These services can improve health, save lives, and arguably, save money. Yet there is a very large gap between what is recommended and what people receive. One study found that only 22.4% of adults received 76% to 100% of recommended preventive services, and 16.3% received 0% to 25%.1 There are several reasons for this disturbing state of affairs, including accessibility and having a dedicated healthcare provider,2 but for people with insurance coverage, cost barriers no longer exist.

Thanks to the Affordable Care Act, private health insurance plans are required to provide certain recommended preventive services without any type of cost sharing. But as an article in this issue of The American Journal of Managed Care® illustrates, there is a lack of awareness about this benefit. About a quarter of the research participants did not know that the preventive service benefit is treated differently (ie, no charge) than a regular office visit. About a third do not understand how the charges should work when a trip to a provider contains both prevention and treatment, opening the window for a large bill to surprise them.

There is an opportunity to realize some relatively easy wins in improving patients’ understanding of their preventive care benefits by capitalizing on some current policy, market, and cultural trends. First, the price transparency movement just took a key step forward with CMS’ November release of a new proposed “Transparency in Coverage” rule directed to insurers alongside its release of the final 2020 Outpatient Prospective Payment System rule that includes hospital price transparency requirements. The new proposed rule would require plans to disclose their negotiated rates for in- and out-of-network providers, a feature likely to garner a fair amount of controversy. It would also require plans to give consumers personalized information about their cost-sharing obligations for all covered healthcare services and items. Although price transparency initiatives are targeted more at costly care, there is an opportunity to leverage these policy changes to provide additional information to beneficiaries about preventive services coverage. If the rule is finalized and contains this requirement, adding personalized information about no-cost preventive services could be one of the insurer innovations woven into its implementation.

Second, outside of any government rules, private insurers are improving their websites regularly to educate their members about benefits and cost sharing, as well as other important healthcare information. They often have sections on appropriate preventive care individualized by the member’s age and sex. Again, a possible easy win: Include not only information about what is recommended but also an interactive module to make it clear that preventive services are available at no cost and examples of billing for visits that combine prevention and treatment.

Third, given the strong evidence over the past 15 years or so that online portals about benefits, costs, and clinical information are underused, one might be skeptical of the value of these sites to help alleviate the tough problems of increasing access and utilization of preventive care and improving health literacy. That is fair enough, but today’s price transparency and interoperability efforts will change the ways that insurers and providers communicate with patients, including using increasingly sophisticated websites and mobile apps. It is helpful to remember that the prevalence of smartphones grew extremely rapidly and has changed the way patients communicate with insurers and providers. Let’s leverage the private- and public-sector efforts to empower patients to access preventive services. Let’s grab the low-hanging fruit.


1. Borsky A, Zhan C, Miller T, Ngo-Metzger Q, Bierman AS, Meyers D. Few Americans receive all high-priority, appropriate clinical preventive services. Health Aff (Millwood). 2018;37(6):925-928. doi: 10.1377/hlthaff.2017.1248.

2. Tuckson R, Blumenthal DS. Why aren’t millions of Americans getting preventive care? STAT website. statnews.com/2016/04/15/preventive-care-public-health. Published April 15, 2016. Accessed November 25, 2019.

Ms Gauthier is affiliated with The MITRE Corporation.

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