1. Newland, Jamesetta PhD, RN, FNP-BC, FAANP, FNAP

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Several weeks ago, a patient, whom I'll call Sally, came to see me at the clinic for a routine gynecologic exam. Although she is employed, Sally is uninsured and, therefore, a "self-payer." The sliding-income scale applies only to services rendered by the NP. Other services, such as in-house labs and procedures, are billed separately. As her NP, I was sensitive to her financial concerns and answered all questions about what was necessary for the exam. Five years previously, at age 20, Sally had abnormal results on her Pap smear-human papilloma virus and high-grade cervical intraepithelial lesion 3, for which she underwent standard treatment at that time. Subsequently, her Pap results returned to normal. When she had health insurance, she followed up with her OB/GYN at the recommended intervals. When she lost her health insurance, however, she delayed annual testing. By the time she had come to see me, it had been over 2 years since her last Pap smear, and she was anxious to find out whether her Pap smear was still normal and HPV negative.

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The high cost of health

After the GYN exam, I agreed that I would not send any specimens to the lab until she was informed of costs and consented. To our mutual surprise, the lab customer service representative and I both reeled from sticker shock when she quoted prices for direct billing to the patient. The ThinPrep Pap smear with low- and high-risk HPV testing was $544. If the HPV were positive, an additional $223 applied for further pathologic evaluation. Additional gonorrhea and chlamydia screening would increase the amount by $244. If my math was correct, the total cost for the patient would be over $1,000!! Unfortunately, the clinic has no control over commercial lab charges; we can only encourage patients to negotiate directly with the lab after they receive the bill. Sally, of course, instructed me not to send the specimens because she would not be able to pay the lab bill. So that she received the care she needed, I suggested she check whether she qualified at a "free" clinic that also operated on a sliding-fee schedule but, unlike our clinic, was affiliated with a public hospital, which would significantly reduce lab costs for uninsured patients. Unfortunately, Sally is not unique; she is among the working poor.


New screening recommendations

The new American Congress of Obstetricians and Gynecologists (ACOG) recommendations for cervical cancer screening released late last year have changed the rules for the annual Pap smear. The new recommendations increase the age of when to have the first cervical cancer screening to 21 years and suggest rescreening every 2 years instead of annually for women under 30 and once every 3 years for low-risk women over 30. By these new standards, Sally might not have had an initial Pap smear at age 20, would not have been diagnosed with an abnormal result and HPV, and not had potentially harmful, invasive treatment. Dr. Waxman, the physician who headed the ACOG committee, stated, "A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs, and avoids unnecessary interventions that could be harmful".1 The ordered tests for Sally were appropriate for her age and medical history. Even though ACOG no longer recommends the annual Pap smear, patients should be assessed individually for cervical cancer risk factors to determine when to start screening and how often.


After resolving her GYN needs, Sally plans to return to the practice for her ongoing primary care. Nevertheless, a larger issue to consider in this case is the outrageous cost of lab tests.


Insurers usually follow recommendations from professional organizations to determine what services to cover and how frequently, especially if the recommendations are based on the best scientific evidence to date. Providers must continue to advocate for access to services that are integral to quality care management, including laboratory tests, for all patients, both insured and uninsured.


Jamesetta Newland, PhD, RN, FNP-BC, FAANP, FNAP

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1. ACOG. Press release-November 20, 2009. First cervical cancer screening delayed until age 21, less frequent Pap tests recommended. [Context Link]