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Cost-Shifting and Care

By November 8, 2011November 9th, 2011Commentary

Over the last decade, employers have increasingly attempted to limit their exposure to health spending increases by transferring more of the total cost burden to employees, both through increased premium contributions and through higher copays, deductibles and coinsurance.  Supposedly this will reduce health spending by making consumers more aware of the cost of care and therefore lead them to avoid unnecessary care.  Whether it does this or not, it clearly helps employers control this growing cost of doing business.  A study reported in Health Affairs looks at the effects of increased cost-sharing for the Mayo Clinic employee population.   (HA Article)

Prior to the change, most employees were in a fairly rich benefit plan with little cost-sharing.  After the change, primary care and preventive services had no cost-sharing, but use of specialists, imaging, outpatient procedures and diagnostic testing did.  There were basically a high premium option with lower cost-sharing or a low premium option with higher cost-sharing for employees to chose from.  The research tracked a stable group of employees and dependents from a period of time before the change to several years after, looking at utilization changes.  It also compared the experience of people who stayed in a high or low premium option with those who switched from a high to a low premium one.  Specialty care use decreased and stayed lowered, as did the use of outpatient procedures and diagnostic testing.  Imaging decreased initially, then increased but probably at a lower rate than would have occurred.  At the same time, there was not a compensating increase in use of primary care, but people did not skip on preventive services.

A couple of caveats are that this is an employee population which is probably unusually health literate, working at one of the country’s premier medical institutions.  And almost all the care under the health benefit plan is provided by Mayo itself and since Mayo’s physicians are salaried, and they were educated on the benefit change, they had little incentive to continue pushing the use of discretionary services.  Nonetheless, the results give some comfort that increasing cost-sharing not only may reduce health care utilization and spending; it does not appear to increase primary care use unduly, even when it is exempted from the cost-sharing.  There was limited evidence that quality and outcomes remained high, and hopefully the next step for these researchers is to validate that the cost-sharing did not result in worse health or health outcomes.

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