Sunday, November 23, 2014

Whac-A-Mole disguised as high-deductible plans

In the zeal to "bend the cost curve," the US health care system has focused on more "consumer-directed" aspects of health care, often in the form of high deductible insurance plans.  As in all such public policy moves, there are unintended consequences.

This has been recognized on the pediatric front, with the American Academy of Pediatrics taking a strong stand, as reported several month ago by Budd Shenkin:

The federal government should consider restricting high-deductible health plans (HDHPs) to adults because the plans discourage families from seeking primary care for their children, according to an updated AAP policy statement. 

But the tsunami is still coming.  Here's the report by Bob Herman at Modern Healthcare.  An excerpt:

“I thought (high-deductible plans) would level off this year and they continue to grow,” said Brigitte Nettesheim, a principal at the Chartis Group who studies the health insurer segment. “They will still be a significant portion of the type of plan designs offered.”

The proliferation of high-deductible exchange plans highlights the core issue of insurance affordability, one of the basic tenets behind the Patient Protection and Affordable Care Act.

Those deductibles already are weighing heavily on Americans. A new survey from the Commonwealth Fund (PDF) found that three in five low-income adults and about half of adults with moderate incomes believe their deductibles are “difficult or impossible to afford.” About 13% of Americans spend 10% or more of their income on out-of-pocket healthcare costs as well.

Bob notes that the trend applies to employer sponsored as well as insurance exchange plans:

These types of plans have taken off in the employer space in recent years as more companies have tried to stem the tide of growing premium costs by putting more of the expense burden on workers. Employers also may be looking ahead to 2018, when the Affordable Care Act will levy an excise tax on so-called “Cadillac” employer health plans that offer generous benefits and little, if any, cost-sharing for employees.

The Commonwealth Fund summarizes the impact on many families:

The results of this survey show that these trends toward greater cost-sharing, combined with little or no growth in median family income, have left many working Americans in the middle and lower end of the income distribution with large healthcare cost burdens. Cost-sharing in health plans is affecting people's medical decisions in ways that should be of concern to policymakers and the medical community.

Here's what the "experts" offer in the way of a solution:

Experts say insurers and providers are the most influential players to educate patients about high-deductible plans and help them determine whether they are a reasonable fit. “If there's anything they can do to talk to patients more, or educate their insured folks more about some of those terms and concepts, they may end up with fewer situations where people are surprised about their out-of-pocket costs,” said Liz Hamel, the director of public opinion and survey research at the Kaiser Family Foundation.

Look, most people can't even understand how to pick a cellphone calling plan that meets their needs. Do you think that people are really going to be able to be that analytical about their health insurance plans?  Even if you are good with humbers, when you choose a plan, you generally have no idea of what your medical needs are going to be for the coming year.  Having talked to many people in this situation, I'd be willing to bet that most people in the middle and lower end of the income distribution are guided by what the monthly premium will be:  That is their only way of judging affordability. No amount of "education" is going to change that.

By the way, the idea that providers will offer such education is laughable. During your next 18-minute visit, just try asking your primary care doctor to opine on insurance plans. Watch his/her eyes roll in frustrated ignorance.

And given the state of the insurance exchanges, can we expect the people at the end of the phone call to have the time and expertise to help consumers truly evaluate their personal needs?

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.


@MedicalQuack said...

From Twitter:

It's more complex with policies as more insurers hire armies of Quants to design them-tons of them.

nonlocal MD said...

Eve more frustrating is the fact that in all this concern with insurance, deductibles, employer-sponsored (or not) insurance, etc. the root cause is lost - the price of American health care. Until that comes down, we are concentrating on entirely the wrong things. Seems to be a specialty of ours, as Winston Churchill observed about Americans doing the right thing, after trying everything else first.