Costs Often Obstacle To Primary Care

For years, leading health experts have said the way to improve healthcare quality and lower its cost is to emphasize prevention over treatment and encourage closer coordination among medical providers caring for a patient.

Those goals are at the core of the Affordable Care Act, which aims to push medical delivery in that direction.

But there’s a counter trend threatening to undermine that vision, according to an article published March 9 in the New England Journal of Medicine: A rapid move toward health plans that impose a larger share of the cost on enrollees, most notably through high deductibles and co-payments.

“The conflict between these two approaches is clear,” wrote the article’s co-authors, Peter Lee, the executive director of Covered California, and Elliott Fisher, M.D., director of the Dartmouth Institute for Health Policy and Clinical Practice. Boosting quality and cutting costs, they said, “depends directly on having patients engaged with their care team — usually a primary care practice.”

The two authors still see an important role for “carefully designed” consumer cost-sharing, which can induce patients to “make wise decisions about what discretionary care they truly need and want.”

But the high out-of-pocket costs embedded in a growing number of health plans can deter people from getting the preventive primary care they need to stay healthy, Lee and Fisher warned. They urged state-based insurance exchanges and employers who sponsor coverage for their workers to offer health plans that make it easier for people to get medical care.

“We need to change the culture of medicine to be about primary care and care coordination,” Lee said in an interview. “Employers and health plans in the public sector have benefit designs that directly conflict with the goal of the ACA.”

So much of the health reform law, Lee added, is about ensuring access to care. Yet, high out-of-pocket costs in many plans can block that objective, he said.

That is particularly true among those who get health coverage through an employer. And that’s a large number: 147 million people, or 54.6 percent of the non-elderly U.S. population, according to a 2015 survey on employer-sponsored insurance by the Kaiser Family Foundation and Health, Research & Educational Trust. 

Lee and Fisher noted that the proportion of Americans who have employer-sponsored coverage with deductibles of more than $1,000 has increased from 10% to 46% in the past decade.

Fisher and Lee noted that Covered California has taken a different approach — an example they said can help avoid a collision between insurance plans with high deductibles and the ongoing effort to improve the quality and reduce the cost of care. 

Among 1.3 million Covered California enrollees as of June 2015, they noted, 75% could obtain primary care without being subject to a deductible and with “modest co-payments” that varied depending on whether they qualified for federal subsidies.

Yet the other 25% of Covered California enrollees — 316,000 people — had chosen the lowest-tier “bronze” option as of mid-2015. Patients in the bronze plan receive one free primary care visit and three visits not subject to the annual $5,000 deductible. But it's not just about the cost. Plans catering to patients’ best interests should be easier to navigate, many agree. Too many plan benefit designs, they say, are confusing and convoluted for the average consumer.

Fisher and Lee noted that Covered California — joined by a handful of other states — has standardized deductibles, copayments and other shared costs for its contracted health plans at each of the four levels of coverage: bronze, silver, gold and platinum. That means shoppers can compare plans at each tier of coverage based only on the premium and which doctors and hospitals are in the network.

Not all state exchanges are designed this way, they observed. Consumers in many states are left to choose among a multitude of insurance policies from a wide range of carriers, with differing deductibles and co-payments. 

The Centers for Medicare & Medicaid Services recently announced it would allow health insurance companies to standardize benefit designs on the federal exchange next year. 

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.