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The new requirements promise significant benefits for consumers — if they take advantage of the services that should now be more readily available and affordable.

In general, the government said, Americans use preventive services at about half the rate recommended by doctors and public health experts.

The rules will eliminate co-payments, deductibles and other charges for blood pressure, diabetes and cholesterol tests; many cancer screenings; routine vaccinations; prenatal care; and regular wellness visits for infants and children.

Other services that must be offered at no charge include counseling to help people stop smoking; screening and counseling for obesity; and tests for infection with the virus that causes AIDS.

“Getting rid of cost-sharing is a long-overdue step in the right direction,” said Kenneth E. Thorpe, a professor of health policy at Emory University in Atlanta. “But we will have to do a major public education campaign to get people to take advantage of these clinical preventive services.”

The rules stipulate that no co-payments can be charged for tests and screenings recommended by the United States Preventive Services Task Force, an independent panel of scientific experts. The rules apply to new health plans that begin coverage after Sept. 23 and to existing health plans that make significant changes after that date. The administration said the requirements could increase premiums by 1.5 percent, on average.

Kathleen Sebelius, the secretary of health and human services, said the rules would extend benefits to 31 million people in new employer-sponsored plans and 10 million people in new individual plans next year.

In many cases, insurers will be allowed to charge for goods and services needed to treat a condition detected in a screening. For example, consumers can receive free screenings for depression and high cholesterol, but they might be charged co-payments for antidepressants and cholesterol-lowering drugs.

In some cases, the task force has specified how frequently a service, like colonoscopy, should be performed. If the guidelines are silent, the rules say, an insurer may use “reasonable medical management techniques to determine the frequency” of services.

The administration is working on a supplemental list of free preventive services for women.

The Planned Parenthood Federation of America says insurance plans should be required to cover contraceptives without co-payments.

“For women, what could be more basic preventive care than birth control?” asked Cecile Richards, the president of Planned Parenthood.

Other services that must be provided without charge include genetic counseling for certain women with a family history of breast cancer, counseling to promote breast-feeding by new mothers and screening for osteoporosis in older women.

Ms. Sebelius said that 100,000 deaths could be averted each year if doctors and patients effectively used five services: colorectal and breast cancer screening, flu vaccines and counseling on smoking cessation and on aspirin therapy to prevent heart disease.

                                                                            

One day, the friend called Fine complaining of severe leg pains.

"Now, this man was stoic by nature," says Fine, a retired physician. "I'd known him for decades. He never complained of pain, so I knew this was big-league."

At the emergency room, doctors thought the man was suffering from bursitis — an inflammation in the hip — or a muscle sprain.

Fine urged more tests. Eventually doctors discovered massive abdominal bleeding. The blood was pressing on the man's spine, causing leg pain.

Fine helped his friend navigate through several additional near-miss episodes. The experience led Fine to get serious about patient advocacy. He and some colleagues founded a volunteer group to help people through the medical maze.

Advocates Can Mean Better Care

Fine says that at one point or another, practically everybody can use an advocate to help navigate the confusing U.S. medical system.

"We don't practice medicine," he says. "We're the advocates. Some of us are physicians, some of us are nurses, others are laypeople, one is a retired judge. But we consult together, work together, meet together, go over cases. The bottom line is we are accessible. We try to relieve unnecessary anxiety and see that [patients'] needs are taken care of adequately, promptly."

One of Fine's other volunteers is a 68-year-old semiretired doctor named Doug Fiero. Fiero's client Betsaida Gutierrez is a tiny, 56-year-old woman with a sunny disposition and a lot of complicated medical problems.

Eighteen months ago, Gutierrez started suffering sharp stomach pains and couldn't eat. When Fiero first saw her, she weighed 77 pounds, down from 125.

"She was very ill at that point, very thin," Fiero says. "She could barely get up and walk. The doctors really didn't have a good idea what was going on."

"I didn't understand it at all," Gutierrez adds. "I just had a sense that I was just wasting, and there was nothing that could be done."

Communication Is Key

She didn't lack for doctors. At one point more than a dozen were puzzling over her diagnosis. But they often didn't talk to each other, and Gutierrez didn't understand what they were telling her.

Fiero's main job has been to keep her caregivers communicating — with each other and with her.

The doctors decided that part of Gutierrez' colon needed to be removed. The surgeons thought they'd fixed the problem, but Fiero knew they hadn't because her health was continuing to fail.

Eventually, with antibiotics and nutritional counseling, Gutierrez was able to start eating again and put back some weight. She says she couldn't have done it without Fiero's help.

"Because I have somebody I trust, somebody who understands who I am, somebody who basically explains it to me 10 times if he has to, together we've been able to do the work," she says.

Finding An Advocate

The problem is, there aren't many groups like Bedside Advocates that provide free advocacy. And it's served only 20 patients over the past three years.

But there are some professionals who are beginning to offer patient advocacy for a fee. Dianne Savastano is a nurse who has set up an advocacy service in the Boston area.

Barbara Porter hired Savastano to be an advocate for her 92-year-old father, Bob Eckhoff, after he cycled in and out of hospitals and nursing homes with infections that weren't caught in time. Eckhoff has diabetes, congestive heart failure, bladder insufficiency, kidney failure and dementia.

"I tell him, 'Dad, you got resurrected,' " Porter says. "He literally did get resurrected. He would either be dead or in a nursing home right now if it wasn't for Dianne."

Eckhoff's primary doctor didn't want to work with Savastano, so she helped assemble another team of caregivers. Eckhoff says he feels well taken care of. "It's been great," he says. "Having somebody to help like this is just ... just wonderful."

Now the goal is to keep Eckhoff out of the hospital when he suffers the next infection. The aim is not to treat him aggressively, but to let him die as peacefully as possible outside a medical institution.

That doesn't happen all by itself. It takes a lot of communication and negotiation. Otherwise, when Eckhoff develops a medical problem, the assisted living facility where he lives would automatically send him to a hospital.

'Getting Health Care Done'

But Savastano's help doesn't come cheap. Porter says she pays about $15,000 a year, "and (she's) more than worth every penny of it."

"I'm expensive. I recognize that I'm expensive," Savastano says. "I would say that if anyone were going to reimburse for such services, you'd have to prove that you were saving a whole lot of money."

That shouldn't be hard to do. Medicare spends near a third of its budget on care during the last year of life. Avoiding just one hospitalization can easily save tens of thousands of dollars.

But Savastano doesn't expect insurers to pay for her services anytime soon.

"It's going to take a long time," she says. "So we have to deal with things as they are. We can't just wait for things to change."

Betsaida Gutierrez isn't waiting. She's been so impressed with Bedside Advocates that she's working as a volunteer patient advocate herself, despite her ongoing health problems.

Her first client is a Hispanic man who suffers from dementia and lung disease. Neither he nor his wife speaks English, and neither can read nor write Spanish.

"One of the great things" about being an advocate, Gutierrez says, is she can see the change when she accompanies her client to an appointment.

The doctors explain things, she says. They order needed tests and pulmonary therapy for her client. Suddenly, the senior doctor comes into the examining room.

"And," she says, "we get health care done."

Courtesy of NPR http://www.npr.org/templates/story/story.php?storyId=105161828