There’s nothing like a high-deductible health plan to make you realize how little you know. Not just about health care, but about life and money and the nature of decision-making.
For instance, I recently received emergency room bills for four identical visits: a family trip for rabies shots, after a midnight visit from a bat. For each of us, the hospital charges were the same. But the adjustments — the amount our insurance company shaved off each bill, for reasons unknown — were different. Really different. One bill said I was responsible for $188, another $1,676. When I called my insurance company for advice, a nice man in customer service looked over my account and said he would call me back.
I haven’t heard from him since. I think he needed a mental break.
At least my family knew what it was getting into. We chose our high-deductible plan after running some numbers, calculating how many office copays we might face for a toddler who’s susceptible to strep throat, and figuring we might well come out even, or ahead. We understood that, for some people, a high-deductible plan can be a good financial deal.
But for many people, high-deductible plans aren’t chosen, but imposed by their employers — or chosen by default, because of price. The number of US employees with high-deductible plans has grown from 10 percent in 2006 to 31 percent today. And on state exchanges, set up under the now-officially-legal Affordable Care Act, high-deductible plans will offer the lowest montly rates.
How these plans will affect the state of public health remains a mystery.
“We enact policies before there’s evidence, and then we don’t actually study the evidence,” said J. Frank Wharam, a physician and professor of population medicine at Harvard Medical School. “It’s not a great situation from a policy-making standpoint.”
Wharam has conducted Massachusetts-based studies on how how high-deductible plans affect emergency department use (it seems to go down slightly) and cancer screenings (they seem to stay stable, depending on the test). But he said there’s not enough data yet to fully predict health outcomes. And researchers are just starting to examine other states, where deductibles can climb as high as $12,000 per year.
Here’s one thing we do know: People in high-deductible plans tend to be flummoxed by health care costs, unaware of what’s covered and what isn’t, and shocked when the bills arrive. Wharam’s colleague Alison Galbraith, a pediatrician, led a recent survey of Harvard Pilgrim Health Care members, focused on families with chronic health conditions and high-deductible plans. More than half of those surveyed reported health care related financial burdens, compared with 21 percent of families in traditional plans.
And many participants admitted that they’d put off care because they didn’t want to pay, forgoing sleep surveys or MRIs for skin cancer, taking a prescription drug every other day, instead of daily.
“It ran the gamut,” Galbraith told me. “And that’s the problem. . . People are not always good judges of essential and nonessential care. They across-the-board just cut back.”
And if millions more people start cutting back on pills, we all should be concerned, said Stephen Soumerai, another population medicine professor at Harvard. A story by Reuters Health last week noted that half of heart patients already don’t stick to their meds.
“Most chronic illnesses in America are treated by medication,” Soumerai said. “You have to be at least worried about the fact that it’s going to affect their outcome and cost.”
Especially when these plans, and the rules, aren’t transparent, to say the least. On a taxi ride to the airport recently, Galbraith said, she started talking to the cab driver, who launched into a tirade once he learned she worked in health care. One of his colleagues had gotten a colonoscopy, he said, and had been charged $1,000. He wasn’t going to get one. No way he could pay for that.
Actually, if he’s older than 50, his colonoscopy might be fully covered, under the glorious provisions of Obamacare. But how is he — or anyone — to know?