Photo: Alex Prolmos via Flickr
High-deductible health plans (HDHPs) discourage families from seeking primary care for their children, according to the American Association of Pediatricians. The problem is so severe that the federal government should consider limiting HDHPs to adults only, the AAP said in a policy statement published in Pediatrics.
“HDHPs discourage use of nonpreventive primary care and thus are at odds with most recommendations for improving the organization of health care, which focus on strengthening primary care,” the association said in its statement. Under the Affordable Care Act, preventive services are covered in full without charge.
This is the second time in as many months that a report has shown consumers skipping needed care because of the cost. Last month, we reported that out-of-pocket health care costs force one out of every eight privately insured Americans to skip necessary medical treatment, according to the survey from the AP-NORC Center, “Privately Insured in America: Opinions on Health Care Costs and Coverage.” The Robert Wood Johnson Foundation funded the survey. In a report earlier this month, “Too High a Price: Out-of-Pocket Health Care Costs in the United States,” the Commonwealth Fund expressed similar concerns.
In an article about the policy statement, Alyson Sulaski Wyckoff, associate editor of Pediatrics, quoted Budd Shenkin, M.D., the lead author of the AAP’s policy statement on HDHPs, saying parents are so concerned about the cost of care that they don’t bring in their children when they should. “They’re reluctant to come in, they seek more telephone care, they’re reluctant to complete referrals, and they’re reluctant to come back for appointments to follow up on an illness,” he said.
For children with chronic conditions, foregoing care can exacerbate illnesses, said Thomas F. Long, M.D., chair of the association’s Committee on Child Health Financing. “If it’s going to cost them out-of-pocket money, they may say, ‘Well, it’s just a cold, I don’t need to see the doctor.’ And ‘just a cold, turns into ‘just pneumonia,’” he added.
The problem of delaying necessary care is one Paul Levy addressed in his blog, Not Running a Hospital, about HDHPs. “Beyond the sad impact on individual families in any given year, I fear that the economic backlash of these policies will be a deferment of needed health care treatments and a resulting future bulge of cost increases. We’re playing Whac-A-Mole here,” he wrote.
For the Commonwealth Fund, researchers found that among privately insured consumers across all income groups, low- and moderate-income adults were most likely to skip the health care they need because of high out-of-pocket costs.
It’s no surprise that adults with the lowest incomes were most likely to skip needed care, the fund reported. Among consumers earning less than $22,890 annually, 46 percent cited at least one example of skipping needed health care because of copayments or coinsurance: 28 percent did not fill a prescription; 28 percent skipped a medical test or follow-up treatment; 30 percent had a medical problem but did not see a doctor; and 24 percent did not see a specialist when needed.
When deductibles are high relative to income, consumers tend to skip care as well, and low- and moderate-income adults had the most trouble, the report showed. Consumers whose deductibles represent 5 percent or more of their income cited at least one example of skipping needed health care because of their deductible: 29 percent skipped a medical test or follow-up treatment; 27 percent had a medical problem but did not go to the doctor; 23 percent skipped a preventive care test; and 22 percent did not see a specialist despite their physician’s advice.
For an article in Modern Healthcare, Bob Herman covered this topic well. He cited the case of a woman in Indiana who was searching for a health plan on HealthCare.gov. A single, 40-year-old nonsmoker, this woman could choose from 29 plans and 24 of them were considered HDHPs, he wrote.
Under IRS rules, (PDF) an HDHP in 2015 is defined as one that has an annual deductible of at least $1,300 for an individual and $2,600 for a family coverage and annual out-of-pocket costs that do not exceed $6,450 for individual or $12,900 for a family.
The Commonwealth Fund report showed that 13 percent of consumers with private health insurance had plans with a deductibles equivalent to 5 percent or more of their income; that figure includes 25 percent of adults with low incomes and about 20 percent of adults with moderate incomes ($11,490 to $45,960 a year for a single person).
