Most doctors say their patients refuse or delay medical care due to concerns about cost, supporting research that's revealed the unintended consequences of shifting more costs to consumers.
Around 4 out of 5 independent physicians say that high-deductible health plans are the primary reason that patients cancel or delay care, according to a survey of more than 700 doctors in late 2019 administered by NORC at the University of Chicago for the Physicians Advocacy Institute. The poll supports other research that found that HDHPs cause people to avoid both high and low-value care.
"Patients have been shown to forgo medically necessary care when they can't afford the services. That is a big concern," said PAI CEO Kelly Kenney, adding that she is also worried about how much out-of-network care patients are forced to get.
High-deductible health plans have proliferated in recent years as employers and employees are lured by lower premiums. Average deductibles for covered workers have increased 212% from 2008 to 2018, while premiums for employer-sponsored insured rose 55%, according to the Kaiser Family Foundation. Around 40% of those with employer-sponsored coverage have a high-deductible plan; deductibles exceed $1,500 for 20% of individual employees.
"We have seen a significant increase in co-pays and out-of-pocket costs with the big shift to high-deductible health plans," said Marianne Udow-Phillips, executive director of the Center for Health and Research Transformation at the University of Michigan, adding that has inflated hospitals' bad debt levels.
Part of the goal was to reduce total healthcare costs and facilitate prudent healthcare shopping. While employers' healthcare costs are growing slower than they had been, the rate still exceeds wage growth and inflation. Research has shown that costs often increase along with patients' acuity and that patients and providers often lack the tools to "shop" for care.
"High-deductible health plans were supposed to make us better healthcare consumers, but they have failed," Donald Palmisano, Jr., executive director and CEO of the Medical Association of Georgia and a member of PAI's board, said in prepared remarks. "They force people attracted by low premiums to choose between healthcare and housing, or food. They're an idea that turned out to be bad for both patients and doctors."
Independent physicians have changed their treatment protocol as patients shoulder more costs. More than 52% of doctors said they often alter their preferred approach to which drugs to prescribe due to patient cost concerns, according to the survey. Around 3 out of 4 doctors say they have a responsibility to talk about costs with their patients, but 35% have very little or no access to the required information involving deductibles and charges.
COVID-19 has exacerbated underlying cost concerns. While many employers and insurers have waived out-of-pocket costs for COVID-19 testing and treatment for workers enrolled in high-deductible health plans, many are still on the hook for surprise bills.
"Insurers say, 'We really want COVID patients to get treated so we will waive deductibles and out-of-pocket costs,'" Kenney said. "But implicit in that is that patients aren't going to get treated if they have to pay their deductible."
The pandemic has pushed many independent physicians to the brink, causing them to close or sell their practices. It doesn't help that insurers, through HDHPs, have pushed the responsibility of collections on healthcare providers who should be focused on care delivery, Kenney said.
Forty-one percent of independent physicians surveyed reported that bad debt has grown over the past two years, while 40% said that it takes more than two months to receive payments from patients and insurers.
"I don't see why insurers come out of this without any skin in the game, if you will," she said. "Insurers play an important role, but all too often they profit when healthcare providers and patients continue to grapple with expenses, and from the physician's standpoint, delivering the best quality of care to patients."