Blunt Tools not the Best Policy Instruments

How do high deductible health plans (HDHP) affect our health care system? Since 2004, HDHP’s have increased in popularity, especially amongst employers and government entities looking to provide coverage to workers. Low premium and high deductible plans are designed to provide catastrophic coverage, decrease health care costs by shifting financial burden onto consumers, and encourage patients to use medical services responsibly. Evidence has shown that while HDHP’s were associated with lower short-term health care costs, they also led to decreases in both inappropriate and appropriate uses of health care services. Those of lower socioeconomic status were deterred by high deductibles from using preventative care and from adhering to medications.  The long-term effects of HDHP’s have yet to be determined, but these results indicate that HDHP’s do not align with value-based models of care.

Health care reform is a simple tool.  How we use that tool is something we must ask ourselves throughout our public discourse on how to restructure the health care system.  HDHP’s have been highlighted in recent reform proposals, most notably in the American Health Care Act, and are often advertised as increasing personal control over what each person pays for in their health care. Whether HDHP’s can act as a panacea for the ills of the U.S. health care system depends on the goal of reform.

The consensus point between liberals and conservatives in health reform is a reduction in costs, both personal and national.  The question that remains is whether this goal is best achieved via a smarter, more efficient system, or by decreasing the number of people who can access health services, and thus lowering costs.

HDHP are a blunt, imprecise instrument that will succeed in lowering both appropriate and inappropriate health care costs.  This will meet the needs of some policy makers, but may not address the overall responsibility of the medical community to produce health for their patients and communities.

Medical professionals must to continue to ask whether HDHP’s, as a cornerstone of future health reform, are congruent with the mission and values of the medical community.  These decisions will determine how we can better incentivize patients and providers to reduce inappropriate expenditures while maintaining, or even increasing, the use of medically necessary services.

commentary by Orlando Sola with assistance from Dr. Robert Wang 

Abstract

Enrollment in high-deductible health plans (HDHPs) has greatly increased in recent years. Policy makers and other stakeholders need the best available evidence about how these plans may affect health care cost and utilization, but the literature has not been comprehensively synthesized. We performed a systematic review of methodologically rigorous studies that examined the impact of HDHPs on health care utilization and costs. The plans were associated with a significant reduction in preventive care in seven of twelve studies and a significant reduction in office visits in six of eleven studies-which in turn led to a reduction in both appropriate and inappropriate care. Furthermore, bivariate analyses of data extracted from the included studies suggested that the plans may be associated with a reduction in appropriate preventive care and medication adherence. Current evidence suggests that HDHPs are associated with lower health care costs as a result of a reduction in the use of health services, including appropriate services. PMID: 28971921 

Agarwal, R, et al. Health Affairs 2017; 36 (10): 1762-1768.