From the Summer 2013 Issue of For Your Benefit pdf format of fybsummer2013.pdf
 Newsletter

By Robert Sorrenti, M.D., UniCare State Indemnity Plan

To screen or not to screen – that is the question. No, this is not a misquote of Shakespeare. It refers to decisions doctors have to make every day when carrying out routine examinations of their patients.  Screening tests are procedures, carried out on people without signs or symptoms, to try to identify health conditions early - to get a head start on treatment or maybe even prevent disease. Fortunately, doctors have help in deciding whether to screen or not.  The United States Preventive Services Task Force (USPSTF), authorized by Congress, is an independent group of national experts who make recommendations about the value of various types of screening, after doing extensive evaluation of medical literature and expert opinion.  Under the national health care reform act, all health plans must completely cover the cost of services recommended by the USPSTF.  Those screening recommendations services are paid by all the GIC plans with no out of pocket costs for the members.

But that is not the whole story.  Much investigation is going on to try to find more things to screen for and better screening tests.  Often, you will read in the newspaper or on the web about one study or another that supports the use of a particular test. Doctors read about those studies as well and have to figure out whether to start using the test. Some doctors may decide to use a screening test even before it becomes widely accepted into standard practice. They may have become convinced of its worth by reading the medical articles. 

Health plans, on the other hand, generally look to the recommendations of the USPSTF as the “gold standard” for what should be covered.  So when a new screening test becomes available, if it is not on the USPSTF list, it is not covered.  For example, screening for Vitamin D deficiency is currently a hot topic. Some doctors have adopted this screening in their routine care. The Endocrine Society, a national professional society with experts on Vitamin D, recommends such screening only for people already at risk, not for everyone. The USPSTF does not include Vitamin D screening in its recommendations and has just begun an evaluation of its value.  As a result, even though a doctor orders Vitamin D screening for a healthy person not at risk of deficiency, most health plans are going to deny coverage. The members will have to pay for this blood test – which could cost around $200.

How can a member protect himself or herself from getting an unexpected bill? As Dolores Mitchell, the Executive Director of the GIC, has said, don’t hesitate to become a “pushy patient”.  Ask questions.  Look at your member handbook. It will provide a listing of the screening and other preventive measures covered by your health plan. Make sure you are getting these procedures done as recommended. Sometimes people give routine screening tests a low priority.  Breast cancer screening and colon cancer screening are prime examples of tests that are often put off. Secondly, when a doctor orders a screening test you are not familiar with, ask her about what it is for and whether it is recommended for someone like you. You are at the center of your health care and you may decide you want a test and will pay for it out of your own pocket. Or you may decide you will stick with the USPSTF recommended tests out of concern about out-of-pocket costs. Your doctor should help you think these issues through to come to the decision that is right for you.

Robert W. Sorrenti, MD, MHA, is the Regional Vice President for UniCare, a subsidiary of WellPoint, Inc., one of the largest health benefits companies in the U.S. His responsibilities include oversight for UniCare’s medical management program and its various components. Dr. Sorrenti has an MD from Harvard Medical School and an MHA from Clark University.


This information provided by the Group Insurance Commission.