June 18, 2020

Patients are still avoiding medical care. This time, it's not just about coronavirus fears.

Daily Briefing

    At the beginning of America's new coronavirus epidemic, patients were delaying care out of fear of contracting the virus—but now, according to health experts, a lot of patients may be delaying critical care due to cost.

    How to communicate with patients amid Covid-19

    Patients might be delaying care due to costs

    According to a 2019 survey of more than 700 doctors administered by NORC at the University of Chicago, about 80% of independent physicians said high-deductible health plans were the main reasons patients chose to delay or avoid care.  And according to the Kaiser Family Foundation (KFF), around 40% of people with employer-sponsored health plan have a high-deductible plan, and about 20% of employees have deductibles that exceed $1,500.

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    "We have seen a significant increase in [copayments] and out-of-pocket costs with the big shift to high-deductible health plans," said Marianne Udow-Phillips, executive director of the Center for Health and Research Transformation at the University of Michigan.

    And when patients "can't afford the services," they "have been shown to forgo medically necessary care," according to Kelly Kenney, CEO of the Physicians Advocacy Institute. "That is a big concern," Kenney said.

    Now, health experts think the epidemic's impact on the U.S. economy will further exacerbate these concerns. With millions of workers furloughed and laid off, a lot of people will lose income and health insurance, making them less likely to seek care, according to Sara Collins, an executive at the Commonwealth Fund. "This is a major economic recession," Collins said. "It's going to have an effect on people's demand for health care."

    And while employers and insurers are covering out-of-pocket costs for testing and treatment related to the new coronavirus and Covid-19, the disease caused by the virus, a lot of workers with high-deductible health plans are still responsible for out-of-network bills and other costs, according to Modern Healthcare. "Insurers say, 'We really want [Covid-19] patients to get treated so we will waive deductibles and out-of-pocket costs. But implicit in that is that patients aren't going to get treated if they have to pay their deductible," Kenney said.

    In fact, a survey published by KFF last month shows the economic recession and health care costs may already be resulting in an increase in delayed care. According to the survey, almost 50% of Americans said they or someone they live with has delayed care since the coronavirus epidemic began—and about one-third of respondents said they planned to either wait longer than three months to seek care or planned to not seek care at all.

    And while the respondents did not say why they were choosing not to seek care, "historically we have always seen large shares of people who have put off care for cost reasons," said Liz Hamel, director of public opinion and survey research at KFF.

    The impact of delayed care

    The impact of these delayed visits can be "troubling," the New York Times reports. For instance, a recent CDC analysis found a steep decline in ED visits and indications that people experiencing heart attacks were avoiding the hospital until their conditions worsened.  

    However, according to the Times, people who have lost their incomes may feel they don't have any other option but to delay care. For instance, Kristina Hartman, who lost her job as an administrator amid the epidemic, said she's not sure if she will have health coverage after July, which is when her unemployment benefits run out. So far, Hartman has skipped a regular visit with her kidney doctor and delayed an endocrinology appointment. "I definitely am avoiding appointments," she said.

    Thomas Chapman lost his job as a sales director and stopped getting paid in March, the Times reports. Chapman, who has high blood pressure and diabetes, didn't refill his prescriptions for two months. "I just couldn't pay anymore," he said.

    Eventually, Chapman's legs started to swell and he felt "very, very lethargic," leading him to contact his physician at Catalyst Health Network, where a pharmacist helped him with his prescriptions. However, Chapman still has no health insurance and won't be eligible for Medicare until later this year, the Times reports.

    Other patients are still seeking some care, but avoiding costly treatments. Eli Fels, a personal trainer and swim instructor from Massachusetts who is pregnant, lost her job but is still insured, the Times reports. However, due to the high cost of care, she said she's attending only her prenatal appointments—and putting off all other "medical care that doesn't involve the baby." Fels currently has a wrist injury, but said she's chosen not to seek care for the issue.

    Health experts fear that people like Fels and Hartman will delay care until it's too late. Jack Choueka, chair of orthopedics at Maimonides Medical Center, said even children are coming in with complications due to care delays, including one young patient who was found to have a tumor after imaging was delayed. "That tumor may have been growing for months unchecked," Choueka said (Kacik, Modern Healthcare, 6/16; Abelson, New York Times, 6/16; Wilson Pecci, HealthLeaders Media, 6/16).

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