An Ounce of Prevention and a Pound of Greed: Insurance Barriers to Preventive Care

Matt Freeman DNP, MPH


The Cough

There is an infectious disease that is more contagious than Ebola. Every year, there are an estimated 16 million cases of pertussis (whooping cough) and 195,000 people die every year from it. The United States hit a peak of pertussis cases in 2012 with 48,277 cases; the largest number since 1955.

PertussisBoy struggling with pertussis
Centers for Disease Control Public Health Image Library

It is unthinkably painful to watch a child gasp for air from whooping cough. There is an unmistakable, strident cough. The kid turns blue from lack of oxygen. Some survive; some do not. In adults, the disease is not usually deadly, but it is agonizing: a so-called “100-day cough” leading to loss of work and school, but—above all–infection to others.

It is easily prevented by a safe, effective vaccine.


The Cancer

Eleven thousand American women are diagnosed every year with cervical cancer, the most common cancer among young women. Four thousand four hundred will die every year from the disease. It is a painful, tragic death at a young age. Almost all of the cases are attributable to human papilloma virus (HPV).

The viral strains that cause cervical cancer are easily preventable with a series of three safe, quick vaccines.


A newlywed, who passed away at age 26 from cervical cancer
Caters New Agency

The Virus

The most recent statistics from the Centers for Disease Control and Prevention (CDC) are from 2013: there were an estimated 47,352 new cases of HIV, and 13,712 deaths from HIV/AIDS. Although deaths from HIV have declined, it is still a life-threatening chronic illness, with widespread complications to multiple body systems.

Although not a vaccine, HIV infection can be prevented by a daily pill, tenofovir/emtricitabine (Truvada,) which is profoundly effective at preventing viral transmission. Deemed no more toxic than ibuprofen, tenofivir/emtrictiabine can be prescribed as “pre-exposure prophylaxis” or PrEP. It has the power to end the gruesome deaths from AIDS and the costly and complicated life of living with HIV.

Mathematical models indicate that the cost per quality-adjusted life-year (QALY) gained was $160,000, a cost saving of $740,000 with a number needed to treat of only 64 patients.

5226171134_137becb684_bThe National AIDS Memorial
Photo by Steve Rhodes 


Defining Prevention

Pertussis vaccine, HPV vaccine, and PrEP are all forms of primary prevention. This is “golden” form of preventive medicine: taking action before a disease actually strikes.

Secondary prevention refers to screening for a disease in order to intervene sooner. An example might be screening a patient with for cervical cancer test to see if the disease has already struck. You are till to late, but you can hope to intervene before she suffers.

Tertiary prevention refers to mitigation of the effects of an illness that has already set in. This might mean preventing the adverse effects and complications of a ventilator used on a child struck with pertussis.


The Surprise Barrier to Primary Prevention

Most healthcare providers I know have pulled their hair out because of “anti-vaccine” efforts that prevent vulnerable patients from receiving vaccines they need. Despite my frustrations with “anti-vaxers,” I have taken a lesson from pediatrician and vaccinologist Paul Offit MD, who urges compassion. Anti-vaccine advocates are presumably genuine in their fears. They have been misled by unscientific, groundless but convincing information.

The surprise barrier is not from “anti-vaxers,” it is from health insurance companies.

Under the Patient Protection and Affordable Care Act (PPACA) of 2010, most health plans must cover preventive service without a copay, coinsurance, or deductible. Even a patient with a high deductible health plan need not worry about a pertussis vaccine or HPV vaccine because these services are covered at no out of pocket cost to the patient.  PrEP is slightly different because some patients have a deductible for medication costs, but the pharmaceutical manufacturer offers generous subsidies to cover out of pocket costs. The bottom line is: cost should not be a concern.

There is one massive snag: insurers may not reimburse the healthcare provider or may not offer enough “in network” providers to cover the costs.


