Patients will skip care with higher deductibles and copays

The Wall Street Journal reported that overall medical use fell as patients had fewer doctor office visits, lab testing, and maintenance medications possibly due to the recession or as a result of consumer driven healthcare in the way of higher deductibles and copays.

This is very worrisome.  Certainly patients should have some financial responsibility for their care, but skimping on care will only result in Americans not becoming healthier, but sicker.  Though the article cited some examples of patients saving money by not seeing their allergist for a refill of medication and simply calling for one and getting an athletic physical at a local urgent care clinic for $40 rather than $90 at the doctor’s office, these tiny behavior changes aren’t going to bend the cost curve in medical care.

Sure, some patients are holding off on elective surgeries.  This might be a good thing as research has suggested that Americans get too many procedures compared to other industrialized countries.  However, this could be equally as bad as there may be an equal number of people who truly need surgery to improve their quality of life and ability to walk but can’t do so because they can’t afford it.

With more financial responsibility of higher deductibles and copays, patients will simply skip care, specifically, needed medical care.  As the drugstore CVS noted, there was a “drop-off in new prescriptions for maintenance drugs tied to a decline in physician visits”.  In other words, patients are not getting treated for their high cholesterol, high blood pressure, or diabetes to prevent premature heart attacks or strokes.

Paul Ginsburg, a respected health economist of the Center for Studying Health System Change noted that this patient behavior “could go beyond the recession. Being a less aggressive consumer of health care is here to stay.”

I disagree with him in the sense that patients weren’t necessarily aggressive before, but behaved in a rational manner when copays were low, there were no costs to medications, lab work, and office visits.  The question is with very high financial barriers to seek care will they make the right choices?  Will Americans change their behavior and become healthier?

The answer is no.

As a practicing primary care doctor I know when I must seek medical care and when I can safely skip.  If this data holds true for the next few years, America will have a very big problem.   We will have a less healthy workforce because they cut corners on their health.  A generation of Americans who will skip important preventive screening tests because they feel fine and aren’t willing to pay the high copays.  Those with medical conditions like diabetes will develop avoidable complications of blindness, kidney failure, and amputations because patients don’t renew their maintenance medications.

Americans will die sooner, have a worse quality of life, and more preventable complications as a result of consumer driven healthcare.  The doctors who are best in advising patients on the right care, the primary care doctors like internists and family doctors, are leaving their practice in droves because of issues of work-life balance and decreasing reimbursement.  Healthcare costs for the short-term may fall only to rise rapidly as patients are forced to be treated for conditions that could have been handled earlier more easily and for a lot less.

In other words, the perfect storm of a worsening healthcare system is upon us soon.

Which will leave the government no choice but to establish a single payer government run system.

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

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  • ri md

    This is really not surprising: It has been known for decades that patients faced with increased general cost-sharing will reduce use of all health services, not just the “optional” ones. See the famous RAND Health Insurance Experiment (started in 1971 and running over 15 years); a synopsis can be found here:

  • kullervo

    Hey, if I started telling my doctor the truth I would have no insurance at all. If I got hit by a bus tomorrow, I’m covered, but I have no help for a couple of painful chronic problems. Luckily I can hide a limp for long enough to get in and out of my doctor’s office.

  • The Happy Hospitalist

    I will accept that patients don’t get necessary health care because of higher copays as an evil concept the moment I can be shown that the same people who aren’t using their insurance because of copays are also not spending their extra money on iPhones and iPads and laptop computers and cigarettes and fancy rims and vacations and new sofas and premium cable television channels.

    Then I’ll feel bad.

    • Taylor

      You took the words right out of my mouth. I have friends that have $50 copays and complain about going to the doctor, but they have no problem spending money on new cell phones, more expensive cell plans, clothes, purses, new cars (when the one they have is fine). People will spend money on basically anything and everything, but their health?! Well how will you enjoy all those things when you’re sick b/c you never went to the doctor. High deductibles are a little bit different though if someone has a deductible of 5-10k. That is a lot of money to spend before your insurance starts sharing the cost.

      • Vox Rusticus

        Agree. As for the high deductibles, I am beginning to think that these might be the end of accepting insurance for outpatient practices. When patients come in with plans that effectively do not pay the doctor (unless they have burned through the deductible, which is not usually the case) then there is little reason to participate with these plans. All they do is impose costs–claims processing– and pricing limits with usually no guarantee of anything. And as anyone who has dealt with these arrangements knows, you must collect the full amount due at the visit. If you don’t, you are counting on the honesty and solvency of your patient to pay when billed, something I have learned is not to be counted on, on principle. This area is the fastest-growing segment of bad debt in my practice. Once patients have the care (particularly for a simple, limited problem) and the claim, the carrier gives them credit for having paid toward their deductible whether in fact they have paid or not. It is so much simpler to just require cash payment and a receipt.

