Costs prompting sicker patients to avoid medical care

Physicians are urged to talk about cost when discussing care options and develop ways to attract patients who should come in but don't.

By — Posted Nov. 21, 2011

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After several surveys found individuals putting off health care because of cost, a recent report says such expense-related reluctance extends to a large number of patients likely to require medical services.

A Commonwealth Fund study, posted Nov. 9 on the Health Affairs website, showed that 42% of self-described "sicker" American adults had cost-related access problems in the last year. The problems included not visiting a doctor, not filling a prescription, skipping doses of medication or not getting recommended care. Of the 1,200 sicker American adults surveyed, 27% said they had trouble paying for care or could not cover medical bills. Cost-related access problems were more prevalent among people younger than 65, who typically are not eligible for Medicare.

"Sicker adults" were defined as those who rated their health as fair or poor; received care for a serious chronic illness, injury or disability within the past year; underwent surgery within the past two years; or had been hospitalized within the past two years.

The Commonwealth Fund, a supporter of the Patient Protection and Affordable Care Act, compared sicker Americans with those in 10 other high-income, industrialized nations and found that "the U.S. stands out with regard to patients going without care and having difficulty paying medical bills with rates far higher than other countries," said Cathy Schoen, senior vice president of the organization.

This was true even measured against countries that had similar percentages of patients responsible for more than $1,000 per year of out-of-pocket costs. Australia, at 39%, and Switzerland, at 35%, had rates similar to the United States, at 36%, of sicker adults who had to pay more than $1,000 per year. Yet only 30% of Australians reported access problems, and only 18% of Swiss reported the same.

Other recent studies and reports have highlighted the trouble Americans have accessing or paying for care.

For example, the Thomson Reuters Consumer Healthcare Sentiment Index, which measures whether patients postponed, delayed or canceled health care during the past three months or thought they would do so in the next three months, dipped from 98 in September to 96 in October. The baseline is 100. The number of people without insurance grew to 49.9 million in 2010, according to the U.S. Census. A Commonwealth Fund analysis published Sept. 8 in Health Affairs found that the number of people who were considered underinsured grew to 29 million in 2010.

Meanwhile, a report released Oct. 12 by J.P. Morgan Chase investment analyst John Rex showed an 8% decrease in office visits per full-time equivalent physician for September 2011 compared with a year earlier -- the third consecutive month of decline and the fourth in five months. Rex blamed the struggling economy for people avoiding the physician's office.

Access to care problems

In the latest Commonwealth Fund study, when broken down by insurance status, 76% of the uninsured had problems with access because of cost. This was true for 38% who were insured. A total of 57% without insurance had serious problems paying a bill or did not pay it within the past year, and this was true for 25% who were covered.

Experts say patients' financial fears can interfere with adherence to physician recommendations and make them less likely to visit a doctor. This means that medical practices may need to be more aggressive about reminding patients when it is time for certain services. This may take the form of emails, phone calls or letters. Including information about the fact that the health reform law requires some preventive services to be fully covered for those with certain health insurance plans may provide an additional draw.

Physicians also may need to talk about cost. This does not necessarily mean talking about specific prices for drugs and services, which can be challenging.

For instance, a report from the U.S. Government Accountability Office issued Sept. 23 found that, when telephoned by patients, few hospitals and physician offices could offer an estimate of the complete cost of care. The GAO said this was primarily because physicians were unclear about what services they would provide and were unsure of the cost of services from outside entities such as labs.

"Physicians are well aware of these issues," said Gregory Misky, MD, a hospitalist with the University of Colorado Hospital in Denver who has studied care transitions and hospital length-of-stay issues. "But it gets frustrating. We don't have support to help us."

Even if specific prices are not available, experts say physicians can help patients prioritize care. Are there some medications or interventions that a patient must have and others that may be helpful but less important? Are generic medications a possibility? Are there lower-cost interventions?

