Men in high-deductible health plans put off serious care

For men enrolled in high-deductible health insurance plans, serious events such as a kidney stone or chest pain might not be enough for them to seek emergency care, according to a study in the August issue of the journal Medical Care.

“Men across the board had a reduction in emergency room visits and hospital care,” said Katy B. Kozhimannil, PhD, assistant professor at the University of Minnesota School of Public Health and the study’s lead author. “The implication is men who transition to HDHPs may forgo needed care in the immediate term.”

The study assessed changes in health care use in the first two years after a switch to an HDHP for about 6,000 men and 6,500 women in the U.S. These trends were compared with men and women who remained in a traditional HMO plan.

Researchers noted a 34% reduction in visits by men for serious problems and a 21% reduction for minor to moderate issues in the year after a move to an HDHP, compared with men who remained in an HMO. Conversely, this trend was reversed the following year, with a 30% increase in hospital admissions for men in an HDHP. “The trends suggest that men might have put off needed care after their deductible went up, leading to more severe illness requiring hospital care later on,” Kozhimannil said.

Although women reduced nonemergent visits by 27%, they had no reduction in visits for more severe problems. “It appears that women were able to select out appropriately,” Kozhimannil said. “But men stopped care for low- and high-severity problems.”

In a similar finding in the August issue of Health Affairs, researchers found that plan members of low socioeconomic status experienced a 25% to 30% reduction in high-severity emergency department visits over both years. Hospitalizations declined by 23% the first year and increased again in the second year.

More data needed

Still, it may be premature to draw conclusions about the initial findings, said Rick Madden, MD, a member of the American Academy of Family Physicians board of trustees and a family physician in Belen, N.M. “Maybe the patient went to their primary care doctor instead. What we don’t know from the study is the cause and effect of the change. The confounding factor is, ‘Where did they go?’ ”

Buoyed by cost-cutting initiatives, high-deductible health plan membership tripled since 2006, and 34% of workers have a deductible of $1,000 or higher. That number is expected to grow in 2014 as the implementation of the Affordable Care Act continues. About 13.5 million people have high-deductible insurance plans with health savings accounts, according to America’s Health Insurance Plans, the national trade association representing the insurance industry.

Although some are quick to point to the financial disincentives of out-of-pocket expenditures, lack of care may be a matter of not understanding their coverage. Such plans lead people to believe they can seek emergency care only when there is a threat to their lives, and this may have different meanings for different people, said Susan Pisano, vice president of communications at AHIP.

Those insured by HDHPs may not realize that under the Affordable Care Act, many wellness screenings are available without an out-of-pocket cost, she said.

Because these studies and others raise issues of use by gender and income, Kozhimannil hopes for more discussion between physicians and patients. “Perhaps physicians can help patients understand the medical benefit versus the out-of pocket expense,” Kozhimannil said. “There are many interesting and important questions related to this worth exploring.”