High deductibles keep patients away from care

Several years ago, 49-year-old Frances Fisher had to switch from a generous health plan to one with a high deductible when her husband switched jobs.

After the health plan switch, she developed gastrointestinal bleeding. And even though she had insurance, she didn't go to the doctor for months, certain it wasn't cancer.

Fisher, a mother of three and Girl Scout leader who lives in an affluent neighborhood, knew that she would likely pay more out-of-pocket by seeing a doctor right away. By waiting until after the first of the year, Fisher thought she would limit her expenses.

"I was making an economic decision about medicine based on absolutely no medical qualification," she said.

Fisher's concern is likely shared by others in Minnesota, which has some of the lowest health insurance premiums in the country, but also tends to have high deductibles. Deductibles also are rising in other states, so much so that there are growing concerns nationwide that there are millions of people with health insurance they cannot afford to use.

Last year eight in 10 insured workers nationwide had deductibles, up from about half in 2006, according Kaiser Family Foundation research. The average amount workers had to pay before their coverage kicked in was $1,217 — more than double the average in 2006.

When Fisher went in for tests, she learned that she did have cancer. Doctors diagnosed a stage three rectal tumor.

Seven years later, Fisher is cancer free. But she'll always wonder whether the surgeries and chemotherapy would have been as much of an ordeal had she gone in earlier. Never again, she says, will she put off health care to save money.

"I knew something was wrong and didn't do anything about it," she said. "Yeah, it wasn't the most intelligent thing I've ever done."

Fisher eventually decided not to let finances trump health, but as deductibles rise nationwide, research indicates more people are making the same economic decisions.

Common features in health plans, deductibles require the consumer to pay a certain amount out-of-pocket before the insurer is on the hook.

Two years ago, nearly nine in 10 insured private sector workers in Minnesota had a deductible, a significantly higher level than the national average.

The high deductibles are intended to discourage unnecessary trips to the doctor to help curb the rising cost of health care, Minnesota State Health Economist Stefan Gildemeister said.

"The policies are very much designed to expect patients to manage their health care use. Now, the downside is that they are relatively blunt tools," he said.

But the tools are so blunt, Gildemeister said, that rising deductibles — more common in Minnesota than any other state — are discouraging people from seeking necessary care.

Deductibles, copays, and other so-called cost sharing are absorbing a significant portion of household income, especially for the less well-off.

Roughly two of five adults who had deductibles that were high relative to their income reported avoiding needed care because of their deductible, said Sara Collins, a researcher at the Commonwealth Fund, a foundation that advocates for a high performing health care system that includes low-income people, the uninsured, minorities, young children and the elderly.

"Either they had a medical problem but didn't go to a doctor because of their deductibles," she said. "They didn't get a preventative care test like a mammogram, they skipped a medical test or a follow-up recommended by a doctor or they hadn't seen a specialist when they thought they needed one of their doctor though they needed one."

Collins says nearly one fourth of people with high deductibles cited them as the reason they had not obtained a preventive care test, even though by law those tests are excluded from deductibles.

Alarmed that parents are keeping their kids away from necessary doctor visits, the American Academy of Pediatrics weighed in on high deductible plans last year. In a position paper, the group concluded that high deductible health plans pose a risk to children.

"We're recommending for children that we not have the high deductible health plans," said Budd Shenkin, a pediatrician who wrote the academy's position paper. "Across the whole country all pediatricians are now seeing parents more reluctant to come in because they have to pay this high deductible."

When parents do take their children to doctors, Shenkin said, some skip follow up visits — even for something like monitoring asthma.

"Parents are saying, 'Well, can't I call in and tell you how he's breathing?'" Shenkin said. "Well, parents are not trained professionals and it's very hard to check that way so the children are really suffering."

But if doctors and researchers fret about the health impacts of high-deductible plans, consumers prefer them.

A Bankrate.com survey found 44 percent of people in the United States favor higher deductible plans with lower monthly premiums while 36 percent favor those with lower deductibles and higher premiums.

When people select insurance plans they need to look at whether a low premium comes with an unaffordable deductible, said Doug Whiteman, an analyst for Bankrate.com.

"The concern that we have is that too many just focus on the monthly price and are really determined to find the lowest monthly premium," he said. "That's not always the smartest way to go."

Whiteman said even though Americans rank picking health plans right up there with a getting a cavity filled at the dentist, it's more important than ever to shop closely. That will help people make good choices about their health care, he said.

"The Affordable Care Act and really other trends that are happening — for example, employers cutting back on benefits — these trends are forcing all of us to really buckle down and try to learn more about our health insurance," Whiteman said.