Gone are managed care's gatekeepers and its tight controls over access to care that has angered so many people over the past decade. Now, large and small businesses are working in different cost-sharing options so employees can choose from a menu of health plans that provide a range of coverage.
That menu could include:
-- higher deductibles;
-- increased co-pays;
-- new co-pays on items traditionally fully covered;
-- reduced benefits in exchange for lower premiums, and
-- incentives for choosing healthcare providers and services that are most efficient, best at various practice specialties or simply lower in cost.
The bottom line, analysts said during a conference sponsored by the Center for Studying Health System Change, is choice will be accompanied by a need for people to be better educated about the healthcare system so they can make sound decisions for themselves and their families.
John Bertko, vice president and chief actuary of Humana Inc., of Louisville, Ky., said employers want to make treatment costs more visible to consumers.
"Most people think an office visit costs $10," he said, when in reality it can cost $50 or $75 or more with the insurer picking up the difference. He said the cost-sharing of the future will be "more difficult for consumers" and "somewhat more difficult for doctors." It will mean a change in the doctor-patient relationship that will, for the first time, have patients engaging their physicians in discussions of treatment costs.
Though moderate- and higher-income workers may be financially able to make choices and pay higher out-of-pocket costs, for low-income or chronically ill employees the only choice might be to forego insurance they cannot afford or purchase a plan that does not afford them access to the healthcare services they need.
"If cost-sharing is to play a larger role, it probably needs to be refined," said HSC President Paul Ginsburg. "It probably needs to apply more heavily to discretionary care."
That also means giving people incentives to select more appropriate care; for example trying a generic drug to see if it works before selecting a more expensive brand medication or having an X-ray as a diagnostic tool instead of immediately opting for the higher-cost MRI.
"Cost containment has shifted from changing provider behavior to changing employee behavior," said HSC senior health analyst Joy Grossman.
A recent Kaiser Family Foundation survey found deductibles for preferred provider organization plans -- which encompass some 80 percent of the consumer market -- have increased by 50 percent in the past several years.
Flat co-payments are being replaced by co-insurance, in which patients pay a percentage of the cost. Co-pays are being applied to inpatient hospital coverage and emergency room services. Drug coverage often is tiered with more comprehensive coverage and higher premiums. Low-premium plans come with very high deductibles.
There is no solid data so far on how this affects maximum out-of-pocket spending limits per year, but Grossman said that is on the analyst watch list.
"The bottom line is that cost-sharing is increasing but it is also becoming more complex as employers choose from among these different options," she said. "Ideally you'd like to reduce inappropriate care but in reality patients typically cut back on needed and more discretionary care."
Industry is sensitive to both sides of the equation because it knows it must offer at least enough of a quality benefit package to attract and keep valued employees.
Dr. Arnold Milstein, a consultant and co-founder of the Leapfrog Group in Washington, a healthcare consortium of employers and individuals, said companies are beginning to incentivize people for changing their behavior.
He said Caterpillar Inc., requires employees to fill out a health risk appraisal and those who do not pay more for their health insurance. He said he expects there also will be financial incentives for employees to participate in disease management programs that can reduce future healthcare costs by providing appropriate ongoing care.
Milstein said large and thoughtful companies are beginning to consider income tiers for health benefits. Rockwell Corp., for example, has begun to tier an employee's out-of-pocket maximum spending limit to income to help reduce the burden on lower paid workers.
An HSC study found 1 percent of people with incomes between 125 percent and 200 percent of poverty -- or $11,225 to $17,960 for a single person -- have out-of-pocket costs exceeding 10 percent of their income under a zero deductible and $10 physician visit copayment benefit structure, compared with 23 percent of low-income people with a $2,500 deductible and coinsurance.
Helen Darling, president of the Washington Business Group on Health, said there also might be a limited effect to simply raising deductibles. For example, raising a $100 deductible to $200 might be hard on an employee but it means relatively little overall if the total cost of the healthcare provided is $30,000.
Ellen Beck covers healthcare policy for UPI Science News. E-mail firstname.lastname@example.org
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