One answer to the increasing cost of health care is limiting utilization through patient cost shiftingexposing patients to a greater share of the financial risk of health care through (HDHP). HDHPs shift costs by requiring members to bear the full brunt of the financial burden for many services until an annual deductible is met. From 2006 to 2012, the percentage of employees enrolled in a plan with at least a $1,000 deductible more than tripled: from 10% to 34%.
While , concerns arise when patients must balance their health care needs with budget constraints. Specifically, concerns have surfaced around the unintended consequences of limiting essential outpatient services. This study used a pre-post comparison group design to examine the impact of an HDHP on outpatient visits and associated laboratory and radiology tests.
The study examined utilization rates of members insured by Harvard Pilgrim Health Care both before and after their enrollment in a HDHP, and compared these rates with controls enrolled in a more traditional HMO. HDHP members were responsible for the full cost of non-preventive radiologic and laboratory tests. Additionally, visits for acute and chronic conditions were classified as high- or low-priority based on benefit of care.
Compared with controls, HDHP members experienced a moderate relative decrease9%in all office visits. Similar reductions were discovered with higher and lower priority chronic condition visits. There were no significant differences in changes in visit rates for acute higher or lower priority conditions or preventive laboratory tests. HDHP members showed moderate relative reductions in the use of general laboratory tests but not radiology tests. Overall, the results suggest that HDHP patients with chronic illnesses might be more likely to reduce health service utilization because of increased exposure to costs associated with outpatient visits.
Enrollment in an HDHP is associated with both intended and unintended changes in the patterns of outpatient health care utilization. Of note, both higher priority and lower priority chronic outpatient visits declined for HDHP members. The obvious concern is whether patients are able to afford essential care when accompanied by a high deductible. The not-so-obvious concerns are the choices made on which services to utilize. The reduction in both high and low priority services suggests patients cannot discern and are not guided toward high value care with their limited resources. This issue comes down to health IQ, and the idea that being a good consumer of health care requires making informed decisions either through thoughtful research or or care manager. Currently, it seems to maximize efficiency for those enrolled in HDHP. Furthermore, as the authors note, additional data points on important proxy outcomes such as emergency department and hospital visits will tell a more complete story by accounting for the individual health status of each plan member.
Patrick Fitzgerald, MPH