        • The Happy Hospitalist

          When you have a patient with a high deductible limit, unless the patient can show you a statement that their deductible has been met You should be collecting the total allowable charge close to what your bill to the insurance will be. You should know what the allowable charge is. If you over collect, you send them back a refund in a few weeks.

          • Vox Rusticus

            Which is what I do.

    • akronite

      Who are you talking about? You really think that is the majority? I don’t know what world you’re living in. That might be some, but certainly not all…as one of the many unemployed (10 months now) WITH a graduate education, even though I was able to continue insurance under COBRA, I have a $3000 deductible. I’m trying to keep my house and keep the lights on. Sure, the hospital will get paid by insurance if something major (over $3000) happens- otherwise, my insurance is useless to me at this point. I don’t qualify for prescription or other assistance programs because I have insurance. I’ve had to stop taking four maintenance prescriptions for chronic conditions just because they cost far too much (including Singulair, for example), and avoiding (much needed) visits to my docs because I can’t afford to pay. I limped along on samples for awhile, but even a caring doc can only do that for so long. In the meantime, I’m stuck trying to diagnose myself on the web and find SOMETHING to treat what’s wrong with me so that I can function, and try not to make things worse. Good idea? Probably not. Alternative? Um…I’m out of ideas.

  • Margalit Gur-Arie

    What does “consumer driven” mean?
    Was somebody else driving demand for health care before it was decided to not insure health care up to a certain high deductible?
    I suggest we change the terminology and call it “wealth driven” health care. Doesn’t sound as pretty and “empowering”, but describes the trend better.

  • kullervo

    Hey, Happy, I’ll confess I have an iPhone, but I also have the only health insurance policy I can get as an individual in this county of this state. I’d like to keep it. That’s why I’m doctor-avoidant, not because I can’t afford a copay. I can’t afford to get anything on my record. It’s a true disaster policy.

  • Donald Green MD

    Happy hospitalist: Is 45,000 excess deaths for the uninsured or under insured enough insight for you. Your remarks are, well, off the mark.

    • The Happy Hospitalist

      Two comments. Not paying a copay because you feel like your money is better spent on dinners at Outback has nothing to do with being uninsured or underinsured. As far as the statistics that show people are dying because of lack of insurance I have two cents worth

      1) The death rate goes down during recessions. Presumably people are not becoming more fully insured with reduced cost sharing as their companies lay them off. This data has remained constant over decades. How does one explain that phenomenon? It’s well described. Studies estimate for every 1% rise in unemployment, the death rate drops by 0.5%.

      2) My experience as a hospitalist tells me that uninsured people generally lead lifestyles that are far greater to lead to an early death. Their lifestyles or choice of occupations are more highly associated with poor lifestyle decisions/ They get sick and die, not because they don’t have insurance, but because they live a lifestyle that leads to heart disease stroke diabetes and cancer.
      3) We know dirt poor smokers die at the same rate as filthy rich smokers. Poor uninsured people have a much higher rate of smoking than rich people. That has nothing to do with lacking insurance. In fact, the dirt poor are often on Medicaid, and are some of the sickest people I care for. Insurance isn’t going to save you if you are a smoker. Quitting smoking will.
      4) How many people die BECAUSE they have insurance. I have yet to see a study showing the dangers of having insurance. CT scan radiation induced cancers. Complicated choles gone bad for nonspecific abdominal pains. Septic knees from indication creep of total knee arthoplasties. Septic shock from PICC line induced bacteremia from complicated aortic valve stenosis repair . Pneumothorax from a false positive lung mass leading to surgical resection and a life of complications.

      There are many unknowns regarding the link between insurance and outcomes. There are many confounding variables. The truth is, health is not created by health insurance. Health is a lifestyle driven process.

      Look at it like this. How many people claim that they didn’t get into a car accident today because they have autoinsurance? And how many people without auto insurance can claim they got into a car accident because they didn’t have insurance?

      • HJ

        ” That has nothing to do with lacking insurance.”

        From BMJ:

        Relation between income inequality and mortality in Canada and in the United States: cross sectional assessment using census data and vital statistics

        Author says, “There were no significant asociations between income inequality and mortality in Canada at either the provincial or metropolitan area levels, whereas such associations were apparent in the United States.

