• Opinion

    High-Deductible Health Plans: Shifting Costs Bring New Risks

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    Ruth D. Williams, MD

    By Ruth D. Williams, MD, Chief Medical Editor, EyeNet


    Facebook is riddled with clickbait lists for almost anything. I was tempted by one entry in my feed, “10 Morning Habits of Happy People,” implying quick and easy results. Then I spotted a more sobering list: “Top 10 Health Industry Issues of 2016,” which takes note of the trend toward high-deductible insurance plans as a major issue for physicians and patients this year.

    High-deductible health plans (HDHPs), in combination with health savings accounts, have long been a strategy to limit costs. Traditionally, those who selected such plans could afford the deductible and high out-of-pocket expenses. However, HDHPs are increasingly used by employers and insurance companies to shift costs to patients and decrease health care utilization. These plans now outpace HMOs in the employer-sponsored health market. In 2015, 24% of all workers were enrolled in an HDHP, up from only 8% in 2009. Overall, 46% of employees had a deductible of at least $1,000 last year.1 This trend is accelerated by the Affordable Care Act, as enrollees select the popular Silver plan, with affordable monthly payments but high deductibles.

    The most obvious effect on ophthalmology practices is the increased responsibility to collect payment directly from patients, many of whom are not prepared for, or cannot af­ford, the large expense. Most often, ophthalmology practices must bill patients, and many find collecting payment for services increasingly difficult.

    We must be proactive. Many patients do not understand the complexity of these new plans and are shocked by the huge bill—and they sometimes shift their anger to the ophthalmologist for “gouging.” It’s essential for patients to be educated about their financial responsibility before the visit or surgery, and it’s up to each practice to do so. This requires substantial staff time and expertise to learn the particular benefit structure of each insurance plan the practice accepts, a huge task in itself. Beyond that, time must be allocated to explain these details to the patient.

    When patients with high deductibles have to pay out of pocket, they naturally become more cost conscious. Proponents of HDHPs claim that these patients are seek­ing high-value health care. But several recent studies have demonstrated that many patients forgo or postpone needed health care due to concerns about cost. I’ve seen this in my own practice. Recently, a patient with normal-tension glau­coma asked me about the least number of visual fields that would determine the stability of her disease. Another patient would only agree to an MRI if it were “very likely to show something,” because of the $1,000 expense. Even though staff should handle most discussions about financial issues before the patient sees the ophthalmologist, questions about sacrificing recommended care must be between the patient and the physician.

    And if the HDHP applies to prescription coverage, then medication adherence is also compromised. Just yesterday, a patient with a small corneal ulcer returned for a follow-up visit but hadn’t filled the antibiotic prescrip­tion because of its cost. This trend may be even more challenging in chronic diseases such as uveitis or glaucoma, where the patient might not immediately see the benefits of medication.

    I also wonder how HDHPs affect patient expectations for the health care experience. Does footing the bill directly create a more empowered patient? Or does it create a more demanding patient?

    Managing an ophthalmology prac­tice has become much more complex in the last few years. The growing trend toward HDHPs subtly shifts financial risk away from the insurance company to the practice, while also increasing the burden of collecting payment and educating patients to the physician and office staff. Unfor­tunately, there is no easy list of “10 Things to Help Doctors (and Patients) Cope With High Deductibles.”

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    1 http://kff.org/report-section/ehbs-2015-section-seven-employee-cost-sharing/. Accessed June 7, 2016.