09 Jan Do High-Deductible Insurance Plans Cause Patients To Delay Health Care?
MedicalResearch.com Interview with:
J. Franklin Wharam MD MPH
Associate Professor, Harvard Medical School
Director, Division of Health Policy and Insurance Research
DPM Site Director, Harvard Medical School General Internal Medicine Fellowship
Harvard Medical School and HPHCI Department of Population Medicine
MedicalResearch.com: What is the background for this study?
Response: High-deductible health plans have been increasing over the last decade and are now the most common form of private health insurance. It also appears that high-deductible plans associated with health savings accounts will be the centerpiece of the new presidential administration’s plan to replace the Affordable Care Act.
In high-deductible plans, members pay more out-of-pocket for services such as specialist visits, emergency department visits, and hospitalizations, so patients might delay or skip needed care due to high costs.
The theory behind high-deductible insurance is that patients paying out-of-pocket for health care, sometimes called having “skin in the game,” will consider their health care use more carefully than if they are spending “someone else’s money.” It is hoped that this will motivate patients to receive only care they truly need rather than services that have not been shown to improve health, such as an MRI for uncomplicated low back pain. However, it could be challenging for patients to make this distinction, and those facing a high burden of costs might decide to take a chance and delay or skip care even if they think it would be beneficial.
We decided to examine how high-deductible health plans affect people with diabetes because these patients often need frequent, expensive health care services and no studies have examined adverse outcomes among chronically ill patients in high-deductible plans. Skipping or delaying needed diabetes care could cause patients to be sicker in the future and could therefore increase the need for more expensive or higher acuity care.
This study focused on whether high-deductible enrollment among people with diabetes changed outpatient visits and routine disease monitoring, and effects of such potential changes.
MedicalResearch.com: What are the main findings?
Response: We found that primary care visits and disease monitoring, which usually have low out-of-pocket costs even in high-deductible plans, showed minimal changes. Specialist visits declined by a small-to-moderate degree, but this reduction was smaller than we expected.
However, we also wanted to focus on a specific type of visit – visits for conditions that patients with diabetes might try to delay, but where such delays would cause patients to be sicker. We called these acute preventable diabetes complication visits. For example, patients with cough, fever, and shortness of breath facing high out-of-pocket costs might try to take over-the-counter medicines to save money, and hope the symptoms go away. But if they have pneumonia, they ultimately will end up needing to see a clinician and having more advanced pneumonia than if they showed up right away.
When we looked at visits like these, we found that high-deductible members with diabetes did delay outpatient visits for acute complications. In addition, in the low-income group of high-deductible members with diabetes, but not in the high-income group, these delays were associated with increased numbers and costs of emergency department episodes for acute preventable diabetes complications. We also found a similar pattern among high-deductible members with diabetes who have health savings accounts. This might imply that those patients either had little savings in their accounts or were not aware of how to use them properly.
We were somewhat surprised by the minimal changes in outpatient visits and disease monitoring in the overall and higher-income groups of patients with diabetes in high-deductible plans. We were also surprised at the large size of adverse outcomes in some of the vulnerable high-deductible groups, such as a 20% increase in emergency department acute complication visits among low-income members and a 30% increase in costs for emergency department complication episodes among health savings account members.
MedicalResearch.com: What should readers take away from your report?
Response: So two key takeaways from our study are that the majority of diabetes patients enrolling in high-deductible plans did not experience the adverse health outcomes we measured, but vulnerable subgroups such as those with low incomes or additional chronic conditions, had evidence of adverse outcomes such as increased emergency department visits for acute complications.
Our results indicate that more tailored health insurance plans might be needed. For example, employers could shift health savings account contributions to their lowest-income workers. In addition, the costs of highly valuable services, such as urgent care or emergency department visits for potential complications could be reduced. It is also important for chronically ill people to understand the details of their benefit designs, and in the future such education would preferably come from user-friendly tools that make decisions about the value of services much easier.
At this point, the best advice for patients with diabetes or other chronic diseases (who might be making decisions about receiving care while weighing out-of-pocket costs) is to consult with a health professional – preferably their primary care provider – to receive timely advice about the necessity of the care in question. Consultation by telephone, email, and nurse hotlines are all approaches I have seen. The potential financial burden of care could be even greater if patients have family members under the high-deductible plan who also need care, but this should not change the decision to quickly get expert advice about the need for care.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: It will be important for future studies to focus on other health outcomes among diabetes patients in high-deductible plans, such as use of the emergency department and hospital, and examine longer-term events such as heart attack and stroke. Studies should also focus on other chronically ill patients; for example those with cancer or heart disease.
Finally, because health savings account-based high-deductible plans are likely to play a major role in health insurance reform, research should focus on these plans and whether generous funding of these accounts reduces some of the adverse outcomes we detected.
MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.
Wharam JF, Zhang F, Eggleston EM, Lu CY, Soumerai S, Ross-Degnan D. Diabetes Outpatient Care and Acute Complications Before and After High-Deductible Insurance EnrollmentA Natural Experiment for Translation in Diabetes (NEXT-D) Study. JAMA Intern Med. Published online January 09, 2017. doi:10.1001/jamainternmed.2016.8411
Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.
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