Vaccine Reimbursement

Human Papilloma Virus (HPV) vaccine is sold to healthcare providers for $178.04 per dose. A healthcare provider stocks HPV vaccine in the refrigerator, administers the vaccine when necessary, and sends a bill to the patient’s insurance company. The insurer then reimburses the healthcare provider for the cost of the vaccine.

Insurance companies maintain reimbursement “schedules,” which generally cover the cost of the vaccine. For example, one insurer that covers half of the market in my state reimburses $187.03 for an HPV vaccine. The extra $8.99 can cover shipping, the cost of the needle, alcohol, the extra time to administer the vaccine, and perhaps the cost of submitting charges. It is fair enough.


But the insurer does not actually have to follow its state “schedule.” In my case, this insurer’s contract states that they will pay 80 percent of the reimbursement schedule for all services. But that’s not where it stops. One insurer knocks off another 20 percent if the vaccine is ordered by an advanced practice nurse rather than a physician.  That means that the reimbursement went from $187.03 to $112.22.

My office loses  up to $65.52 per dose and we lose $197.47 per HPV vaccine series.

It would be unethical and a breach of our contract to bill the patient for the balance.

When we discussed this issue with the “network coordinator” for the insurance company, she said, “That’s why most people just give up.” I wonder how she would feel if a loved one died of pertussis or cervical cancer.

There is no regulation on vaccine reimbursement to healthcare providers. The insurance companies’ primary responsibility is to their shareholders, not public health. They are required to make certain that vaccines are covered but not required to make certain that it is financially feasible for doctors’ office to make the vaccines available.

One could ask, “Shouldn’t these patients go to a health department or some other office?” Most of my patients are covered by commercial insurance, and are therefore ineligible for subsidized vaccines under the “Vaccines for Children” (VCF) program available by some health clinics and health departments.

When my office spoke with the same networking representative, we inquired about sending patients to a pharmacy to receive vaccines. She explained that most pharmacies would not cover these patients as they were not “in network.” Network relationships aside, it seems absurd that we could not just administer the vaccine sitting in our refrigerator.


Network Participation

The preventive service mandate of the Affordable Care Act requires that the service be rendered by an “in network” provider. This means that the clinician: (physician, physician assistant, advanced practice nurse) has been deemed worthy of participating in the insurer’s network and has been granted a contract.

As discussed here: network participation is complicated and expensive.

The law in my state requires that an insurer have an adequate network to offer preventive services within 60 days. One insurance company claimed that they are “closed” and do not need any more providers, so my office tested their claim:

Screen Shot 2016-03-07 at 14.39.52

On the insurance company’s web site, there were 24 listings available when I said I wanted to see a male primary care provider who is accepting new patients. That sounds promising.

Take a second look: five of those listings were duplicates. Nine were not actually in primary. Since these clinicians had completed internships and residencies in internal medicine prior to their fellowships, they are listed as “internists,” but some are cardiologists, nuclear medicine specialists, even one pathologist. They are not serving in a primary care role.

Only four were accepting new patients, and the wait time for an appointment was six weeks for a “sick visit” (state law requires insurers to guarantee a 15 day maximum wait time for a sick visit.)

If you are enrolled in that particular insurance plan, and you want to obtain preventive services from an “in network provider,” you are going to be waiting a long time.

In some cases, insurers have said that they will cover a preventive service such as a vaccine or routine physical examination. My office has been skeptical, called the insurer advance, received the name, time, date, and a “call reference number” stating that the service would be covered. Then the patient got a bill for $350. When asked why the service was not covered, the insurer just says “no.” It is an expensive problem for a patient who is trying to protect his or her own health, yields fury toward our office, and we can end up “writing off” the cost of vaccines because the insurer said that they would cover the cost, but then changed their mind.

Patients complained bitterly, hoping to see me. They wrote to the local networking representative, the State Department of Insurance, and the national ombudsperson for the insurance company. A representative from the “Resolution Office” for the insurer told me that I was lying, and that patients “will never hear back from us.” I asked if she was willing to go “on record” with that statement. “Yes, but I wouldn’t phrase it that way,” she replied.