Of course co-payments cause patients to skip necessary care. This was proven with 30 years of high-quality research, starting with the Rand Health Insurance Experiment (HIE), a randomized controlled trial. We should have been warning our readers, when our politicians started imposing co-payments, that co-payments have consistently failed in the past.
http://www.rand.org/pubs/research_briefs/RB9174.html
The Health Insurance Experiment: A Classic RAND Study Speaks to the Current Health Care Reform Debate,
by Robert H. Brook, Emmett B. Keeler, Kathleen N. Lohr, et al.
Free care improved the control of hypertension. The poorest patients in the free care group who entered the experiment with hypertension saw greater reductions in blood pressure than did their counterparts with cost sharing. The projected effect was about a 10 percent reduction in mortality for those with hypertension.
Aaron Carroll looked at the more recent literature a few months ago in his New York Times blog:
http://www.nytimes.com/2014/05/20/upshot/why-patients-with-chronic-illnesses-should-pay-less.html
People With Chronic Illness Fare Worse Under Cost-Sharing
New York Times
Aaron E. Carroll
MAY 19, 2014
The full citations of his articles are:
http://archpedi.jamanetwork.com/article.aspx?articleid=1872780
Financial Barriers to Care Among Low-Income Children With Asthma: Health Care Reform Implications
Vicki Fung, Ilana Graetz, Alison Galbraith, et al.
JAMA Pediatr. May 19, 2014. doi:10.1001/jamapediatrics.2014.79
Objective: To examine the associations between cost sharing, income, and care seeking and financial stress among children with asthma.
http://www.nejm.org/doi/full/10.1056/NEJMsa0904533
Increased Ambulatory Care Copayments and Hospitalizations among the Elderly
Amal N. Trivedi, Husein Moloo, and Vincent Mor
N Engl J Med 2010; 362:320-328 January 28, 2010 DOI: 10.1056/NEJMsa0904533
In plans that increased copayments for ambulatory care, mean copayments nearly doubled for both primary care ($7.38 to $14.38) and specialty care ($12.66 to $22.05). In control plans, mean copayments for primary care and specialty care remained unchanged at $8.33 and $11.38, respectively. In the year after the rise in copayments, plans that increased cost sharing had 19.8 fewer annual outpatient visits per 100 enrollees…, 2.2 additional annual hospital admissions per 100 enrollees…, 13.4 more annual inpatient days per 100 enrollees…, and an increase of 0.7 percentage points in the proportion of enrollees who were hospitalized….
There are other articles in the NEJM by Trivedi and others. For example, Trivedi showed that with asthma, patients with copayments were less likely to control their asthma, more likely to wind up in the ED, and wound up spending more money in the long run than patients without copayments.
The Pediatrics article http://pediatrics.aappublications.org/content/early/2014/04/22/peds.2014-0555.full.pdf inter alia summarizes in a page the arguments in favor of cost sharing. The benefit is that patients can lower their premiums, if they are healthy, and wealthy enough to easily pay for cost sharing, for example if they are physicians themselves or work in a medical facility and have immediate access to (free) medical advice for their cost/benefit decisions.
There is also a theory, in conservative economics, that patients will make better decisions if they have a stake in the game. The problem is that the theory doesn’t work. When large corporations, like IBM, shifted to cost sharing, they found that their costs went *up*. There’s a case history of a corporation that looks like IBM in the NEJM. See Gaffney The “Cadillac” health plan is a myth http://www.salon.com/2013/08/16/the_cadillac_health_plan_is_a_myth/ or Trudy Leberman http://www.cjr.org/the_second_opinion/the_great_healthcare_cost_shift_comes_into_focus.php
The benefit of copayments seems to be simply to shift costs to patients, and reduce their spending by reducing their access to necessary, appropriate, and cost-efficient care. Copayments are a way for policy-makers to come in under budget, even if the budget is so low that cuts low-income people off from needed care. The Affordable Care Act is “affordable” for low-income people, because it has low premiums, in exchange for very high co-payments. But if you need care, the co-payments are unaffordable.
I think the big question that we, as journalists, should have been asking is, who are the policy makers who successfully promoted copayments and why did they do it? Did they really believe it would create “wisesr consumers,” or were they just cynical? I think the job of journalists is to warn our readers when our government is moving forward with a scheme that, according to evidence in the peer-reviewed journals, is doomed to fail.