Unnecessary medical spending doesn’t decrease with high-deductible plans

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 - Rachel Reid, MD, MS
Rachel Reid, MD, MS

High-deductible health plans have been framed as a way to give healthcare consumers more “skin in the game,” leading them to avoid low-value services as a way to save money. According to researchers from the USC Schaeffer Center for Health Policy and Economics and the RAND Corporation, they’re having little to no impact.

The study, published in the American Journal of Managed Care, examined insurance claims data from more than 376,000 patients aged between 18 and 63, comparing spending before and after they switched to a high-deductible plan on services deemed to have unclear or no clinical benefit by healthcare groups. The 26 low-value services ranged from imaging for nonspecific low back pain to preoperative chest radiography to undergoing an MRI for an uncomplicated headache.

“Theoretically, the increased cost-burden of those plans could be an incentive for consumers to pinch pennies by specifically avoiding low-value services that don’t offer them clear clinical benefits,” said Rachel Reid, MD, MS, a Schaeffer Center fellow, associate physician policy researcher at RAND, primary care physician at Brigham and Women’s Hospital and one of the study’s authors. “Instead, we found that patients are reducing their spending overall, but not for low-value services in particular.”

Overall, those in these higher-deductible plans did reduce their annual spending on outpatient procedures by $231.60 compared to customers on traditional health plans, including spending $22.17 less on imaging services and a decrease in laboratory services. For the low-value services, however, the difference between the high-deductible and traditional health plan patients was only $3.

Reid and her coauthors said this matched other research into consumer behavior on high-deductible plans—spending is reduced, but on all services, low-value or not. With fewer customers understanding their health benefits, they don’t shop based on price as expected and may avoid high-value services and preventive care out of concern over paying their medical bills as out-of-pocket spending continues to climb.

The study offered two possible solutions: focusing on value-based insurance design, which can vary cost-sharing based on a value of a service and payment arrangements which focus on providers, not patients, having “skin in the game” and encourage physicians to steer patients away from low-value services.

“Use of low-value services appears to vary substantially among provider organizations,” Reid and her coauthors wrote. “This suggests that providers can influence demand for value-conscious care and that appropriately targeted provider incentives have potential to reduce wasteful low-value spending. More research is needed to understand how provider and group characteristics influence delivery of low-value services.”