New insurance options may lead patients to skip care

Some patients with high-deductible plans forgo needed screenings, a study found. But supporters of such plans cite contradictory data and say coverage still works.

By Kevin B. O’Reilly — Posted Nov. 14, 2005

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High-deductible health plans combined with health savings accounts are an increasingly popular choice for employers and patients but could hurt long-term outcomes by discouraging necessary care, according to new poll data from market-research firm Harris Interactive.

An online Harris survey including 900 patients enrolled in HDHPs found they were less likely than those with traditional plans to get preventive care such as Pap tests and prostate-specific antigen tests. The surveyed patients were enrolled in plans with a deductible of at least $1,000 for individual coverage and $2,000 for families, though the plans were not necessarily paired with health savings or reimbursement accounts.

Patients with chronic conditions who were enrolled in HDHPs were more than twice as likely as patients insured by a traditional plan to fail to fill a prescription because of cost, according to a Harris phone survey. The study found that 28% of those enrolled in HDHPs planned not to fill a prescription compared with 13% in traditional plans.

"My hope would be that health plans would figure out some kind of strategy so people aren't just cutting out all kinds of care across the board," said Kinga Zapert, PhD, vice president for health policy research at Harris Interactive, New York. "It's difficult for patients to determine on their own which care is needed and which is not."

The data, published in the Sept. 22 New England Journal of Medicine, also show patients are no more aware now than they were in 2001 of publicly available quality ratings of physicians, hospitals and health plans.

Although HDHPs are not new, the tax-advantaged health savings accounts with which they are being paired were brought into existence by the Medicare Prescription Drug Improvement and Modernization Act of 2003. Medical savings accounts have been available since 1997, but were limited to individuals and businesses employing 50 or fewer workers. American Medical Association policy has long supported expanding MSAs to everyone as part of a broader set of health insurance reforms.

In March 2005, the number of Americans covered under HSAs surpassed the 1 million mark, according to an America's Health Insurance Plans survey of its members. Six months earlier, HSAs covered only half that number. And there's no sign of the growth slowing, as more than 100 insurers offer the coverage.

Supporters of consumer-directed health plans such as HSAs and health reimbursement accounts say the skeptics are missing the boat.

"This is a revolution in health care," said Greg Scandlen, founder of the advocacy group Consumers for Health Care Choices. "For years, we've been browbeating and hectoring patients to become better informed about health care and it hasn't done a damn bit of good because they don't have any skin in the game. In terms of the immediate payback, it's just not there. There's nothing like financial incentives to get people to pay attention."

Scandlen pointed to a study by Pittsburgh consulting firm McKinsey & Co. that polled 2,500 patients insured by either consumer-directed health plans or traditional plans. The poll revealed that patients in consumer-directed plans were 25% more likely to carefully follow treatment regimens for chronic conditions, 20% more likely to participate in company wellness programs and 30% more likely to get an annual check-up.

Consumer-directed health plans are allowed to offer first-dollar coverage of preventive care services, and knowledgeable observers say it appears that many large employers are opting for plans that do just that. Otherwise, employees would have less reason to switch from the comprehensive plans they already have.

Both sides in the debate acknowledged that with HSAs nearing only their second birthday, it may be too early to judge their impact.

"People are hungry for the data," Zapert said.

"The question is whether we want to wait for it to come in. I don't think it would be smart to rely on consumers to decide which type of health care they could cut back on."

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Cost matters

Patients who have chronic conditions and are enrolled in high-deductible health plans of any type cited cost as the reason that made them more than twice as likely as patients with traditional insurance to not fill a prescription. Here's the percentage of people who said they've skipped filling prescriptions by type of health condition and coverage.

Condition Comprehensive
Diabetes 15% 24%
Depression 9% 30%
Chronic pain 9% 23%
Arthritis 9% 16%
Heart disease or
8% 18%
Asthma 9% 23%
Allergies 7% 23%
High cholesterol 2% 16%
Other 17% 25%

Source: Harris Interactive poll of 1,354 patients

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