Sunday, August 05, 2012
Deductibles and Clinical Responsibility
Health insurance policies with high deductibles are advocated
on the grounds that they cause people to be more prudent in the use of
services. The assumption is that fully
insured patients have a tendency to demand health services they don’t need and
to opt for high cost services when less expensive ones would do just as well. Presumably, having to bear some significant
part of the cost will cause patients to be less likely to make unreasonable
demands.
The issue raises the questions of (a) whether the financial
incentives created by the high deductibles have the intended effect and (b) whether
there are unintended consequences.
Those questions were explored in a column that appeared on
the op-ed page of the July 29 issue of The Boston Globe. The column was stimulated by the personal
experiences of the author, one Joanna Weiss, with a high deductible policy she
and her husband had taken out on their children.
Although there is a dearth of data on the subject, Ms. Weiss
cited anecdotal evidence that at least some people elect high deductible
policies based on a gambling logic; a calculation that they will save more by
electing lower premiums than the high deductibles will cost. Others are responding mainly to the lower premiums
without thinking very much about how they will pay the high deductible if they
ever have to. Some of them later find
they can’t afford the high deductible and go without needed services as a
result.
The other question the issue raises is that of how
responsibility for health care decisions should be allocated between patients
and providers. Under what circumstances
and to what extent should patients make their own decisions about care?
In the past, that question arose in the context of physicians. It was commonly said that a physician who
treated himself (they were mostly men then) had a fool for a doctor and a fool
for a patient. Presumably, the same
would be true of a self-treating patient.
All of the discussion about patient involvement in medical
decisions has the danger, it seems to me, of relieving providers of
responsibility that ought to be theirs.
I think they should be publicly and privately accountable for their
decisions and patients should have a say when the differences are too close to
call, but I think we need a system in which providers have the basic
responsibility for deciding what patients need and which tests and procedures
are the most cost-effective.