        Another major difference between the two countries is the way in which resources such as health care and high quality education are distributed. In the United States these resources tend to be distributed by the marketplace so their utilisation tends to be associated with ability to pay; in Canada they are publicly funded and universally available. As a consequence, in the United States an individual’s income, in both a relative and absolute sense, is a much stronger determinant of life chances and, in turn, “health chances” than in Canada.”

        The Happy Hospitalist says, ” My experience as a hospitalist tells me…”

        Isn’t this anecdotal? Are the Canadians so different that their poor make healthy lifestyle choices?

      • A.N. Mousse

        Many of us – myself included – are not going to the doctor as often as the doctor recommends because we cannot afford the co–pay. I do not go to the doctor and refuse to pay the co-pay – I just don’t go. I believe the doctor deserves to be paid. I understand that the co-pay can be the difference between losing money and making a profit in some medical practices. I do have an iPhone – it’s actually necessary to my work (freelance and unsteady – and all I can find in this recession – for 3 years) – but I doubt you’ll believe that to be true. I do not eat out. I do not go to the movies. I do not take vacations. I do not have cable. I do not smoke. I do not drink. My BMI is 19. I exercise regularly. I eat mostly a plant-based diet – no soda, no snacks. I will admit to an addiction to fresh blueberries.

        If my co-pay were $15, as it used to be, and not $40 for the doctor and $40 for the facility fee for a total of $80, as it is now, I could probably arrange my budget in such a way as to see my oncologist more often. Certainly radiation therapy co-pays at $80 a day/five days a week for 4 months is well beyond my capability to pay. I scrape together enough to pay the premiums to my high-risk pool insurance policy – mostly to ensure that society isn’t stuck paying end-of-life expenses and/or extensive medical expenses in the event of an accident. I don’t qualify for charity care.

        I’m curious – what are the H.H. approved essential expenditures beyond which a patient will be judged as wasting money that could otherwise be spent to fund medical expenses? Clearly, owning a pet – (even though pets are known to relieve stress and anxiety thus contributing to health) are forbidden.

        Are there no little treats or small luxuries permitted in a patient’s world?

        What sort of person is worthy of compassion in H.H.’s world? You seem to have very specific criteria. Who qualifies?

        • The Happy Hospitalist

          The choices one makes in life are a product of free will. If you feel you cannot support yourself with your iPhone and your free lance work, I might suggest you apply to your local community college or four your state subsidized university and study in a field that can support your needs, or to become better at your freelance work so someone is willing to pay you for your efforts.

          I am not in the position to declare what you can or cannot afford. I am here simply to state that if you feel you cannot afford your copays, it is up to you to change your reality and not rely on others to meet your needs. There is nor right from Heaven nor from our Constitution for $15 Copays. If you cannot afford the service others are offering, it’s up to you to make the change and make it happen. If you cannot make it happen because you were not given the God given capabilities to provide for yourself, then it’s up to you to petition the government for assistance. If you feel the government is unfairly excluding you from your basic right to life, liberty and the pursuit of happiness, I might suggest you take legal action against them.

        • rswatkins

          If you are being charged a professional fee and a facility fee for an outpatient visit, you are the victim of one of the biggest frauds out there. You should protest this to the highest level, including going to the local media.

    • Dr.J

      I personally dislike the heavy handed moralizing about the reported”45,000″ excess deaths and the kind of guilt infused logic it produces. Instead of lecturing to us, why not start a “compassionate care initiative” in your community? Our local medical society has one.
      As for the reported sterling performance of the Canadian health care system, personally I would prefer to live in a country where if I hit my head in a freak ski accident, I won’t die from an epidural hematoma because the nearest CT facility is several hours away.

      • HJ

        “As for the reported sterling performance of the Canadian health care system, personally I would prefer to live in a country where if I hit my head in a freak ski accident, I won’t die from an epidural hematoma because the nearest CT facility is several hours away.”

        I would like to live in a country where people didn’t die on the emergency room floor.

        • Dr.J

          I realize that our ERs are overburdened sometimes with” professional” ER overutilizers ( I recall a study of ER overutilization by a handful of individuals at the public county Brackenridge Hospital System in Austin,Tx. where a handful of individuals were responsible for multimillions of dollars of tax payer funded medical care) and presumably there are hospitals worldwide which are better run than others, however if you have personally witnessed the scenario you described without intervening,then you have only yourself to blame. Absence of available technology or treatments is more likely a cause of preventible morbibity than the problem your unduly glib comment portrays.