The Case for PrEP

Since it is a comparatively new feature of preventive medicine, PrEP is prescribed by only a handful of clinicians. In fact, fewer than ten percent of infectious disease specialists stated that they had prescribed it. But infectious disease is also the wrong place for those who are not infected. PrEP is a primary care preventive medicine responsibility, and thus should be in the hands of a competent primary care provider.

In the case of the insurer with only four available primary care providers, none of their office representatives said that they offered PrEP.

When we asked the insurance carrier where to send patients who did want PrEP they had no answer.

Like vaccines, PrEP cannot be offered as an “out of network” service since it is preventive in nature. It just is not available.

Ironically, the insurer has built a national marketing campaign regarding LGBT health, a bold move in a conservative business. But their actions defy their marketing. Patients in my city of one million people have to drive 161 kilometers (100 miles) every three months if they wish to see an “in network” provider who offers PrEP.


What does this all mean?

The failure to make preventive services like vaccines and PrEP financially feasible and readily available is a failure of our public health infrastructure. We have legislation requiring that insurers cover these services, but coverage is not the same as availability. Furthermore, if the cost to the healthcare provider is so extreme, preventive care can be so costly that fewer healthcare providers will be available and willing to provide the service. As a consequence, more people will be infected with infectious diseases, morbidity, mortality, and costs will skyrocket.

It is a tragedy that insurers are so morally bereft that they would suggest “just giving up,” and that patients should never expect a response to their concerns. Insurers do not need to care. As long as their revenues please their shareholders, nobody is going to stop them.


What are potential solutions?

  1. Narrow networks may save money for insurers, but drastically prevent access to care. Insurers blame doctors for failing to update their “demographic information,” but any outsider looking at the provider directory can see that the insurance company is inattentive to the availability of primary care providers. A network can be so narrow that it is useless.

    Since legislative action, such as “any willing provider” laws would take a glacial pace, it is up to healthcare consumers to speak out against insurers and to launch class-action litigation.
  2. Preventive care should not be limited to network participation. This is stop-gap measure until the networks are opened, and possibly an “easier pill to swallow” for insurance companies.
  3. Vaccine reimbursement must never be “discounted.” This is a fixed cost. It is unreasonable to ask any healthcare provider to bear a $194.47 cost to immunize a young person against human papilloma virus. It is profoundly morally bankrupt for the insurer’s response to the problem to be, “just give up.”Although vaccine manufacturers have laws preventing negotiations with insurers over reimbursement, I would bet that Merck would want to facilitate the availability of its HPV vaccine. They have shareholders too.
  4. If an insurance company does not have an “in network” provider offering an essential preventive service like PrEP, they have an ethical duty to make certain that this service is available. They also have a financial responsibility: PrEP saves money, so it seems contradictory to make it unavailable to those who wish to take it.Since legislation and government oversight is likely to be weak on a good day, the pressure should come from the pharmaceutical manufacturer. After all, the patients were told that they would “never hear back” from their insurance company.




Chen A & Dowdy DW. Clinical effectiveness and cost effectiveness of HIV pre-exposure prophylaxis in men who have sex with men: risk calculators for real-world decision making. PLOS One. 6 October 2016.

Conniff J & Evensen A. Preexposure Prophylaxis (PrEP) for HIV prevention: the primary care perspective. Journal of the American Board of Family Medicine. 29:1; January-February 2016.

US Centers for Disease Control and Prevention. Pertussis. Retrieved 18 April 2016.

US Centers for Disease Control and Prevention. HPV. Retrieved 18 April 2016.

US Centers for Disease Control and Prevention. HIV in the United States At a Glance. Retrieved 18 April 2016.

US Department of Health and Human Services. Preventive Services Covered Under the Affordable Care Act. Retrieved 18 April 2016.


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