The downside of high-deductible

There is no shortage of criticism - and praise - for high-deductible health plans, the increasingly popular insurance model that seeks to change how consumers think about medical costs by forcing them to pay for more of the "purchase" themselves.

Praise: They save money. Criticism: Patients skip care.

A new study led by Jeffrey T. Kullgren, who is affiliated with both Penn's medical school and Wharton, drills deeper into the downside by asking whether income level affects decisions to delay care in these plans, which typically feature family deductibles of $2,000.

Their short answer: It does.

In surveys of families enrolled in high-deductible New England plans, 57 percent of those earning less than 300 percent of the federal poverty level ($54,630 for a family of two, $82,710 for four) said they had avoided or delayed care in the previous six months because of cost, vs. 42 percent of those earning more.

The percentages were smaller - but the disparity greater - when the patients were children (24 percent vs. 14 percent).

The study of 414 families, published in Archives of Internal Medicine, came up with some head-scratchers. Asked whether they found their plan difficult to understand, for example, only about one-quarter of both groups said yes. Yet far higher proportions said cost had led them to delay or forgo preventive care - which is free in their plans.

Another surprise: In response to a hypothetical question, lower-income respondents were more likely than higher-income (79 percent vs. 63 percent) to say they would like their doctor to help them determine whether a $100 routine blood test was worth the money. It is the kind of decision, Kullgren said by phone, that "many physicians don't feel well-equipped to help their patients make."

Since people in high-deductible plans have trouble telling which care is essential, Columbia's Victor R. Grann wrote in an accompanying commentary, a model known as "value-based insurance design" may be better. It weights the options by setting low co-payments for interventions of high clinical value and high co-payments for those of low value. Insurers are already phasing this in under the health-care overhaul.