It is pretty well-established that consumers have cost sensitivity around health care use; if they have to pay more they use less health care. And obviously, the impact is greater for low-income consumers. High-deductible health insurance plans take advantage of this basic economic fact to impose higher cost-sharing on patients to discourage use of unnecessary services and encourage shopping for lower-cost treatment. The concern is whether only low-value care is being discouraged. A new piece of research in Health Affairs addresses this issue. (HA Article) The study is a meta-review, it just combines and analyzes findings from a variety of prior research on the topic. The authors winnowed the research to 28 studies that they viewed as relevant and conducted in a good enough manner to be included in their analysis. They classified higher-cost sharing to be beneficial if it reduced use of unnecessary services and/or spending and to be adverse if it reduced use of necessary care.
Many high-deductible plans still provide first-dollar coverage of preventive care. Notwithstanding this, 4 of 8 studies directly addressing this outcome found that there was a significant reduction in preventive care use under higher cost-sharing. Of course, patients may have a different view of the value of preventive care than do the supposed experts and they may also need better education about what services their cost-sharing applies to. Most studies showed a reduction in both needed and inappropriate office visits under high-deductible plans. In general HDHPs appear to reduce unnecessary ER use. The impact on hospital use and spending was more ambiguous. Use of prescription drugs was also generally reduced in the studies, with uncertain impact on health. As these authors note, just because increased cost-sharing may appear to deter necessary or appropriate services doesn’t mean ultimate health outcomes or the patient’s health is harmed. There is almost no research that actually addresses this issue. Such research might help us define what really is a necessary service. This study doesn’t really add much of anything to our knowledge, but undoubtedly will be publicized as indicating that HDHPs are bad, which really isn’t a supported conclusion.