High health spending is more persistent than you might think

[eridani]

http://mcr.sagepub.com/content/72/3/277.abstract?etoc

Surprisingly little is known about long-term spending patterns in the under-65 population. Such information could inform efforts to improve coverage and control costs. Using the MarketScan claims database, we characterize the persistence of health care spending in the privately insured, under-65 population. Over a 6-year period, 69.8% of enrollees never had annual spending in the top 10% of the distribution and the bottom 50% of spenders accounted for less than 10% of spending. Those in the top 10% in 2003 were almost as likely (34.4%) to be in the top 10% five years later as one year later (43.4%). Many comorbid conditions retained much of their predictive power even 5 years later. The persistence at both ends of the spending distribution indicates the potential for adverse selection and cream skimming and supports the use of disease management, particularly for those with the conditions that remained strong predictors of high spending throughout the follow-up period.

http://blog.academyhealth.org/high-health-spending-is-more-persistent-than-you-might-think/

If you’re unlucky enough to get hit with a very costly health condition, consider yourself relatively lucky if it’s not highly persistent. The new work by Hirth and colleagues shows that such persistence is surprisingly common and remarkably long. This is how sickness saps savings, for those with coverage that comes with high enough deductibles and copayments. Today, we call that “insurance.” Is it?

Comment by Don McCanne of PNHP: We already know that high deductibles and other cost sharing can result in financial hardships for individuals who develop major medical problems. But how many face the additional burden of having to pay the high deductibles in the years following? This study provides an answer.

Of health plan members or their family members who were in the top 10 percent of spending in a given year, 43 percent were still in the top 10 percent the following year, and an astonishing 34 percent were still in the top 10 percent five years later.

These are workers and their family members - largely middle-income Americans - who had employer-sponsored health plans. These are the plans that the Affordable Care Act was designed to protect. Now that employers are are switching to “consumer-directed” high-deductible health plans, these plans are devastating to the personal finances of these families that must meet the high-deductibles and other cost sharing year after year. Forget retirement funds, college funds, vacations, and the like and plan to spend time with bill collectors and bankruptcy referees.

When you think about the financial protection that you should be receiving from your health plan, it is deplorable that one-third of those who have the greatest needs for health care are exposed to years of recurrent, persisting financial burdens simply because of the fundamentally flawed design of our private health plans. Austin Frakt is right to question if this is even "insurance."

The authors of the study suggest that the solution is found in disease management. What? Disease management only tweaks spending on major medical problems and would have no impact on the high-deductibles that patients would have to pay before their coverage kicks in. Let’s get real.

A single payer system with first dollar coverage would eliminate the burden of high medical bills that these unfortunate individuals face under our current, dysfunctional health care financing system. Yes, they need qualified health professionals to help them manage their diseases, but that’s a function of the health care delivery system. Intrusive, private, third-party money managers need to get out of the way.

[merrily]

1. America seems highly resistant to the best way to do things.

[SamKnause]

2. Truer words have never been typed.

I would add The Powers That Be are intentionally

resistant if it hurts their bottom line.

Money is 'God' and King in the U.S.

[JDPriestly]

4. Yes.

[nashville_brook]

7. theres the *best* way, there's the way that makes $$ for corporations.

and we don't get to pick which is used.

[daredtowork]

3. A lot of this also has to do with the poverty system

The medical system is the gateway to a lot of social services. Therefore, poor people have to keep knocking on the door of the medical system to build up documentation to get the services they need. A lot of their issues are chronic, which means they are there to be "managed", not to be cured. Another problem is "vague symptoms", which is frustration for both the doctors and patients where they go through years of medical appointments and trying out different treatments trying to figure out exactly what the problem is. Often what the patient wants is social support so they can survive while nature takes it's course. But what happens instead is doctors drag things out, don't document the appropriate things, so patients don't get that social support while they feel like crap, and thus continue to be a drag on BOTH the medical and social system when they could have sailed through both if they had gotten the support they had needed up front.

At the poverty level much of the problem is about the medical system and the social system failing to work together, and the doctors often failing to understand the situation patients are in. For instance, if a patient isn't working, they can't drag themselves around in pain or take cognitively compromising meds 9 months between appointments. But doctors feel not only at liberty to do this, but to Judge Judy their patients for basically not having the same lifestyle options as wealthy doctors at the same time. This is, to put it mildly, uncool. Throw a little racism, sexism, and weight discrimination into the mix, and doctors are almost creating more trouble than they're worth. Why do they get paid so much again?

Anyway, as an inside observer, I think a ton of money could be saved if more of it was spent on case management and understanding what the *patient* needed, and how to get that for the patient most efficiently. There should be easy ways for patients to report prescription problems and other medical issues between doctor's appointments, ways to record your medical issues so it didn't become a matter of trying to get a doctor's attention during the first 15 seconds of an appointment, and ways to insist on diagnoses or some other outcomes by certain deadlines. Doctors should be required to learn about the social welfare system as part of their "continuing medical education".

Right now the entire system is run from the perspective of the doctor. This means the doctor can string people along for years without a particular overview of their condition. The doctor can do this out of overwork or sheer laziness, but all the while they can throw their weight around like an arrogant jerk, and they get to sign off on all prescriptions and be the gatekeepers for whether you are disabled or not. This system needs to flip to be patient-centered, with the appointment always addressing these three things:

1) Cure/management of patient's medical condition.
2) Relief of patient's pain.
3) Documentation of patient's condition for other bureaucracies.

If the appointment isn't addressing those matters for the patient, then the appointment is about the doctor's ego. The doctor is probably forcing the patient to listen to him/her blather on to some version of the diet/exercise speech that everyone has heard a million times before. Perhaps the doctor is belittling the patient for having symptoms? Or the doctor is over-treating the patient for symptoms in order to get big pharma kickbacks. Neither of those things are about what the patient wants.

Hope this opinion is worth more than 2 cents.

[dreamnightwind]

5. Excellent post!

Thanks, I agree with most all of it, well said.

[tavalon]

6. Especially Dental, which while currently a different creature from Health Care,

is the cornerstone of that healthy body. Healthy mouth, healthier body. It's all over the news that mouth health is the best predictor of better general health. But aside from the soapbox that Dental should be rolled into Health, my actual point is that I have spent 10,000 on my son's dental health this year, 2000 of which was covered by a very popular dental plan. I've also spent about 3,000 in health spending and if I get my tonsils and my, um, boobs removed this year, I'm looking at another 5-10 thou. Especially the boobs, elective in, elective out.

Oh, and my vacation time is going to surgeries so that's an added bonus but doesn't really speak to the OP.

However, on a plus side, because I have a union mandated plan, my son's anti seizure med that runs over 4,000 a year costs me 140 dollars. It's something.