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):588-593Takeaway 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.
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, CMS.gov).
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?
Patient and Health Insurance Company Interactions
Speaking with a health insurance customer representative to clarify coverage is unlikely to be as easy as one would expect or desire. As Parasuraman et al19 describe, determinants of high-quality customer service include factors such as responsiveness or willingness to assist customers, assurance of knowledge or ability to inspire trust and confidence, and empathy or care for the customer—all of which, when not present, may hinder a patient’s ability to receive quality and timely information to help them understand service types and insurance coverage regarding future medical visits.
The element of customer satisfaction is becoming increasingly important in today’s consumer-driven healthcare landscape,20 in which patients expect their health insurance providers to deliver both good customer service and value.18 Customer satisfaction not only mediates the relationship between service quality and customer loyalty21 but also plays a vital role in repurchase intentions,22 likely contributing to whether patients return for their next medical visit. Given the importance of these interactions in helping patients become more health-literate and cost-conscious healthcare consumers, we pose our final research question: How do patients describe telephone calls with their health insurance companies?
Survey items to answer the current study’s research questions were added within a much larger experimental study surrounding patients’ decision-making processes when selecting new primary care providers.
Amazon Mechanical Turk (MTurk) was used to gather the data for this study; participants were paid $1 for completing the questionnaire. Recruiting participants through MTurk allows social scientists to tap into more diverse samples compared with more standard internet and college student samples.23-25 Data cleaning procedures outlined by Dennis et al26 were used to obtain 866 valid survey responses from US participants in 49 states. Participants’ mean (SD) age was 39.2 (12.6) years (range, 18-82 years), and 57% identified as female (n = 493). Most (n = 626 [72.5%]) were Caucasian, followed by African American (n = 92 [10.7%]), Hispanic (n = 63 [7.3%]), and Asian (n = 56 [6.5%]). Small numbers identified as Native American (n = 8 [0.9%]), Pacific Islander (n = 2 [0.2%]), and other (n = 16 [1.9%]). Most had completed some level of college, with 21.1% (n = 182) having a 2-year degree, 38.9% (n = 336) having a 4-year degree, and 13.2% (n = 114) having an advanced degree. Of all participants, 92% (n = 797) indicated that they currently had health insurance.
Knowledge. Participants’ knowledge regarding the differences between preventive and office visits was assessed by providing a list of 7 procedures or tests and asking whether that procedure/test would be classified as a preventive visit or an office visit (eg, undergoing a cancer screening, getting an x-ray because of a particular injury). Participants were also given the option to respond with “I don’t know.” These items were adapted from a preventive/office visit quiz developed by BlueCross BlueShield Minnesota.14 Individual items and response frequencies can be found in Table 1. A combined knowledge score was then calculated by summing the number of correct responses participants provided; a perfect score was 7. Responses of “I don’t know” were recorded as incorrect responses.
An additional question provided participants with the following scenario: “Imagine that you go into the doctor for your annual preventive visit and physical. When the doctor asks you about your diet, you explain that you have been eating healthy—many fruits and vegetables—but you have been eating a little differently since hitting your head in a soccer match. The doctor then questions you about your head injury. The doctor suggests and performs an exam to test for a concussion. How do you think you would be billed for this visit?” Participants were then given 2 options: (1) The entire visit would be covered at 100% (free) because the primary purpose of the visit was preventive and (2) I would not be charged for the preventive portion of the visit (eg, the physical) but would be charged/billed for the portion of the visit testing for the concussion. This scenario seeks to ascertain participants’ recognition of when both preventive and office services are present within the same visit.15 This topic was designed to be applicable to all adults, regardless of age or gender, as preventive checkups are recommended for all adults,27 and the test for the concussion (ie, office service) was performed because of the possible symptom of a change in appetite.28
Ease of information seeking. Participants were given 2 single-item, 7-point Likert scale items (1, strongly disagree, to 7, strongly agree) asking them to rate their level of agreement with the following statements: (1) It is easy to get information from my health insurance provider about what is and is not covered under my insurance and (2) It is easy to have a discussion with my healthcare provider/doctor about the costs of treatment/care during a consultation.
