Personal Responsibility In Health Care: The Slippery Slope

I am fascinated by the way “the press,” picks up on certain reports from medical journals and ignores others. In my experience, many of the headline news reports on medical journal articles focus (not so surprisingly) on subjects that are likely to raise the interest of readers or are likely to be controversial. In my opinion, the journalists miss many very noteworthy articles. For example, the January 24, 2008 issue of the New England Journal of Medicine contained an article entitled “Effect of Cost Sharing on Screening Mammography in Medicare Health Plans,” written by A.N. Trivedi and colleagues from Warren Alpert Medical School of Brown University, the Target Research Enhancement Program, Providence Veterans Affairs Medical Center- both in Providence, RI, and Brigham and Women’s Hospital, the Department of Health Care Policy, Harvard Medical School, and the Department of Health Care Policy and Management, Harvard School of Public Health- all in Boston, MA.

What is “Cost Sharing” and why should I care?

The concept of cost sharing in health care costs is not very complicated even for those not expert in economic theory. Cost sharing means that the total costs for a medical service (e.g., medication, clinic visit, laboratory test, surgical procedure) are shared. Here the cost sharing is between Medicare and the individual patient. For the patient, this could be a copay, a deductible, or a predetermined percentage of the total costs that the health care plan pays and the patient pays (e.g, 80% by the health care plan, 20% by the patient). The patient’s cost is thus over and above the basic patient cost for the health care plan.

Trivedi and colleagues remind us in the introduction to their article that previous studies have shown that policies that increase patients’ share of health care expenses, decrease their use of discretionary health services. This means that patients tend to use more health care services if they perceive them to be free- of course, the services are often not really free, since the patient might have a fixed monthly charge for the insurance. The investigators also note that patients use fewer non emergency-type health care services if there is some cost sharing. In contrast, patients do not skimp on services for problems they perceive as life-threatening (e.g, chest pain) whether or not their health care insurance plan requires cost sharing (that’s good). The question the investigators ask is here is whether cost sharing reduces the use of important preventive care procedures, in this case, mammography?

The investigators reviewed coverage for mammography within 174 Medicare managed-care plans from 2001-2004. The numbers were huge- over 500,000 observations in more than 350,000 women between the ages of 65-69. They compared rates of every-two-year breast-cancer screening in plans that required cost sharing for mammography with screening rates in plans with full coverage (i.e., no cost sharing). The investigators also analyzed data on screening rates in plans that switched from full coverage to cost sharing for mammography as compared with rates in matched control plans that did not switch to cost sharing. NOTE: I apologize for presenting the study design in such detail, but it is important for you to understand exactly what was being studied.

The study results

So, what did the study show? First, cost sharing was defined as requiring a copayment of more than $10 or coinsurance of more than 10% for screening mammography. The total cost for mammography was somewhere between $100-$150, depending on the heath care plan. For plans that required cost sharing, the average out-of-pocket patient costs averaged about $20 with the highest cost $30. Anyway, the investigators found that screening rates were about 8% lower in plans that had cost sharing compared with plans without cost sharing ( 77.5% vs. 69.2%). Screening rates were directly related to income and educational level. Perhaps, most interesting were the findings that screening rates increased by about 3% in plans that eliminated cost sharing and decreased about 6% in plans that instituted cost sharing (a net change of about 9%).

What do these findings mean?

First, whether free or with a copay, many women do not take advantage of screening mammography despite abundant evidence that mammography will detect breast cancer at an early stage and result in better outcomes. Why that is, I haven’t a clue but it might be fear that the test would detect a cancer (a form of denial)? Perhaps, it’s something as simple as the perceived inconvenience and discomfort of the procedure vs. the perceived benefit? There are lots or other possibilities. Adding cost sharing just makes things worse. For whatever reason, even small costs (the investigators call them “modest copayments”) are a barrier to health screening, at least for mammograms in Mediicare patients. The investigators conclude that for cost-effective preventive services (such as mammography), perhaps elderly Mediicare beneficiaries should be exempt from cost sharing.

What does all of this really mean?

In my opinion, this study is not only interesting, but it also raises many questions about health care policy. In this national election year, we are all caught up in rather intense political discourse, which includes many discussions about health care. The various candidates for President of the U.S. have proposed vastly different plans for health care. But, I believe there are no easy or inexpensive solutions to the present U.S. health care problems. Any high quality health care plan would need to take into account the issues raised in the mammography screening study reviewed here. For example, should cost sharing be part of all health care plans, knowing that some patients will not obtain this or that service if there are out-of-pocket costs, even if sound data show the health benefit (e.g., mammography, vaccinations). No doubt, cost sharing (really cost shifting) decreases costs for the health care plan, but not the individual plan holder. Is it a question of personal responsibility (maybe a better term is “personal choice?) or should we facilitate patients getting this or that medical service that has been shown to be of benefit? Should we mandate health care insurance for all people, or leave it up to the individual, knowing that people without health care insurance end up shifting many of their health care costs to all people with health care insurance. Does personal responsibility/personal choice trump collective responsibilities? I do not have any answers to these very difficult questions. At least we can think about these issues as we listen to the politicians rant and rave about this and that until November.

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