The Skin That's In the Game
Advocates for so-called 'consumer-oriented health plans' are fond of saying that patients (consumers) should have 'skin in the game'. I find this offensive, because no one has more 'skin' in the 'game' of health care than someone with an illness or injury who is seeking care. However, what the market advocates mean by this is something else. They mean that buyers of health services should be paying for those services out of their own pocket because that is the only way that 'market' forces will reduce health care costs. Buyers with 'skin' in the game will not spend money on unnecessary services, or so this theory goes. Now comes a report from the Kaiser Family Foundation about the effect these 'consumer-oriented health plans' are having (find the report here). Excerpts:
Kaiser Family Foundation
November 15, 2011
The Economy and Medical Care
By Gary Claxton and Larry Levitt
Various market watchers have reported that the use of health care services has not been growing recently as it had in the past, resulting in lower than expected health care claims for people with private insurance and higher than expected earnings for insurers. A look at physician office visits by nonelderly patients with private insurance over the past decade illustrates the change in the use of services.
Although the total number of visits jumps around somewhat from quarter to quarter, the analysis shows generally that the quarterly number of office visits by privately insured patients increased from about 140 million visits per quarter at the beginning of the decade to 160 million visits early in 2005. The number of non-elderly people with private insurance changed hardly at all over that period, increasing by about 1% according to our analysis of the National Health Interview survey. So, the increase was driven by people with private insurance going to the doctor more often.
From 2005 through 2008, the trend in physician visits was largely flat as the number of people with private insurance dropped slightly (about 1.7%).
Then, as the economic downturn deepened, the number of physician visits among the privately insured started a downward trend, which has continued even as the recession technically ended in June of 2009. The number of visits fell to a low of 129 million in the 2nd quarter of 2011, a decline of 17% from 156 million visits in the 2nd quarter of 2009. The number of people with private insurance declined over this period as well as many people lost their jobs and their insurance along with them. But, the decline in the number of people with private insurance is much smaller than the decline in visits – about 2% between 2009 and 2010.
Even people who are insured are going to the doctor less. Likely, consumers are reacting to the severe economic downturn and significant job-loss which has defined the economy over the last several years by cutting back on health spending. Higher deductibles, copays and coinsurance increase the cost of care, and their impact may be magnified in these tough economic times. The Kaiser/HRET Annual Survey of Employer Health Benefits finds that the share of workers covered on the job by plans with a deductible of at least $1,000 grew from 18% in 2008 to 31% this year. In some cases people may be foregoing unnecessary care, meaning that health costs are reduced with little or no effect on health. In other cases people are likely cutting back on necessary care, potentially endangering patients' longer term health and leading to higher costs over time.
To see the Kaiser Family Foundation report about the increase in high deductible health plans (what is really meant by consumer-oriented) look here.
My experience as a primary care physician informs me that patients do not know what is a necessary health care service and what is not. When symptoms are present, patients and their families most often need the guidance of a primary care physician to interpret the symptoms. But placing a high deductible on health benefits puts the patient and family in the position of gambling about whether the care will matter or not. In bad economic times, more often, the choice is to forgo care because the money simply is not available.
The advocates for these market oriented strategies will call this a victory. Physician visits are down 17% and health insurance profits are up by a mirror image amount. But the cost savings of a 17% downturn in outpatient visits are miniscule in the overall scheme of our hugely wasteful $2.5 trillion annual nationwide health bill. But the future costs for care that was not delivered to those with chronic degenerative conditions like hypertension, diabetes, asthma, and arthritis will likely be big. The 'skin in the game' approach is penny wise and pound foolish.
Dr. Joe Jarvis