Incorrect billing. Participants were asked a single yes or no question asking whether they had ever been charged for a medical visit when they thought it should have been covered 100% free of charge.
Descriptions of telephone calls. Participants who indicated they had previously called a health insurance provider to ask questions about their coverage before visiting a doctor (n = 387 [44.7%]) were asked the following open-ended question: “Please describe what that call/conversation with your health insurance provider was like.” To analyze these responses, 3 coauthors (K.J.S., G.M.H., S.P.M.) developed a coding scheme to examine the valence of participants’ descriptions (ie, the calls being positive, negative, or neutral, or having both positive and negative elements). Two coauthors (G.M.H., S.P.M.) then independently coded all responses yielding a sufficient level of agreement (κ >.77 and 94%-99% agreement for all categories) and subsequently met to resolve their disagreements until 100% agreement was reached.
Research Question 1
Research question 1 sought to determine individuals’ level of knowledge regarding the differences between preventive and office visits. The mean (SD) number of correct responses on the 7-question knowledge measure was 4.99 (2.01). Nearly one-third of participants achieved a perfect score (n = 284 [32.8%]). However, nearly one-quarter (n = 212 [24.5%]) answered 3 or fewer questions correctly (Table 1). Education levels of participants also had a significant effect on knowledge scores (F3,859 = 10.34; P <.001). Using a Sidak post hoc test to assess mean differences (mean values with different subscripts differ at P <.05), those who had only a high school diploma had the lowest knowledge scores (mean = 4.53a), followed by those with a 2-year college degree (mean = 4.87ab) and a 4-year college degree (mean = 5.11b). Those with a graduate degree reported the highest knowledge scores (mean = 5.75c).
Additionally, when provided the scenario asking how the consultation containing elements of both a preventive and an office visit would be billed, just under one-third (n = 254 [29.5%]) answered incorrectly that the entire visit would be covered at 100% because the primary purpose of the visit was preventive.
Research Question 2
Research question 2 sought to determine how patients’ ease of seeking information is related to whether or not patients reported being incorrectly charged for a visit. Only participants who indicated that they currently have health insurance (n = 797) were included in the analysis. Bivariate logistic regression with both variables related to ease of seeking information were included as predictors of whether or not a patient indicated yes or no that they had been charged for a visit when they thought it should have been covered at 100%. The analysis revealed a significant effect for patients’ ease of seeking information from their health insurance companies (b = —0.293; P <.001). In other words, the easier that patients perceived it was to obtain information from their health insurance companies, the less likely they were to indicate that they had been erroneously charged for a visit. See Table 2 for regression results.
In total, 223 participants (28.0%) indicated some level of disagreement with the statement that it is easy to get information from their health insurance companies about what is covered, and 217 (27.3%) indicated some level of disagreement with the statement that it is easy to have a conversation with their doctor about the cost of treatment.
Research Question 3
Research question 3 sought to investigate how patients who called their health insurance providers with questions about their coverage prior to their doctors’ visits described their calls. Of the 387 patients (44.7%) who indicated that they did call their insurance company, 379 provided a response to the open-ended question asking them to describe what their call was like.
Positive conversation. Twenty percent (n = 76) of calls were coded as positive (Table 3). Participants recalled, for example, that their conversations were “helpful” or “informative” or that the customer service representative was “friendly” or “able to answer the question.”
Negative conversation. About 15% (n = 56) of calls were coded as negative. For example, participants described their conversations as “confusing,” “long,” or with “no clear answer.”
Both positive and negative conversation. Seven participants (1.9%) described their call as having both positive and negative elements. For example, one participant recalled, “The wait time to speak to an actual human was longer than it took for them to answer any questions of mine. Overall, it went well and they always answer my questions with respect and accuracy.”
Neutral. The majority of participants’ descriptions of their conversations with their insurance providers were coded as neutral (n = 232 [61%]). Neutral descriptions were responses for which a valence could not be clearly determined. Responses of these types included descriptions such as “brief,” “seemed businesslike,” or “just an explanation of benefits.”