          • HJ

            Absence of available technology or treatments is more likely a cause of preventible morbibity than the problem your unduly glib comment portrays.

            I would suggest you look up Edith Isabel Rodriguez and Esmin Green.

  • Max

    Those ‘uninsured’ and ‘under insured’ aren’t in that position necessarily because of circumstances. Many are there because of choice as well. They choose the ipad or ipod or that trip to Disney instead. It’s funny how choice can affect your health that way. If you don’t treat your chronic condition, you could *gasp* die? Um yep, pretty much. How about that patient that asks for samples but has 2-3 pets, smokes, travels, has 2 cell phones, cable tv, eats out 4 nights per week and leases a car. Sure here’s your sample..after you prove you have not travelled, cut off your cable tv, sold your pets, bought a 74 Pinto, stopped smoking, etc etc.

    • Margalit Gur-Arie

      Trying to understand this:
      We are artificially pricing a vital service – health care – out of reach for most Americans (and with 10K HD plans, it is out of reach), and then we ask them to sell their dog or cat to pay for these services?
      At what point will we be asking them to pull the kids out of school and send them to work?

      • Max

        You have misunderstood. These same patients who complain about their deductibles are spending $$$money on vet bills, smokes, eating out, ipods, travel, car leases, etc. It is reasonable to ask them to cut their non-essential expenses first in order to cover their deductibles. It’s common economincal sense. Discgard the wasteful spending first. Prioritize their dollars.

        • A.N. Mousse

          I can imagine that it may seem that all patients who complain about their deductibles are spending their money on other “luxury” items. These may be the people you actually encounter. There are others out there you never see – because they do not go to the doctor because they cannot afford the co-pays – and sometimes the insurance in the first place. It seems very easy for you to generalize and categorize the people you encounter. How much do you really know of what they may struggle with on a daily basis? What are acceptable expenditures? Is having a pet – perhaps from before one was laid off three years ago – and accepting that one has a responsibility to that pet – really forbidden? Pets have been shown to help relieve stress and anxiety and contribute to well-being. Are we to be warehoused in bunks, in ghettos, allowed out only to beg in the streets and grovel for charity – and only be granted it once we have met your rigorous tests of worthiness?

          • Max

            You are correct. Welcome to hope and change. You will be rationed. To each according to need. From each according to ability. Marxism at it’s best. If I deem you too rich, too well-travelled, etc. Or youou just got back from Disney, etc and I haven’t been on a trip in years then yes, the sample will go to a more worthy person. Someone who is barely scraping by will get the sample. Rationing starts now. I’d suggest you play up the impoverished role real well.

    • Becky

      From someone who is going through it right now–we can’t even think about health insurance for us–if it was just co pays it would be fine. But the premiums are so astronomical that we can’t afford it. Premiums for me and my husband are more than the payment on our home. Cell phones? ipods?? iphones?? Are you kidding? Not around here. TV? off of the antenna, for free, no cable nothing. Furniture for free from folks just wanting to get rid of their old furniture. Dinners out only at birthdays when my mom sends us birthday cash. Yeah, we have pets, but the money we save on the pets would maybe give us $50 a month toward premiums that cost $600 a month! We see our local doctor, she charges us just what a copay would cost us if we had health insurance, she gives us meds for free and then we pray every day that we don’t have a serious accident with broken bones that requires medical care or we are sunk. medicaid?? We don’t qualify–we are not old enough and we have no children under the age of 18.

      • Happy Hospitalist

        1) Most cities have federally subsidized sliding scale clinics that can help you get access and have subspecialists that provide free care or on a sliding scale.

        2) Most nonprofit hospitals have their mission to provide care for free to patients who cannot pay and the government pays them money to subsidize care for the poor.

        If you cannot afford your care, you have many free or nearly free options available to you even if you have no Medicaid or no insurance at all.

        If you cannot afford care because you are spending money on iPhones and iPads, then you have the option to stop spending money on iPhones and iPads.

        • Margalit Gur-Arie

          The problem here is that you need to be totally destitute to get all those free services, and most people that cannot afford health care nowadays are not.

          The argument seems to be that because health care is so expensive, having a decent car, a computer, a dog, furniture or a vacation should be considered luxury items for most Americans.
          This is a far cry from where we were a few short years ago. So how did we get here and why should we accept this point of view?

          • The Happy Hospitalist

            If you are totally destitute, you go on Medicaid and get all the free care you could ever imagine, and then some.

