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Penny Wise, Pound Foolish

By Dr. Nilesh Kalyanaraman
. 1 Comment(s)

I’m used to seeing people in my clinic who can’t afford medications. Last week I saw a woman who was supposed to be on ten different medications but was only taking five of them because they cost too much. As a result, her diabetes and high blood pressure were uncontrolled. Our 25-minute visit consisted of us going through each medicine, deciding if it was essential or replaceable, and then figuring out which area pharmacy offered the lowest cost for that medication. Between providing her with samples and pricing her meds at two local pharmacies, I was able to get her pharmacy bill down to about $30, a lot better than the $150 she was paying.


The troubling thing about this encounter was that she had insurance. Of late, I’ve been seeing more instances of people with insurance who cannot afford all their medications. The problem is that all these people have high deductible insurance plans.


High deductible insurance plans are health insurance plans where the deductible for in-network care for a family can range from $2,400 to $12,100. More and more people are being enrolled in high deductible insurance through employer sponsored health plans. Premiums are lower than regular plans because much of the cost of the plan is shifted onto the patient.


The RAND Corporation estimates that in the next ten years 50% of employer sponsored health insurance will be high deductible plans. They estimate that the savings would be about $57 billion or 4% of total health care costs. In looking at data from 2003-2007 on the effects of switching to high deductible plans they found that two-thirds of the spending savings came from fewer visits to the doctor and one-third came from choosing cheaper alternatives to care. Of concern, there was also a decrease in utilization of preventive care services even though some of these services were offered at no cost.


When cost is a barrier to care people will spend less money as my patient’s experience shows. But spending less money isn’t, in and of itself, a good thing. The costs to her health of not being able to take her diabetes and high blood pressure medications – heart disease, kidney disease, strokes- won’t show up for years. Studies like this have too short a time window; their cost savings figures seem more meaningful than they are because long-term costs cannot be factored in. More importantly, it costs money to take good care of people and spending on medications and consultations for diabetes, high blood pressure and other chronic medical conditions is necessary for achieving good outcomes.


High deductible plans are a blunt instrument and though they lead to decreased costs in the short term, I suspect that they will lead to adverse long term outcomes and costs. There is a good deal of fat to cut in the world of health care insurance but forcing patients to skimp on necessary health care expenses does more than just cut out some fat, it cuts to the bone.

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  1. Ina, M.D.

    So glad to hear sense spoken about these "sneaking" changes that are being introduced to cut insurance co costs. It's clear they're not thinking about patients - we need to push to make them do so.

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