I’m overdue for one of the rituals of middle age in 21st century America: the screening colonoscopy. Now this may have been a rationalization, but just after my doctor referred me for one, I changed employers, and therefore insurance plans (moving into a high-deductible plan), so I needed to see what the coverage would be. Of course, it’s taken me 2 years to do it. Can’t read the fine print too carefully, I always say.
Turns out, I’m not atypical. A study in Medical Care looked at people who were switched from an HMO to a high-deductible health plan (HDHP). Compared with those who stayed in the HMO, people in the HDHP tended to use fewer low acuity services (such as non-urgent ER visits). Interestingly, women had similar rates of use for medium- to-high acuity services, while men reduced their use across all levels of acuity. It appears that women are better health consumers than men, wisely saving resources for services that are more necessary. Men are either just cheap, or looking for an excuse not to go to the doctor.
There are many myths and uncertainties surrounding HDHPs. More and more Americans are enrolled in them – including an increasing share of employees at Children’s Hospital of Wisconsin – so it’s worth addressing a couple of those. First, preventive care (including, if it’s coded right by the provider, screening colonoscopies) is generally covered at 100% and not subject to cost-sharing. So don’t skimp on the check-up and vaccines; you’ve already paid for them through your premium. Second, research has shown that for most people, HDHPs lead to more rational use of health resources (that is, avoiding unnecessary treatment while preserving needed treatment), with no worse health outcomes compared with forms of insurance that do not require the patient to bear as much of the cost. There is an important exception: the RAND Health Insurance Experiment showed that lower income people deferred both needed and unneeded care similarly, and had some worse health outcomes associated with that. (And maybe stubborn men, as well.) That said, making good choices requires some guidance. It’s not necessarily easy for people without medical training to distinguish low-value services from those that are necessary. A key principle is to ask questions. Is a brand name drug necessary, or would a generic do? Or what about no medication at all – would the condition get better on its own? How will doing a diagnostic test change what the provider will recommend in terms of treatment? There are many sources of information on line, many of which are of dubious quality. A particularly reputable one is Choosing Wisely, where you can find recommendations from the leading medical professional organizations about services that are generally agreed to be low value.
When used well, high deductible plans are nothing to be afraid of, and may have the potential to decrease costs with as good or better outcomes. I guess the same is true of colonoscopy….