(UPDATE) When U.S. employers switch from a low-deductible health insurance plan (LDHP) to a plan with a higher deductible, patients with chest pain may be more reluctant to go to the emergency room (ED), news suggests. published data. Among those who make the trip, hospitalization is less likely for those who have recently switched to high-deductible health plans (HDHP).

The observational study, published online in Circulation, found that patients living in very poor neighborhoods are the most vulnerable to this financial burden. For them, the change of deductible carries an increased risk of being hospitalized within 30 days of their visit to the emergency room.

Lead author Shih-Chuan Chou, MD (Brigham and Women’s Hospital, Boston, MA), told TCTMD he was a little surprised to see insurance having an effect in this context, given the strong messages. to see a doctor for chest pain. Angina, he said, is particularly worthy of attention because it is so common.

Chou stressed that it is not possible to know what happened to people who did not go to the emergency room, if they saw their doctors elsewhere, for example, but said the data supports the idea that the Health deductibles have influenced these decisions. If insurance hadn’t mattered, hospitalization rates wouldn’t have differed among patients who presented to the emergency room.

The study shows that “having high out of pocket expenses can be potentially very damaging,” especially for low-income people, Chou said. Insurance companies should consider whether money is actually saved when some patients “postpone care that could be beneficial,” he added.

Samuel Jones, MD (Chattanooga Heart Institute, TN), chair of the American College of Cardiology Health Affairs Committee, said, “It’s important for clinicians to understand what’s going on with our patients because it has a considerable impact on their care.

These results indicate that patients may delay treatment for chest pain, Jones said, which could mean they present to the hospital with more serious illness. COVID-19 has made it clear “how disastrous this can be for a lot of our patients,” he told TCTMD, although many doctors may not realize that insurance status can have a problem. also strong impact.

When delays occur in cardiovascular disease, they can be fatal. “It’s one thing if we’re just talking about a stuffy nose and earache, but for cardiologists that’s not what we’re dealing with sometimes,” Jones commented.

It was originally believed that higher deductibles gave patients the freedom to choose a plan with lower premiums, Jones said. “More and more, what we’re seeing maybe is that patients haven’t really chosen this. This is something their employer has chosen for them, and it is not the right thing for their particular situation. . . . That bothers me. It is removing it from the patient’s hands.

The spectrum of reimbursable expenses

Chou and his colleagues used a database of commercial and Medicare Advantage claims to identify adults aged 19 to 63 whose employers had initially only offered an LDHP (≤ $ 500), but then made a pass. mandatory at an HDHP (≥ $ 1,000) between 2003 and 2014. They compared 557,501 people meeting these criteria to 5,861,990 checks whose employers continued to offer only low-deductible insurance.

Of those 6.4 million people, the average age was 42, half were female, and about two-thirds were non-Hispanic Caucasians. Just over a quarter lived in neighborhoods where at least 15% had not graduated from high school and 17% lived in places where at least 20% were below the federal poverty line.

When employers switched to HDHP, emergency room visits for nonspecific chest pain declined, as did the percentage of those visits leading to hospitalization.

Patients converted from LDHP to HDHP

There was no difference in the likelihood of non-invasive testing or revascularization within 30 days of the emergency department visit among patients switched to HDHP, although there was a decrease in angiography. (relative -8.2%; absolute -0.8 per 10,000 person-years). The 30-day acute MI rate was also not significantly affected.

Patients who lived in areas of high poverty were responsible for most of the reduction in emergency room visits and hospitalizations observed with the switch to HDHP. And unlike the group as a whole, these patients saw a slight increase in hospitalizations for acute MI within 30 days of the emergency room visit (relatively 29.4%; absolute 0.6 per 10,000 person-years).

The researchers say their “findings indicate a growing need to incorporate cost of care information into shared decision making between clinicians and patients at a time when most employees have HDHP.”

After doing all this research on high deductibles, I find it hard not to ask patients, “How much are you paying for this?” Can you afford it? ” Shih Chuan Cabbage

Neil M. Kalwani, MD, and Alexander T. Sandhu, MD (Stanford University, CA), writing in an editorial, note that this study does not address the influence of insurance on patients “with a condition. truly emerging, ”in that sense nonspecific chest pain by definition excludes people with ACS or other diagnoses. “Further study is needed to determine whether patients covered by HDHP are more likely to avoid or delay emergency room visits for chest pain caused by life-threatening illnesses, such as ACS, resulting in morbidity and excessive mortality, ”they write.

Still, they agree that there are potential implications for health policy. Right now, price transparency is hard to find in the clinical setting, observe Kalwani and Sandhu. “To determine cost sharing for a patient covered by an HDHP, a clinician needs to know the details of the patient’s health plan, health expenses to date and the rate negotiated by the insurer for a given service. Realistically, the cost of care will only be available to patients and clinicians during a clinical encounter if there is real-time integration of health plan data with the electronic health record.

How exactly to apply this information is still uncertain, they point out. “Even for trained clinicians, when a patient primarily complains of chest pain, it is often difficult to determine the clinical need and the financial ramifications of recommending an urgent assessment. We must therefore ask ourselves whether it is reasonable to expect patients to make these decisions, especially when their physical and financial health is at stake. ”

For Chou, it’s important for clinicians to think about the financial stress their patients are facing. That said, “there is an ethical question” about how this knowledge should or should not influence decision-making, he added.

“After doing all this research on high deductibles, I find it hard not to ask patients, ‘How much are you paying for this? Can you afford this? Is this gonna make you give up [anything]? Are you going to work [more] because of that?'”

He continued, “I also feel pretty lost in the sense that I’m not sure it’s a good thing for patients to ask. But at the same time I have a hard time with [the knowledge that] this is the reality for patients. So they’re going to ask that question whether I ask it or not.

Only research can discover how having price information at the point of service will affect the results, Chou observed. There is the fear that patients less able to afford will not receive the same treatment once the money enters the conversation.

Hospitals are increasingly cost conscious and patients also want transparency, Jones agreed. “A lot of us clinicians think it’s something that should be there. I get very frustrated on behalf of my patients when they ask “What’s the cost of all this?” And that they are trying to make decisions in such an opaque system. “

It’s not yet clear exactly how and when that plays out, but there will be a shift towards clarity, Jones said. “This labyrinth of obscuration by insurance companies, sometimes by hospital systems themselves, is really hampering our patient-doctor relationship and it’s not something we want to see.”

High-deductible plans may contain some benefits, but shouldn’t be used as a blunt instrument, he said, adding that employers should think about what different plans mean for their employees.