"When physicians are with a patient who either has no insurance or has insurance with a substantial deductible, they cannot assume they will always go out and do whatever they recommend to them," Schoen said. "It's good to have a conversation about cost and what the patient can do. It may be a difficult conversation, but it's more patient-centered care."

The Commonwealth Fund study also said the patient-centered medical home could help sicker adults get the care they need. Although cost was considered the major factor for access problems, the Commonwealth Fund said the fragmented U.S. health care system contributed, with patients declining to move along as their care is transferred from one physician to another, or to a hospital.

The survey did not correlate affordability of care or delaying receipt of services and the medical home model, but a total of 56% of U.S. patients were cared for in a medical home as defined by the Commonwealth Fund.

Of those in this model, 90% said their blood pressure was controlled. This was true for only 76% who did not have a medical home. In addition, 77% of those cared for in a medical home rated their care during the past year as excellent or good, but this was true for only 43% of those who were not in a medical home.

"Patient-centered medical homes make a difference," Schoen said.

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Out-of-pocket costs for sicker adults

A Commonwealth Fund survey found that patients in industrialized countries have health care bills, but U.S. patients with complex medical needs were more likely to have trouble paying them. "Sicker adults" were defined as those who rated their health as fair or poor; received care for a serious chronic illness, injury or disability within the past year; underwent surgery within the past two years; or had been hospitalized within the past two years.

Country Less than $100 More than $1,000
U.S. 19% 36%
Australia 13% 39%
Canada 30% 24%
France 47% 6%
Germany 20% 12%
Netherlands 30% 11%
New Zealand 29% 13%
Norway 12% 16%
Sweden 21% 5%
Switzerland 14% 35%
United Kingdom 58% 1%

Source: "New 2011 Survey Of Patients With Complex Care Needs In Eleven Countries Finds That Care Is Often Poorly Coordinated," Health Affairs, Nov. 9 (link)

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U.S. tops list in payment problems

Patients with complex medical needs in the United States fared more poorly than those in other industrialized countries when it came to paying medical bills and choosing to receive care because of costs, according to a Commonwealth Fund survey. This is true even for patients who had a regular physician or place of care.

Country Trouble paying
medical bills
access problems
Had regular doctor or
place of care
U.S. 27% 42% 91%
Australia 8% 30% 97%
Canada 8% 20% 96%
France 5% 19% 99%
Germany 6% 22% 97%
Netherlands 14% 15% 100%
New Zealand 11% 26% 99%
Norway 7% 14% 99%
Sweden 4% 11% 95%
Switzerland 8% 18% 99%
United Kingdom 1% 11% 99%

Source: "New 2011 Survey Of Patients With Complex Care Needs In Eleven Countries Finds That Care Is Often Poorly Coordinated," Health Affairs, Nov. 9 (link)

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Better care through medical homes in U.S.

The medical home model tended to improve access and care coordination, according to a Commonwealth Fund survey. Patients were defined as having a medical home if they had ready access to clinicians who knew their medical history and coordinated care.

Experience With medical home Without medical home
Has a physician-patient relationship 80% 41%
Engaged in care of chronic condition 67% 45%
Controlled blood pressure 90% 76%
Has gap in care coordination in past two years 33% 54%
Experienced a medical error in past two years 17% 29%
Has gap in hospital/surgery discharge planning 19% 46%
Regular doctor not informed about hospital/surgery care 9% 15%
Care quality in the past year was excellent/very good 77% 43%

Source: "New 2011 Survey Of Patients With Complex Care Needs In Eleven Countries Finds That Care Is Often Poorly Coordinated," Health Affairs, Nov. 9 (link)

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External links

"New 2011 Survey Of Patients With Complex Care Needs In Eleven Countries Finds That Care Is Often Poorly Coordinated," Health Affairs, Nov. 9 (link)

To download Community Hospital 100 Survey: Community Hospitals-Financial Health and New Initiatives, Anthelio Healthcare Solutions (link)

Consumer Healthcare Sentiment Index, Thomson Reuters (link)

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