Monday, April 28, 2014

High Deductible Health Plan - Big Article is Published

OK, sports fans, I have opined here at some length on the nefarious character of High Deductible Health Plans – HDHPs. Now, at long last, my definitive article has been published.


And here is the AAP News article announcing the new policy:


High-deductible health plans discourage primary care visits, services for children

  1. Alyson Sulaski Wyckoff, Associate Editor



The federal government should consider restricting high-deductible health plans (HDHPs) to adults because the plans discourage families from seeking primary care for their children, according to an updated AAP policy statement.
High-Deductible Health Plans (Pediatrics 2014;133:e1461-e1470Abstract/FREE Full Text), from the AAP Committee on Child Health Financing, reviews the pros and (mostly) cons of HDHPs and suggests how the plans could be improved.

The economics

More than 5 million people younger than 20 years are enrolled in HDHP plans. A 2013 survey found 20% of small companies and 40% of large ones offered an HDHP plan to its employees, with 20% of all employers having an HDHP as the only choice. In addition, such plans increasingly are used by companies employing mostly low-income workers.
To receive government approval, the 2013 plans required a minimum deductible of $1,250 for an individual and $2,500 for a family. Total out-of-pocket expenses (not including premiums) were capped at $6,250 for an individual and $12,500 for a family. While the Affordable Care Act (ACA) allows for basic preventive services in nongrandfathered plans with no cost-sharing, related services administered during those well visits generally are subject to the deductible.

Pros and cons

Among the positive features, the plans are simpler to implement; offer lower premiums than conventional plans; may be an incentive to living healthier; and can be combined with a health savings account (HSA) or a health reimbursement arrangement (HRA) to allow consumers to pay for qualified out-of-pocket medical expenses on a pre-tax basis. Overall, HDHPs result in lower use of health care services.
Figure
Dr. Shenkin
For families with young children, however, many aspects of these plans pose “significant concerns,” according to the policy, because parents have an incentive to avoid doctor visits.
“They’re reluctant to come in, they seek more telephone care, they’re reluctant to complete referrals, and they’re reluctant to come back for appointments to follow up on an illness,” said Budd Shenkin, M.D., M.A.P.A., FAAP, lead author of the policy. “So it really interferes severely with continuity of care.”
The result can be unexpected consequences, particularly for children with chronic conditions, said Thomas F. Long, M.D., FAAP, chair of the Committee on Child Health Financing. He worries about all the care required by children with congenital abnormalities or other special needs.
Figure
Dr. Long
“If it’s going to cost them out-of-pocket money, they may say, ‘Well, it’s just a cold, I don’t need to see the doctor.’ And ‘just a cold, turns into ‘just pneumonia,’” Dr. Long added.
Some families who do not qualify for Medicaid but cannot afford the deductibles can be caught in the middle.
“If you’re in the working class … you’re just making it. Your kid gets sick, and you really have to think, ‘Is my child $150 sick?’ Because that $150 has a huge meaning to you,” said Dr. Shenkin. He believes the plans place families in a “terrible position” and conflict with principles of the patient-centered medical home.
There also is concern about families of children with special needs who forego chronic care management if it’s not covered, said Dennis Z. Kuo, M.D, M.H.S., FAAP, member of the AAP Council on Children with Disabilities. That could include critical medications, outpatient lab testing, imaging services and specialty care visits, depending on the plan.
Figure
Dr. Kuo
“It needs to be recognized that for children with special needs, their families will likely have little to no control over the amount of care they need,” said Dr. Kuo.
For many of them, a medical event or diagnosis could be unexpected, he added. “Their child may seem healthy at first and if they elect to utilize a high-deductible plan, they’re going to get hit financially very hard if something does happen.”

Other concerns

Pediatric offices face administrative burdens when families don’t understand the plans’ payment structure, said Jill Stoller, M.D., FAAP, chair of the AAP Section on Administration and Practice Management Executive Committee.
Figure
Dr. Stoller
“Most insurers don’t have computer systems where we can … find out ahead of time what the parents should owe for that visit. So you end up submitting your claims and having to wait to find out how it gets adjudicated, then billing it out to parents. So there’s a big delay. It impacts cash flow in the practice.”
Dr. Stoller also worries about parents holding back on physician visits: “It’s scary,” she said. “How much are parents going to decide to put off because of cost-sharing?”

Recommendations

If HDHPs continue to be offered to families with children, AAP policy recommendations include the following:
  • Permit a generous number of primary care visits without the deductible and exempt some key procedures.
  • Eliminate deductibles for children with special needs.
  • Require employers to fund HSAs and HRAs at high levels.
  • Include all elements of the medical home in the benefit package.
  • Insurance companies should devise procedures to allow offices to determine the complete bill at the time of a visit; issue debit or credit cards to patients with HSA and HRA accounts; compensate practices for the additional overhead; and encourage preventive visits.
  • Primary care offices should assign a staff member to answer parents’ questions.
  • Policymakers should pursue alternative strategies to reduce health care costs without affecting primary care.

Budd Shenkin

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