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.

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