« Teaching Health Cent... | Main | No Margin, No Missio... »

Tuesday Dec 18, 2018

High-deductible Plans Shouldn't Endanger Continuity of Care

"Nobody's walking out on this fun, old-fashioned family Christmas. No, no. We're all in this together. This is a full-blown, four-alarm holiday emergency here."
-- Clark Griswold in Christmas Vacation

[high-deductible health insurance plan on desk]

As we approach the close of 2018, I want to thank you for following and reading In the Trenches during the past year. I have enjoyed engaging with you on health policy issues impacting family medicine and our health care system. There is so much work to do, but I am optimistic about our future as a discipline and truly amazed by the great work each of you do for your patients and communities. I hope you have a nice holiday season and a happy new year. I wish you a healthy and prosperous 2019.

Please reach out to a family member, friend or neighbor who may be alone this holiday season. Loneliness can be a serious issue(news.uga.edu), and social engagement is important to our overall health. If you know someone who is alone or socially isolated, take a few minutes this holiday season to reach out.

I noted that my previous post was the first in a series to outline the AAFP's policy priorities for the 116th Congress. The first priority I outlined was the need to reauthorize funding for the Teaching Health Center Graduate Medical Education program. In this post, I am going to take a closer look at how we can create greater connectivity and continuity of care from family physicians among individuals and families who have high-deductible health plans (HDHPs).

We know from research that there is a relationship between health care coverage, having a usual source of care and health outcomes. This is usually framed as, "Those with health care coverage and an ongoing relationship with a primary care physician experience better health and utilize fewer health care services." The relationship between a usual source of care and outcomes was reinforced in a recent study published in the Annals of Family Medicine(www.annfammed.org) that showed the value of a longitudinal relationship (continuity) with a primary care physician. There is growing concern that changes in the types of health insurance people have threaten the patient-physician relationship.

During the past decade, there has been considerable growth in HDHPs in the employer, small group and individual insurance markets. According to The Kaiser Family Foundation and Health Research & Educational Trust Employer Health Benefits 2017 Annual Survey,(files.kff.org) 28 percent of individuals with employer-sponsored coverage had insurance coverage that qualified as an HDHP.

Although HDHPs often feature lower monthly premiums, the required out-of-pocket costs via coinsurance (deductible and copayments) for covered individuals and families have increased to levels that are raising concerns about their negative impact on access to health care. The Kaiser report also found that, among those with employer-sponsored insurance, the average deductible was slightly greater than $2,000 for individuals and about $4,500 for a family.

A 2017 report from Avalere(avalere.com) forecast changes in coinsurance for individuals and families purchasing coverage in the health insurance marketplace. According to that report, the average deductible in 2018 was expected to be $5,873 for bronze plans and $3,937 for silver plans.

There is growing evidence that these higher out-of-pocket costs, largely due to coinsurance requirements of HDHPs, are incentivizing patient behaviors that are negative to these individuals' overall health and well-being. The primary concern is that HDHPs and high out-of-pocket costs are leading to individuals forgoing medical care for prevention, wellness and chronic disease management. Instead, many are opting to delay care until their health condition worsens.

Notably, some individuals and families have health savings accounts (HSAs) that provide a mechanism to cover out-of-pocket health care costs. However, despite the availability of HSAs, few individuals and families take advantage of this tax-favored opportunity when financing their health care coverage. It is my opinion that the current construction of our health insurance markets, specifically the prevalence of HDHPs, are the health care equivalent of the 2008-2009 housing bubble: a low-cost point of entry to a product with consequential and unaffordable out-year costs.

Recognizing the economic incentives and disincentives that out-of-pocket expenses have on patient behavior, the AAFP has advocated for policies that increase access to primary care in a manner that nullifies, or at least lessens, the negative impact of high deductibles. We have approached this issue in two distinct ways. The first is to establish a defined set of primary care visits as a condition of selling HDHPs, and the second is to allow individuals to use HSAs to enter into arrangements with family physicians via direct contracting models such as direct primary care (DPC).

Primary Care Benefit: During the 115th Congress, the AAFP worked closely with Reps. Elise Stefanik, R-N.Y., and Brad Schneider, D-Ill., to introduce the Primary Care Patient Protection Act(www.congress.gov) (HR 5858). This legislation takes a patient-centered and moderated approach to ensuring that individuals and families with HDHPs have access to their primary care physician without cost-sharing for a limited set of primary care services. The bill would require all HDHP plans to allow two visits each plan year for primary care office visits, ensuring that individuals and families do not forgo health care when they are sick or experiencing worsening health conditions simply because of out-of-pocket costs. We anticipate that Schneider and Stefanik will reintroduce the bill in the 116th Congress, and the AAFP will work to advance this important, patient-centered legislation.

Direct Primary Care: The AAFP remains a vocal and active supporter of DPC in Washington, D.C., and state capitols. It is hard to believe that I am entering my second decade of work on DPC. From the early days of supporting this model as a qualified health plan in the Patient Protection and Affordable Care Act to our current work aimed at expanding access to DPC practices through health savings and health reimbursement arrangements, the AAFP has been a consistent supporter of the model. This past Congress, the AAFP strongly supported the Primary Care Enhancement Act of 2015(1 page PDF) (HR 365), and we were thrilled that the House of Representatives approved a modified version of the legislation in the summer of 2018. Although the legislation didn't secure Senate approval, the momentum built during the past two years will benefit our efforts in the 116th Congress.

The AAFP will be working closely with our DPC Member Interest Group and other advocates to advance the legislation and secure its enactment into law.

In closing, there are numerous other policies that impact our nation's health care insurance markets that the AAFP will work on in the 116th Congress. The two policies outlined in this post are aimed at establishing continuity of care from a family physician specifically for those individuals who have HDHPs.

Wonk Hard

Each year I like to take a few moments to recognize the incomparable AAFP team and its countless contributions to family physicians, the AAFP and the American health care system. It is an honor to be a small part of this larger team and to have an opportunity to work alongside a group of talented, dedicated and highly motivated women and men. The AAFP team is a force organized around and focused on the AAFP's vision, mission and member value statement, which says, "The AAFP provides value to its members by advancing the specialty of family medicine, strengthening members' collective voice and providing solutions to enhance the patient care members provide."

Programming Note

Due to the upcoming holidays, the Fighting for Family Medicine newsletter and the In the Trenches blog will not publish again until Tuesday, Jan. 8.

Posted at 08:00AM Dec 18, 2018 by Shawn Martin

« Teaching Health Cent... | Main | No Margin, No Missio... »


Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

Read author bio »



The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.