My patient Pete is 55 years old and has a great job (and employer-sponsored health insurance) at a bank. His wife and three boys are healthy, but Pete has high blood pressure, high cholesterol and hyperparathyroidism. He also has a high-deductible health plan (HDHP). Despite his health issues, Pete hasn't come into my office more than once a year for the past three years because of the out-of-pocket costs.
Another patient, 61-year-old Sal, works for our hospital mega-system driving an employee bus, and he moonlights as a preacher in a storefront church. Sam also has high blood pressure and high cholesterol, as well as diabetes and obesity. I've been watching his weight and A1c go up the past few years. But I haven't seen Sal in my office for more than a year because, like Pete, he has an HDHP.
Pete was recently in the ER for chest pain. Because of that visit, he met his high deductible, but he now has had to take out a home equity loan to pay for the cost of his care.
Sal had a myocardial infarction and needed a stent. In the hospital, a nurse told him he should see an endocrinologist for his diabetes. He had met his deductible, so he asked me if I would refer him to the subspecialist and also send him to the orthopedic surgeon so he could get his knees checked out now that he gets to use his insurance.
With an HDHP, "prevention" means that patients with "good" insurance feel prevented from going to primary care visits that might help prevent the more urgent, costly care that patients like Sal and Pete often end up needing instead.
As a further insult, our hospital mega-system charges my patients a facility fee for anything I do for them in my office, including immunizations and blood draws. This is not the kind of surprise most people enjoy.
Meanwhile, visits to primary care physicians continue to drop. Do you think high-deductible plans have anything to do with this? According to the CDC, more than 20 percent of people younger than 65 with private insurance are covered by HDHPs. It seems my Medicaid patients have the best access to primary care (if they can get a ride to the office).
I can't imagine how our independent practices are getting by. It must be even worse in rural areas.
I was heartened last year, however, by the introduction of a House bill that would have waived cost-sharing for patients with HDHPs for at least two primary care visits a year. The bill is expected to be reintroduced this spring. But a limitation on the number of visits could still force many patients to seek care at high-cost sites and wouldn't entirely eliminate acute visits at ERs or urgent care centers. These types of visits fragment care and, in many cases, lead to inappropriate care.
Primary care visits need to be covered for all, similar to Medicaid (but of course with better reimbursement). Somehow, nonemergency ER visits need to be discouraged. Facility fees need to be abolished. Independent practices need to be strengthened. A recently completed physician survey that aimed to examine the value of evaluation and management services may help with reimbursement, but what good will that do if patients with HDHPs are reluctant to seek care?
Perhaps insurance companies should adopt advanced primary care payment models similar to the direct primary care structure, with per-member, per-month payments. Or, better yet, maybe all payers should adopt the Academy's Advanced Primary Care Alternative Payment Model, which would enable primary care physicians to manage chronic conditions for patients and would give patients better access to care without the burden of copays.
Insurance companies seem willing to gamble that they will be able to pocket the premiums of consumers with high-deductible plans who won't seek care, but that approach is certainly not best for patients or health care in our country.
Robert Raspa, M.D., is a member of the AAFP Board of Directors.