Updating Patients on Benefits and Absence of Co-Pays in Wellness Care

In a recent report, "Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally," Karen Davis of the Commonwealth Fund (2014a) provides evidence that although the United States spends substantially more per citizen on health care than other industrialized countries, it continues to have very poor outcomes. While the United States spends about $8,508 per citizen annually, the United Kingdom spends only $3,406, and yet ranks number one in outcomes (Commonwealth Fund, 2014b).

Among the 11 nations studied in this report — Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States — the U.S. ranks last, as it did in the 2010, 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling is the finding that the U.S. fails to achieve better health outcomes than the other countries. As shown in the earlier editions, the U.S. is last or near last on dimensions of access, efficiency, and equity. (Commonwealth Fund, 2014a)

On quality measures such as patient-centered care, safety, efficiency, and care coordination, the U.S. falls in the middle of ratings despite the fact that the Institute of Medicine has been advocating for improvement in these areas since 2001. Other industrialized countries, where universal health care is the norm, have much higher ratings and have developed modern health information systems. Given our capitalistic, market-based economy, the United States has not had coordinated efforts to develop sophisticated information systems that are interactive across settings of care; consequently, health care providers often do not receive timely and accurate information regarding patients. Frequently, this leads to redundant testing and errors. Only about 20% of U.S. hospitals have fully integrated information system. Patient-centered care plans and handoffs between settings and providers are often nonexistent. Physicians and hospitals in this country are trying to catch up as a result of significant federal financial incentives to develop and adopt health information systems that provide data for meaningful use.

The U.S. ranks a clear last on measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year. (Commonwealth Fund, 2014a)

The United States scores on all three indicators of healthy lives — mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60 — achieved the lowest rank of 11 in each area (Commonwealth Fund, 2014a). Many of the poor outcomes in the country are related the absence of universal health care, thus limiting access to care often due to cost. Patients in the United States have rapid access to specialized health care services such as emergency department visits; yet, "they are less likely to report rapid access to primary care…however, the Netherlands, U.K., and Germany provide universal coverage with low out-of-pocket costs while maintaining quick access to specialty services" (Commonwealth Fund, 2014a).

As has been discussed in prior ViewPoint columns, the Affordable Care Act (ACA) of 2010 has provisions that aim to remedy many of the U.S. problems discussed above. In 2014, we have seen more than 7 million uninsured gain insurance and others benefit from provisions in their current insurance where they do not have lifetime limits for health care expense and cannot be denied care due to preexisting conditions. Ambulatory care nurses need to be acutely aware that although many uninsured have signed up and received insurance fostered by the ACA, these newly insured patients may not be aware of benefits of their newly insured status. A recent Robert Wood Johnson Foundation (2014) Content Alert describes a 2014 finding that there has been no increase in physician office visits despite the increase of newly insured patients. Ambulatory care nurses will need to enhance patients' understanding of benefits, and encourage participation especially in wellness, health promotion, and early detection of diseases. Because wellness and preventive care have been cost prohibitive for many, we have populations who do not routinely access primary care and prevention. For example, newly insured patients (and even patients who are continuing on their current insurance plan) may not know that preventive screening and immunizations no longer have co-pays because of ACA provisions. In the United States, chronic diseases, which are responsible for 7 of 10 deaths among Americans each year and account for 75% of the nation's health spending, are often mostly preventable if precursors or symptoms are detected early and treated (U.S. Department of Health and Human Services, 2011).

In the United States, there is evidence that women have consistently not accessed preventive screenings such as mammograms or Pap smears. Female patients need to know that these tests are now fully covered with no copays. On August 1, 2011, well-woman visits, contraception, and interpersonal and domestic violence screening and counseling became part of preventive services without a co-pay. Other women's preventive services are now covered without cost-sharing. Included are: gestational diabetes screening, HPV DNA testing, sexually transmitted disease counseling, HIV screening and counseling, as well as breast feeding support, supplies, and counseling (U.S. Department of Health and Human Services, 2011).

Women are usually responsible for seeking and arranging health care visits and following through with recommended treatments. Therefore, ambulatory care nurses should be informing women about available preventive screenings and counseling that do not require out-of-pocket costs. Once fully informed, women will hopefully initiate wellness and preventive screenings for themselves and other family members.


Commonwealth Fund. (2014a). Mirror, mirror on the wall, 2014 update: How the U.S. health care system compares internationally. Retrieved from http://www.commonwealthfund.org/publications/ fundreports/ 2014/jun/mirror-mirror

Commonwealth Fund. (2014b). U.S. health system ranks last among eleven countries on measures of access, equity, quality, efficiency, and healthy lives. Retrieved from http://www.commonwealth fund.org/ publications/press-releases/2014/jun/us-health-systemranks- last

Robert Wood Johnson Foundation. (2014.) ACAView: Tracking the impact of health care reform — First observations around the Affordable Care Act. Retrieved from http://www.rwjf.org/ en/research-publications/find-rwjf-research/2014/07/acaviewtracking-the-impact-of-health-care-reform.html?cid= xem_a8279&rid=3D_AhTVu0Mbh9s9JLheDPQ

U.S. Department of Health and Human Services. (2011). Affordable Care Act rules on expanding access to preventive services for women. Retrieved from http://www.hhs.gov/healthcare/ facts/factsheets/2011/08/womensprevention08012011a.html

Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at shaas@luc.edu