http://www.medscape.com/viewarticle/733002November 22, 2010 — Lower-income families with high-deductible health plans (HDHPs) may delay or forgo care because of costs, according to the results of a cross-sectional survey study reported in the November 22 issue of Archives of Internal Medicine.
"In the midst of the current economic downturn, many Americans are paying more for their health care," write Jeffrey T. Kullgren, MD, MPH, from Robert Wood Johnson Foundation Clinical Scholars, Philadelphia VA Medical Center and the University of Pennsylvania, and colleagues. "One way in which a growing number of families are facing higher levels of cost-sharing for health care is enrollment in high-deductible health plans. These plans, which feature annual deductibles of at least $1000 per individual and at least $2000 per family before most services are covered, seek to encourage patients to become more cost-effective consumers of health care and frequently offer lower premiums than other types of health insurance."
The investigators surveyed a stratified random sample of families in a New England health plan's HDHP with at least $500 in annualized out-of-pocket costs. The main study endpoints were care delayed or forgone because of costs, difficulty understanding plans, unexpected costs, information-seeking, and the likelihood that families would query their physician regarding hypothetical recommended services subject to the plan deductible. Potential confounders of associations between income group and primary outcomes were controlled for using multivariate logistic regression.
Compared with higher-income families (n = 273), lower-income families (n = 141; those with incomes <300% of the federal poverty level) were more likely to report cost-related delayed or forgone care (57% vs 42%; adjusted odds ratio
, 1.81; 95% confidence interval , 1.15 – 2.83). Report of delayed or forgone care because of cost was more likely in the lower-income group for care for an adult (51.1% vs 34.8%, P = .002), care for a child (24.1% vs 13.9%, P = .01), and operations or procedures (19.8% vs 6%, P = .003).
Understanding of the plan, unexpected costs, or information-seeking by income did not differ between higher- and lower-income groups. However, the lower-income families were more likely to ask their physician about a $100 blood test (79% vs 63%; AOR, 1.97; 95% CI, 1.18 – 3.28) or a $1000 screening colonoscopy (89% vs 80%; AOR, 2.04; 95% CI, 1.06 – 3.93) subject to the plan deductible.
"Lower-income families with out-of-pocket expenditures in an HDHP were more likely than higher-income families to report cost-related delayed or foregone <> care but did not report more difficulty understanding or using their plans, and might be more likely to question services requiring out-of-pocket expenditures," the study authors write. "Policymakers and physicians should consider focused monitoring and benefit design modifications to support lower-income families in HDHPs."
Limitations of this study include self-reported, cross-sectional data subject to recall bias; lack of generalizability to other HDHP populations; possible differences in families who have HDHP plans vs those who do not; possible lack of correlation between respondents' reported willingness to discuss hypothetical recommended services and their actual behaviour; and lack of a non-HDHP comparison group.
"Contrary to our initial hypothesis, respondents from lower-income families voiced an even greater desire than those from higher-income families to talk with their physicians about 2 of 3 hypothetical services," the study authors conclude. "These findings suggest that physicians have a central role to play in helping their patients navigate the challenges of decision making in high-deductible health plans. Beyond the implications for clinicians, our findings have important implications for federal health reform."
In an accompanying Invited Commentary, Victor R. Grann, MD, MPH, from Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, and Mailman School of Public Health, Columbia University, New York City, defines appropriate care as care known to offer a benefit that is greater than any potential harm.
"tudies have shown that consumers cannot easily distinguish appropriate from inappropriate care in their purchasing, at least not based on the information currently available in the marketplace, "Dr. Grann writes. "Value-based insurance design may be a better model. In this design, copayments are minimized for those interventions of high clinical value, while high copayments are required for those interventions of low value. This could potentially decrease health insurance premiums and overall health care costs without resulting in people forgoing those treatments that would actually benefit them."
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