AAFP Calls for Changes in Preventive Services Coverage Rule

The AAFP has raised concerns about various parts of an interim final rule (35-page PDF; About PDFs) that addresses coverage of preventive services under the recently enacted health care reform law. In a letter (3-page PDF; About PDFs) to HHS Secretary Kathleen Sebelius, Labor Department Secretary Hilda Solis and Treasury Department Secretary Timothy Geithner, the Academy notes that the rule, as written, could have adverse cost implications for physicians who provide wellness services.

The Patient Protection and Affordable Care Act requires new health plans (i.e., those established on or after Sept. 23, 2010) to cover or eliminate copays, deductibles and coinsurance amounts for preventive services with an A or B rating from the U.S. Preventive Services Task Force, or USPSTF. New plans also have to eliminate copays, deductibles and coinsurance for other preventive services and vaccines whose health benefits are strongly supported by scientific evidence and recommended by agencies within HHS.

But the interim rule may contain an "unforeseen cost ramification" for physicians who see patients in an office setting, said (then) AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho, in the letter.

"If a patient comes in for a preventive service visit, also called a 'well-visit,' typically, a copay will not be collected," Epperly said. "If, however, during the visit, the patient brings up something else not related to a well-visit and the physician bills the insurance company, many times, the insurer/payer covers the preventive service at 100 percent, but the problem-oriented part at something less than the full cost."

In fact, he noted, some patients may ask the physician for treatment beyond what is typically done at well-visits, knowing that they will avoid the copay. This could put a strain on the physician-patient relationship, according to Epperly.

"Most insurance companies will have edits to 'catch' this situation, but then ... they may turn around and pay the physician less than the negotiated fee schedule," Epperly wrote.

The Academy estimates that the new law will result in an increase in the number of well-visits and a corresponding increase in the number of well-visits that include a request to provide other problem-oriented services that are not fully reimbursed. Thus, Epperly urged HHS to revise the final rule so that payers or issuers of plans that include preventive services are required to provide explicit descriptions of both a preventive visit and a problem-oriented service visit.

"We also suggest that HHS allow both a preventive service and a problem-oriented service (to) be billed when that occurs," Epperly said. "By allowing this, it provides the patient with timely provision of care for the problem and the physician the appropriate payment for handling the problem in a timely way that prevents the patient from needing to be seen at another time."

Epperly also noted that the interim final rule addresses the development of value-based insurance designs that "provide information and incentives for consumers that promote access to -- and higher appropriate use of -- value providers, treatments and services."

"The AAFP agrees that consumers should be provided information regarding in-network providers versus out-of-network providers, as suggested in the interim final rule," said Epperly. "However, the AAFP is concerned that many existing networks were developed -- or subsequently reduced in size -- based solely on cost or efficiency and, by their very nature, are a true reflection not of value-based design, but of cost considerations."

The AAFP is concerned that a proliferation of efficiency-based networks could negatively affect an already strained primary care base and, thus, curtail the ability of primary care physicians to provide preventive services, Epperly said.

He suggested that the agencies add language to the final rule that would clarify the meaning of value and that it is not solely a function of cost.