Patients at Integrative Family Medicine in Montpelier received a warning before they came in for their primary care check-ups: be careful what you ask your doctor.
“Insurance coverage for yearly physical exams does NOT include review or discussion of new or current health problems,” patients were advised in a letter that went out this fall. If they ask their doctor about those health issues, “your insurer may have us bill you for the services above and beyond the yearly physical exam limit.”
The intent was noble — to let patients know when and how they’d be charged for their exams, said Teresa Fama, a rheumatologist at Central Vermont Medical Center and chair of the committee that drafted the letter. “The goal was to try to protect patients, have them understand what to expect,” she said.
But the communique came as a surprise to some patients who go to the doctor planning to ask about all of their health issues. After people raised questions about the letter, Central Vermont Medical Center had the practice stop sending it out last month.
“It’s clearly something we’re all kind of struggling with,” Fama said.
There was nothing wrong with the letter itself, said Mike Fisher, health care advocate for the state of Vermont. “I applaud the provider for communicating to patients what they’ll be charged for,” he said.
However, the communication raises broader issues about the relationship between a doctor and their patient, particularly in an era of health care reform where a more comprehensive approach is being pushed as opposed to charging a fee for each service.
Fisher expressed concern patients might be reluctant to discuss health problems if they think they will be charged.
“There’s a dynamic where [a doctor’s] patients can’t communicate what’s going on for them,” he said. “It doesn’t benefit anyone.”
Fisher said he had heard a handful of complaints of similar letters in the past.
Under the Affordable Care Act, primary care visits are fully covered by insurance, and include no cost for patients — as long as it’s preventive. Primary care visits include a review of “current health status,” “a hands-on physical examination of the body,” and recommendations for immunizations or screenings such as for cancer, according to the letter. In short, Fama said, check-ups are meant to review existing problems, not to diagnose and treat new ones.
Insurance bills new treatments separately, she said, which neither the clinic nor the hospital has any control over.
Doctors don’t like patients being concerned whether they can bring up an issue, she said.
The same issue happened in breast cancer screenings, according to Fisher. Insurance covers the cost of a screening, but not a diagnostic test. When a woman brings up an irregularity, for instance, she could be charged; it’s no longer a preventative visit. The Legislature ultimately passed a law to expand insurance coverage for breast cancer screenings in 2018.
“These are some of the challenges, honestly, doctors face, trying to provide care and be clear about what the patients are charged for,” Fisher said.
For now, patients won’t be getting any letters. Integrative Family Medicine, owned by CVMC, which is a member of the University of Vermont Health Network, was the only practice Fama knew of that was sending out the letter. After a complaint in October, CVMC had them stop sending them out.
Nothing will change in the near future, with or without the letter. The federal government — not state government or doctors — dictates most billing decisions, according to Fisher.
Next month, hospital officials hope to rewrite the letter and send out a new version to patients — though Fama said she wasn’t sure what the new letter would say.
“It’s a tough subject,” she said. “It’s not something that’s easily explainable to people.”
