Insurance deductibles: the impact on patient care

A review of the RAND Health Insurance Experiment results reveals that many of its conclusions are relevant today.

Key Points

As health insurance continues to become more expensive, some insurance plans are trying to decrease this cost by covering fewer services or implementing higher deductibles. As patients pay more expenses out of pocket, the theory is, they will become more savvy consumers of health care and begin to ask more questions about the costs and benefits of the various treatments and medications we recommend.

Recently, I wrote about a case in which I initially prescribed oral voriconazole (Vfend, Pfizer) to prevent fungal keratitis in a patient who had dislodged a LASIK flap with the pine needle of a Christmas tree.1 After consulting with her pharmacy, she asked for, and I agreed to, fluconazole (Diflucan, Pfizer), saving her almost $1,000. Clearly, there are such cases in which the high deductible of an insurance plan had the desired effect on both patient and physician, and money was saved in our health-care system.

The flip side

Later that morning, the technician came to tell me that the patient with flashes and floaters did not want a dilated exam because she figured it would cost extra. I told the technician to tell the patient that a dilated exam was mandatory in this situation and I could explain that to the patient myself if she still disagreed.

The patient agreed to dilation. As I began to examine her about 30 minutes later, I asked about her insurance issue. She explained that she had insurance, but it only covered catastrophic expenses, not smaller expenses such as a doctor's visit. She said her coverage also was her motivation to wait a week before making an appointment; she had hoped the flashes and floaters would resolve spontaneously. As I proceeded with scleral depression, I found a retinal tear. I explained to the patient its significance and chance of progression to a retinal detachment. At that point, she dropped all talk of saving money and agreed to see my retina colleague immediately for laser retinopexy.

Living the RAND experiment

From 1971 to 1982, the RAND Health Insurance Experiment (HIE)2 was conducted-a prospective trial with 7,700 patients randomly selected to examine the impact of co-payments (ranging from 0% to 95%) on the number of doctor visits, the quality of care, and the impact on the patients' health.

The results of this seminal study perfectly mirror my experiences with my own patients and continue to inform the health-care debate in the United States today.

As a brief summary, the study found:

Use of services

Quality of care

Health outcomes

Based on those results, it is clear that cost-sharing in the form of co-payments is a blunt instrument, decreasing the utilization of both appropriate and inappropriate services.