High-Deductible Plans Push Physicians to Change Practice

Marcia Frellick

June 18, 2020

Most independent physicians in the United States have changed their practice as a result of the high deductibles patients face with health insurance, survey data show.

The survey, which included interviews with 706 practicing independent physicians, was conducted for the Physicians Advocacy Institute (PAI) by the independent, nonpartisan research group NORC at the University of Chicago. The work was funded by PAI.

Among key findings were that 80% of physicians say their patients delay or forgo care because of out-of-pocket costs or push it to the end of the year when they have met their deductibles. More than half of physicians (51%) said that causes office capacity issues.

The authors explain that 40% of people with employer-sponsored coverage have a high-deductible health plan (HDHP), and 21% of those patients fall into the highest-deductible category described as at least $3000 a year for individuals and at least $5000 for a family.

More Than Half Alter Treatment Plans

The researchers found that 55% of physicians said patients' cost concerns are causing them to alter treatment plans. Sixty-six percent have changed their decisions about whether to prescribe drugs, and 86% have changed which drugs they prescribe.

The problem has worsened considerably over a decade. Between 2008 and 2018, the average deductible for employer-covered workers went up 212% for patients. At the same time, premiums for employer-sponsored insurance rose 55%.

Frank Wharam, MD, MPH, director of the Division of Health Policy and Insurance Research at Harvard University in Boston, Massachusetts, told Medscape Medical News this survey is unusual in that it looks at the HDHP barriers from physicians' point of view.

Though administrative burdens come with HDHPs, he said, the plans' effect on patient outcomes is the most disturbing aspect he sees.

Wharam has studied effects of HDHPs on care, particularly among people managing diabetes and women tested and treated for cancer.

He found that low-income patients with diabetes delay even visits for acute complications — skin infection or a pneumonia, for instance — when out-of-pocket costs are perceived as too high.

"That led to more emergency department visits," he said, and higher costs.

Wharam said those with diabetes also delayed their visits for symptoms related to cardiovascular disease and for testing and procedures to treat cardiovascular disease.

Regarding cancer care among women the NORC researchers studied, there were delays in getting follow-up testing for concerning breast lesions and there were delays in diagnosis and treatment.

"The delays were greatest among low-income women," Wharam said. "The biggest delays were among women who lived in rural areas."

What Can Be Done

HDHPs are not likely to go away anytime soon, Wharam noted. He explained that the COVID-19 pandemic adds another barrier to care because patients may have fears of catching the virus in a physician's office on top of avoiding or delaying care in general because of the costs.

The survey was taken from December 11 through December 18, 2019, before trends were interrupted by the pandemic.

A population health management approach is more important than ever, Wharam says, which will mean reaching out to patients at home and helping patients maintain and prioritize care.

"Whereas before it may have been the most vulnerable patients not showing up, now it's an issue that's affected everyone," he said.

After connecting with patients, understanding the barriers to care is the second key step, he said.

Patients may also need information on heath savings accounts, he said, so money can be deducted from paychecks and serve as a tax-free way to help pay for their care.

Physicians also should learn what financial help is available for patients, whether through state programs, charitable foundations, drug manufacturers discounts, and even through the practice itself.

Asking patients in the office to show their insurance card may reveal deductible amounts or what kind of plan they have to start the conversation, he said.

Having a staff member dedicated to dealing with insurance issues may be the best solution, he explained, though he acknowledged that may be easier in well-resourced practices.

Physicians say they feel unprepared to help patients know what they will pay. More than half of physicians (51%) say at least half of their patients request cost of care discussion, but 75% of physicians said they didn't feel they had the information they needed to have those discussions.

That missing information includes the amount of deductible, balance on the deductible, amount of adjusted bills, and benefit design. Only 15% of physicians say they have the cost information and feel confident they can help patients make an informed decision.

That's no surprise to Wharam, who noted that "the price of a service between a clinician and a health insurer is a secret, in some sense. It's a negotiated price and one group has a different price from another."

Lack of Timely, Accurate Information

Donald J. Palmisano Jr, executive director and chief executive officer of the Medical Association of Georgia and a member of PAI's board of directors, told Medscape Medical News the lack of timely, accurate information has been particularly frustrating.

As an example, physicians may get a prior authorization for a procedure and when it is time to collect, the insurance company says the patient is no longer employed.

"It's a double-edged sword for the physician," Palmisano said. "They have more hassles put on them and the information that is supposed to be there is not accurate."

He said the ultimate solution will likely have to be a regulatory one that will ease the HDHP burden.

"Clearly the insurance companies are not doing that," he said.

Palmisano said legislation that reins in deductibles will be especially important as insurers try to recover costs from COVID-19 at the same time unemployment climbs.

The survey was funded by PAI. Palmisano is a member of PAI's board of directors. Wharam has disclosed no relevant financial relationships. Methodological information about the data researchers acquired from SurveyHealthcare's physician panel is available here.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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