Survey: High Deductibles Often Steer Patients Away From Care

Those high-deductible and consumer-directed health plans may be all the rage in the insurance industry, but researchers say they ultimately may pose a threat to people's health. A new survey from the Employee Benefit Research Institute and the Commonwealth Fund concludes that members of high-deductible health plans – which can carry minimum deductibles of $1,000 for individuals and $2,000 for families while tied to tax-sheltered savings plans – are discouraging many of the sickest citizens in our country to avoid doctors' offices when they need them the most. Members facing high deductibles do, in fact, show a much higher sensitivity to costs, say researchers. And that is exactly what the plans' designers had hoped for, suggesting that once consumers spend more time shopping and budgeting for healthcare they'll demand higher quality and fair prices. Only about one percent of Americans are in a CDHP with nine percent in a CDHP unassociated with a tax-sheltered account. Those numbers are expected to grow fast, though, as insurers spread the word about the new plans. If they do, it will be at odds with the sentiments of most Americans, who view CDHP will a great deal of skepticism. "Cost-conscious decision making is one advantage of consumer-driven plans," says EBRI CEO Dallas Salisbury. "But the perception of those who are enrolled is that these plans do not provide the tools and resources to make decisions and that they reduce use and increase out-of-pocket spending. Overall, satisfaction is lower with consumer-driven plans than with comprehensive insurance." Dr. Michael Parkinson, chief health and medical officer and executive vice president of the consumer-driven plan Lumenos – had little good to say about the new study. First, he says, the survey group was too small: "185 people does not a trend make." Also, he adds, survey participants are probably largely self-employed and stuck in a high deductible plan with no outside support. To hear that the group would avoid needed health care as a result is no big surprise. The Rand Corporation came up with the same results for a high-deductible PPO 30 years ago. But Parkinson's concern is that people will see the Commonwealth/EBRI study as an objective take on the whole consumer-driven movement, which he feels simply isn't fair. To make consumer-driven plans work, he adds, requires 100 percent coverage of preventive care with first-dollar coverage of needed services. The deductible should be put in the middle of the account design. And any out-of-pocket expenses need to be competitive with a typical PPO. Add incentives for better care for the chronically ill, he adds, and plenty of support systems for members, and you'll see better results, lower costs and high satisfaction rates for both members and employers. Dr. Neal Kohatsu, president of the American College of Preventive Medicine, says he believes the study was simply too narrow in scope. "I think we have to take a better look not only at healthcare utilization in these types of plans, but also managed care and traditional PPO kinds of healthcare arrangements," says Kohatsu. People may well not be getting the care indicated in CDHPs, he adds. But the same may be true in a variety of plans. "Most people would say we don't have a healthcare system per se," says Kohatsu. "Healthcare is not well integrated or well organized. There are a lot of places where people fall through the cracks." And it would be better to compare a variety of offerings to get a better idea of where those cracks appear. But for the study authors, a close look at CDHPs reveals some troubling gaps. One of the problems with the new CDHPs is that few offer the kind of cost and quality data that consumers need to make the tough financial decisions that they now face. As a result, many avoid getting the care they need, with the poorest and the sickest often the most reluctant to seek help. "These findings provide evidence that high-deductible and consumer-driven plans may undermine the two basic purposes of health insurance: to reduce financial barriers to needed care and protect against high out-of-pocket cost burdens for patients," said Commonwealth Fund president Karen Davis. "Enrollees with low incomes or with health problems are particularly vulnerable to spending a high proportion of income on medical expenses under these types of plans." The survey found that: - 63 percent of respondents were extremely or very satisfied with their comprehensive health plans, compared to 42 percent of the people in a CDHP and 33 percent in a high-deductible plan. - 60 percent of comprehensive plan members said they would stay with their plans if given the opportunity to switch, compared to 46 percent of consumer-directed plan members and 30 percent of members in a high-deductible plan. - Those consumer-directed and high-deductible plans are taking a bigger bite out of people's income, with 42 percent of CDHP members and 31 percent of high-deductible members reporting spending more than 5 percent of their incomes on healthcare costs – compared to 12 percent who report the same for their comprehensive insurance packages. - Roughly a third of patients facing high out-of-pocket costs delayed or avoided care compared to about 17 percent of comprehensive plan members. And the lower their income, the more likely it was that they would steer clear of the doctor's office. - Only one in seven members of high-deductible or consumer-directed plan said their plan offered information on doctors and hospitals. - One bright spot: More than 60 percent of members of higher-cost plans said that the bigger financial responsibility compelled them to consider costs when seeing a doctor or seeking help – compared to less than 40 percent of the others. "This survey finds that consumer plans do, in fact, significantly raise consumer sensitivity to costs and reduce use," say the authors of the report. "But the survey also demonstrates that cost-related reductions in demand are highest among those with the most to lose – those who are sick and those who have low incomes. To the extent that the health care cost problem is a problem owned by all of us, early evidence from the consumerism movement suggests that solving it through blunt, demand-side instruments like high deductibles gives disproportionate responsibility for the problem to the most vulnerable among us." There were few demographic differences between the different groups studied, although comprehensive insurance members were on average younger than members of the other plans.