  • IVF-MD

    We all contribute to the world a certain extent and we all consume from the world a certain extent. We are limited in what we can consume because there is scarcity, even in healthcare. This means that the world’s most desired hospitals and doctors can’t give care to an unlimited number of people. Therefore, there has to be way to ration who gets first choice of this healthcare. Not only is it impossible to give everybody access to the top providers, it’s not even possible to give everybody access to all procedures and drugs (regardless of the provider). In nearly any industry other than healthcare, this rationing is implemented invisibly based on an entity known as pricing. With our system the way it’s devolving, we could well have rationing based on central planning, where bureaucrats will make decisions that affect who gets what, rather than letting the free market decide and that is NOT better than rationing based on individual choice.

    Money is a place marker that imperfectly (but closer to perfect than any other way) keeps score of how much we contribute to what others want.

    Having laid out this general foundation, it should be clear that people are free what to do with their money that they have accumulated from contributing to the world. In fact, it also has the nice advantage of encouraging all of us to contribute more.

    We all spend at least a minimum amount on food, water and other essentials. But the rest is up to us. People can choose to pay their money on this nebulous entity known as “healthcare”, meaning they’ll give money to somebody who will give them “expert” advice, give them permission to obtain certain drugs or to physically manipulate their body via surgical procedures in an attempt to ease pain or improve function.

    This whole co-pay issue is a smokescreen. Whether you discuss a co-pay or a full amount, it’s all about how much the general public wishes to allocate their earnings towards the betterment of their health. When something bad happens to your car or to your house or to your body, it is your responsibility to take care of it. Insurance is a means of smoothing out the wild fluctuations, so that if something rare happens that would incur a lot of costs to address, then you and your fellow insured have spread out the cost of that burden among yourselves, so that the ones who didn’t get “unlucky” will all chip in to help the one who did get unlucky in a previously agreed-upon manner.

    With all due respect, if you want to educate and enlighten us on these supposed 45,000 “excess deaths” we’d be open to learning more about it and perhaps if your argument is sound, we might be swayed towards your opinion. But as for me, I will hold to my current opinion that co-pays are not to blame for all these deaths. Thanks for listening.

    • HJ

      If you read Dr. Green’s post carefully, you would see that we are talking about the uninsured and the underinsured, not copays.

      From: Health insurance and mortality in US adults.

      “Lack of health insurance is associated with
      as many as 44789 deaths per year in the
      United States, more than those caused by
      kidney disease (n=42868).43 The increased
      risk of death attributable to uninsurance
      suggests that alternative measures of access
      to medical care for the uninsured, such as
      community health centers, do not provide the
      protection of private health insurance.”

      Of course, the post is about high deductibles/copays.

  • kullervo

    Nice to know so many doctors take a dim view of their patients. I bow to experience, of course, but we’re not all dirtbags. I take care of my health, I see my doctor, I got my Hep A&B vaccination because I want to avoid preventable illness. I’m even a blood donor on my way to my eighth gallon. My health insurance is there to prevent me and my family from being wiped out if something bad happens. To that end, I lie to my doctor to keep my records clean and I have for years. I have a lot more years to get through before I reach Medicare, if it’s there when I arrive. I am not consuming medical services, and am in pain, but I won’t risk losing my insurance. It’s expensive, it does not cover pharmacy, but it’s all I have.

  • Doc99

    What third party payor giveth, third party payor taketh away.

  • Happy Hospitalist

    If you get an outpatient colonoscopy at your local community hospital you can bet you’re going to get a charge from the hospital for the cost of the facility and you’re going to get a charge from the private practice doctor who did the procedure.

  • Donia

    I have been sacrificing dental and vision care for years because of the co-pays. I have medical issues that take precedence over other medical issues that I can live with. Too many doctors, office visits, and prescription co-pays all add up.

    Even though, I’m in the middle class and have insurance coverage through my husband, I am totally bleeding my poor husband dry with my medical bills! I cannot hold down a job to help him. Because of his income level, I don’t qualify for any kind of assistance or programs to help fund all of this.

    I cannot wait anymore to get new glasses because I need to see well in order to read people’s lips. Yes, I am totally deaf and am a good candidate for a cochlear implant.

    There is no way I can get a cochlear implant because what the insurance don’t pay, since they are an 80% coverage, the cost is just prohibitive. I will have to live in a world of total silence because of this. Unless I win the lottery sometimes in my lifetime, which is really unlikely.

    My husband has had enough of all these co-pays that I’m incurring. I feel really bad for my husband. I love him and WANT for him to do what he wants to. He can’t do some things because he is totally out of funds.

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