By Gary Claxton and Larry Levitt
Kaiser Family Foundation, November 15, 2011
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.
KFF – Increase in employer-sponsored high-deductible plans:
http://ehbs.kff.org/?page=charts&id=2&sn=22&ch=2257
Comment:
By Don McCanne, MD
In the past two years, office visits by privately insured patients under age 65 decreased by 17 percent. Although the insurers attribute this lower utilization to the economic downturn, it does correlate very closely to the increase in enrollment in employer-sponsored high-deductible plans.
Although it is difficult to predict future trends, it is very likely that the diminished utilization will persist since other studies have confirmed that high out-of-pocket expenses deter access to health care. It is also clear that many of the forgone services are beneficial.
Every reasonable person in the policy community agrees that patients should have access to beneficial services, but some believe that financial disincentives to care are important because they will encourage patients to forgo unnecessary services. The problem with this reasoning is that a person with symptoms cannot know without a consultation whether or not the visit is unnecessary. Even if it turns out that no intervention is required other than reassurance, even reassurance itself provides an important medical outcome in the form of reduced anxiety.
The consumer-directed advocates are winning the battle. The increase in high-deductible plans has placed financial barriers between patients and the care that they should be receiving. By making patients more sensitive to the costs of office visits, they are using fewer. But is this wise?
Studies such as the RAND Health Insurance Experiment suggest that there is not much harm done. But those studies do not measure certain endpoints such as symptom relief or simple reassurance. They also do not measure longer term consequences such as complications from inadequate management of chronic disorders – diabetes, hypertension, consequential hyperlipidemia, and many others. They do not measure the benefits of preventive screening in this under 65 population, which may prevent or ameliorate disorders that might occur only decades later.
Most of these office visits are for primary care services and constitute only a very small percentage of our national health expenditures. Reducing office visits by 17 percent does not save much overall because 17 percent of a small number is a very small number. Since primary care is essential in improving value in health care, we should be adopting policies that encourage primary care access, not discourage it as these high out-of-pocket costs do.