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The High-Deductible Gamble

High-deductible health insurance plans can leave cancer patients scrambling to pay the bills for tests and treatments. By Charlotte Huff
Photo © iStock / -strizh-
Photo © iStock / -strizh-

Tammy Pope had already exceeded her health insurance plan’s $5,000 deductible for 2015 by August. She was still facing a double mastectomy for stage III breast cancer when she got into a debate with her oncologist over whether she could skip a magnetic resonance imaging (MRI) test of her brain. The doctor had recommended the MRI because Pope had been falling down, episodes she blamed on her cancer medications.

 
High-Deductible Considerations
Limit surprises by doing your research.
But the doctor insisted on the scan, saying the malignancy had already proved unexpectedly aggressive, with 23 positive lymph nodes removed during Pope’s lumpectomy. “She said, ‘We don’t know for sure if it has spread, and it does love going to the brain,’ ” as Pope recalls the conversation. “Of course,” Pope adds, “when they put it like that, you’re going to do it.”

Pope, a retail worker in Louisville, Kentucky, was already fielding bills she couldn’t pay for tests that had led to her triple-negative breast cancer diagnosis, as well as the chemotherapy that treated her cancer but left her with severe neuropathy in her hands and feet. And while the MRI showed no signs of brain metastasis, the bills kept multiplying: slightly more than $600 for her portion of the MRI’s cost, roughly $6,500 for various tests that led to her diagnosis, and at least $20,000 for her share of the cost of chemotherapy. (Even after Pope met her $5,000 deductible, she had to pay a percentage of each bill under the terms of her insurance policy.) Discussing those figures in early December 2015, a day before her double mastectomy, the 52-year-old noted that come January 1, 2016, her deductible would kick in again.
 
High-deductible plans, once a rarity in health insurance, have become more common. Nearly half of Americans on employer-provided insurance, 46 percent, were required to meet an individual deductible of at least $1,000 in 2015, compared with 10 percent in 2006, according to a Kaiser Family Foundation/Health Research & Educational Trust annual survey. In addition, the average deductible has increased, from $917 for individual coverage in 2010 to $1,318 in 2015.

Because high-deductible plans are relatively new, individuals might not understand the out-of-pocket ramifications unless they get a serious diagnosis, says Peter Ubel, a physician and behavioral scientist who studies health care decision-making. But signs of strain are starting to emerge, says Michael Diaz, an oncologist in St. Petersburg, Florida, and director of patient advocacy for a practice with 200 oncologists. “It’s causing problems because they [the high-deductible plans] are interfering with what we [doctors] would normally routinely want to do,” says Diaz, referring to delayed diagnoses or patients pushing for different treatment because of high-deductible worries.
 
Diaz described a middle-aged woman seen at the practice who had put off getting a lesion growing on her head checked out because of the out-of-pocket cost. By the time she reached an oncologist’s office, the squamous cell lesion was large enough that she needed to undergo radiation in an effort to reduce its size before surgery could even be considered, Diaz says. Another patient, a man in his 60s diagnosed with advanced prostate cancer, asked that chemotherapy be postponed for two months until the following January. The patient’s rationale: He’d only max out his $5,000-plus deductible in a single year rather than in two consecutive years. But, says Diaz, “he’s delaying what would be considered optimal therapy.”

Deductibles: A High Hurdle
With the exception of some preventive measures like flu shots or screening mammograms, patients on high-deductible plans typically must pay for all doctor visits, lab work and other medical care until the deductible is met. Along with becoming more common through employer-provided insurance, high deductibles also are a feature on many plans sold through the Affordable Care Act health exchanges. And that’s just part of the burden for many patients. Plans vary in the amount they will pay once the deductible is met, with some covering everything and others just a percentage.
 
Because high-deductible plans are relatively new, individuals might not understand the out-of-pocket ramifications 
unless they get a serious diagnosis.
A Kaiser Family Foundation analysis reveals how daunting high deductibles can become if serious illness strikes. Overall, 63 percent of adults under age 65 have enough financial resources on hand—via bank accounts, certificates of deposit, nonretirement mutual funds and stocks, among other assets—to meet a $1,200 deductible for an individual and $2,400 for a family. For the higher deductible—defined as $2,500 for an individual and $5,000 for a family—51 percent have sufficient funds, according to the analysis, published in 2015.

Another study, conducted by the nonprofit organization Families USA, looked at nonemployer health insurance coverage in 2014 and found that adults with a high deductible were more likely to skip care. Nearly 30 percent of adults with a deductible of at least $1,500 reported forgoing care versus 19.6 percent of those with a lower deductible.

To some users, high-deductible plans can feel like scant protection, says Ubel, based at Duke University in Durham, North Carolina. “You think that you’ve bought health care insurance,” he says. “And what you’ve really bought is insurance that will eventually kick in when you need a heck of a lot of health care.”

Despite tales of patients delaying or refusing tests or treatments because of high deductibles, it’s still unclear whether or in what way these plans influence cancer patients’ decisions, says Frank Wharam, an internist and a researcher at Harvard Medical School in Boston, who is leading a large-scale breast cancer study that’s trying to gain better insight into whether the deductibles can be linked to delays in diagnosis or altered treatments. “There is this tension and open question about whether the costs of cancer diagnosis and care are so high among high-deductible members that women will delay care, versus, is cancer such a scary and concerning potential diagnosis that women will not delay care no matter what the cost?” he says.

03/28/2016
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