This research sought to understand patients’ degree of health literacy regarding their knowledge of preventive visits (ie, those generally provided at no cost) versus office visits. The results revealed that about one-fourth of participants answered fewer than half of the knowledge questions correctly, and about one-third incorrectly thought that if a visit’s primary purpose was preventive, an acute condition treated at that same visit would still be covered at no cost. Additionally, this research found that the greater ease that respondents indicated they had in receiving information from their insurance companies, the less likely they were to be erroneously charged for a visit they thought would be covered at 100%.
Although most patients described their calls with insurance companies in neither positive nor negative terms, 15% did describe their calls with insurance companies as negative. For example, patients stated that “it was confusing and I had to have the information repeated over so I could understand it” or “I got disconnected twice and no clear answers on what I needed to know prior to going to the doctors.” Of more concern, though, more than half of patients indicated that they have never contacted their insurance companies to obtain clarification of their coverage prior to visiting a doctor.
Therefore, these findings reveal dual needs: to help patients understand the differences between preventive and office visits and to encourage them to actively seek information from their insurance providers. For example, future educational outreach should focus on helping patients understand when a preventive visit might be morphing into something that a provider could potentially code as an office visit. This type of education—to help facilitate increased patient engagement and empowerment in their own care—is a key component of providing patient-centered care.29 It is expected that, in the near future, some physician reimbursements likely will be tied to the Agency for Healthcare Research and Quality’s Consumer Assessment of Healthcare Providers and Systems survey measures—measurements that assess patient-centered experiences during the care process.30 Therefore, helping patients be more aware of what is and is not covered as a preventive visit might not only help patients avoid surprise bills but also help healthcare organizations achieve higher patient experience scores.
One limitation of this study was the convenience sample of Amazon MTurk that was used. Although a geographically diverse sample of participants was collected, nearly three-fourths identified as Caucasian, and most had completed some level of college education. Future studies should try to achieve greater ethnic diversity and recruit older participants. Additionally, because survey items used in this study were added to a much larger experimental study, we were only able to assess global measures of participants’ ease of speaking with their insurance companies and providers and whether or not they were ever erroneously charged for their medical visits. Future research should strive to investigate the types of medical visits that patients attended for which they believe they were erroneously billed and whether or not in those particular cases they contacted their insurance companies previously or had a conversation with their provider. Determining if there are common ailments or procedures for which patients feel as though they are being erroneously charged may help health educators determine where additional resources could be spent to educate both patients and providers.
This research uncovered that nearly 1 in 4 people has limited health literacy regarding the differences between what constitutes a preventive visit and an office visit, with just 1 in 3 answering all knowledge questions correctly. However, all it takes is 1 healthcare visit that someone erroneously thinks is covered at 100% for a large bill to wind up in their mailbox. If health educators are able to increase patients’ knowledge regarding what is covered at no cost and insurance companies continue to improve patients’ ease of obtaining information, preventive visit utilization will, hopefully, increase along with the overall health of our society. If patients continue to be confused or even scared that they will be charged for a healthcare visit when they should not be, population health will likely be slow to improve.Author Affiliations: Brian Lamb School of Communication, Purdue University (EKP, KJS, GMH, SPM), West Lafayette, IN.
Source of Funding: This research was funded by start-up funds provided by Purdue University, College of Liberal Arts.
Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (EKP, KJS, GMH, SPM); acquisition of data (EKP, KJS, GMH, SPM); analysis and interpretation of data (EKP, KJS, GMH, SPM); drafting of the manuscript (EKP, KJS, GMH, SPM); critical revision of the manuscript for important intellectual content (EKP, KJS, GMH, SPM); statistical analysis (EKP); obtaining funding (EKP); and supervision (EKP).
Address Correspondence to: Evan K. Perrault, PhD, Brian Lamb School of Communication, Purdue University, 100 N University St, West Lafayette, IN 47907. Email: firstname.lastname@example.org.REFERENCES
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