Editor`s Opinion: Don`t Let Winds of Change Blow Patient-Provider Relationships

  A relatively small provision that became law in 1996 continues to profoundly affect how we provide care and interact with patients. As is often the case with legislative bills, the 1996 Health Insurance Portability and Accountability Act (HIPAA) included verbiage that approved implementation of a pilot program to test high-deductible health insurance plans and savings accounts.¹

  Fast forward to 2003 — President G. W. Bush signed the Medicare Prescription Drug, Improvement and Modernization Act into law, which allowed employers to offer high-deductible health insurance plans and health savings accounts (HSAs).² The pace of shifting health care costs to consumers increased and continues to accelerate following implementation of the 2010 Affordable Care Act (ACA) — the vast majority of health plans available at the ACA marketplace are high-deductible or high-copay (or both) plans.

  We don’t know much about the effects of this major transformation in insurance models on consumer health, and what is known is generally not encouraging. The most frequently cited study³ — claims data from 808,707 households — showed families enrolled in high-deductible plans spent less money on health care and the use of preventive care was (albeit moderately) reduced. Similarly, the results of a 2008 study⁴ (N = 6,343 enrollees) showed participants in high-deductible plans were much more likely than persons in other plans to discontinue taking their prescription drug medication. These and other studies have caused considerable concern about the ethical, financial, and health implications of the cost-sharing trajectory we have been on for the past decade or more.⁵

  Meanwhile, this trend clearly affects how we provide care. Based on what we know, patients are more likely to question the need for follow-up appointments, medications, or interventions. Alternatively, they will not ask questions, opting to simply cancel appointments already made or not fill the prescription provided. Patients also are confused and may get very upset when receiving a bill. Of the 1,069 consumers who responded to the Health Reform Monitoring Survey⁶ in 2013, only 43% indicated they were very or somewhat confident in understanding terms related to health insurance costs and 50% were confident in understanding benefit terms such as covered services, provider network, annual limits on services, and excluded services.

  We not only must educate patients about their condition and make sure they understand the rationale for their plan of care, but we also must ascertain whether they understand the cost implications. This means providers need to know how much their services cost. An important criticism of consumer-driven health care is the cost of care cannot be obtained in advance or even estimated, so how can anyone choose? This has resulted in a movement for price transparency in health care services; as an example, the state of Massachusetts passed legislation requiring providers to disclose prices to patients in advance of delivering services.⁷

  In the years ahead, we hopefully will learn more about the actual health outcomes of this major health insurance change. We can only hope that, if needed, laws to correct whatever deficiencies are detected will be authored and enacted. In the meantime, we can use what we know to make sure the current gusts are tailwinds propelling us forward toward better care, not headwinds trying to thwart our best efforts.

This article was not subject to the Ostomy Wound Management peer-review process.