With more than four million Medicare fee-for-service beneficiaries expected to receive medical care through accountable care organizations beginning in 2012, hospitals and physicians are aligning to provide the coordinated care that could eventually entitle them to federal financial incentives.
A briefing paper from the actuarial and consulting firm Milliman, however, suggests that becoming an integrated delivery system, partnering with a health plan and focusing on the Medicare Advantage market may make more sense.
"I always advise my clients not to take risk for things they can't control," explains Rob Parke, Milliman's lead researcher on the project. ACOs, he says, as designed by the Center for Medicaid & Medicare Services, carry significant financial risk because CMS will share only aggregate data about beneficiaries. An ACO can request individual data, but the patient can decide not to allow CMS to release the information. "Providers could be financially responsible in terms of incentives for a patient they know nothing about."
Parke suggests that the system CMS will use to benchmark quality and performance standards will favor inefficient ACOs because the improvement bar will be set lower. "If you have been doing well you will have to work much harder to show improve than someone who hasn't been doing quite as well."
He noted that The Everett Clinic, which has participated in demonstration projects for Medicare ACOs since 2005, has decided not to seek certification as an ACO under the Affordable Care Act. Instead the Washington State clinic will move its patients out of traditional Medicare and into the Medicare Advantage managed care program. "They just aren't seeing the financial rewards for taking better care of their patients," explains Parke.
A simpler organization structure is among the chief advantages of an integrated delivery system partnering providers with health plans. The rules aren't final, but ACOs will need to be a legal entity of some sort and agree to participate in the program for three years. Also, there are some legal challenges to overcome so the ACO can allocate start-up costs between the hospital and physicians. Physicians will need to have at least 5,000 Medicare fee-for-service patients.
According to the brief, there are fewer legal impediments to sharing expenses and allocating financial risk when a health plan is the intermediary between providers and beneficiaries. As part of a partnership, the health plan can provide the administrative and financial support necessary for the startup.
Parke says a health plan could require members to comply with care coordination and case management to improve their health and help reduce costs. According to the proposed CMS rules, patients in ACOs can opt out of care coordination by refusing to share their personal medical information with all of the providers. But, they will still be counted as part of the ACO and thus will affect the quality points earned for financial incentives.
Why would a health plan want to be in a partnership? Parke says there is growing acceptance that integrated delivery systems are more cost effective and will allow a health plan to have more competitive premium rates.
Also, once the partnership is up and running, the health plan can delegate some of the administrative functions to the integrated delivery system. That will make it easier for the health plan to meets its surplus and profit goals under the Affordable Care Act.
Chicago-based Alexian Brothers Health System is to become part of St. Louis-based Ascension Health. The two announced on Wednesday that they have signed a non-binding letter of intent. Financial terms were not disclosed.
Citing the challenges facing hospitals around the country and the imminent demands of healthcare reform, Alexian Brothers has been seeking a partner for two years.
Ascension Health has long been interested in acquiring additional hospitals and recently created a joint venture to provide funding for that effort. In February 2011, Ascension Health and Oak Hill Capital Partners formed Ascension Health Care Network to provide an alternative funding source for the acquisition of Catholic hospitals and other properties.
In an e-mail, Trudy Hamilton, an Ascension Health spokesperson, said the discussions between Ascension and Alexian pre-date the formation of Ascension Health Care Network.
In the Chicago area Alexian Brothers owns two medical centers, three specialty hospitals and a medical group. It also owns senior living facilities, rehabilitation services and community-based programming for the elderly in Missouri, Tennessee and Wisconsin.
Ascension Health System owns or has an affiliation with 500 hospitals and other healthcare facilities in 20 states, including St. Anthony Hospital in Chicago. Under the deal, staff and leadership at Alexian are to be retained. As for governance, the ABHS Board of Governors, its subcommittees, and the system's Quality Councils will remain intact, according to a statement issued by Alexian Brothers.
"This proposed partnership is a significant step forward in the evolution of the Alexian Brothers Health System," Mark A. Frey, executive vice president of Alexian Brothers, said in a press statement. "Ascension Health shares our commitment to patient-centered care, to charity care and to strengthening Catholic healthcare nationwide. In terms of the healthcare services we provide, we expect this to be an opportunity for Alexian Brothers Health System to grow and expand."
There is a lot of chatter these days about improving the patient hospital experience. Ask any C-suite hospital executive to list his or her priorities and some variation of patient experience (patient satisfaction, patient safety, quality care, etc.) will likely top the list.
Money is the root of some of this interest. The federal Affordable Care Act and the creation of Accountable Care Organizations have healthcare stakeholders looking at ways to measure improvement in the healthcare delivery system. It's easy to see why. The soon-to-be-implemented value-based purchasing program will pay hospitals for their actual performance on quality measures rather than just for the reporting of the measures. That means performance will be attached to federal dollars.
But here’s the rub: no one is quite sure what really makes a patient hospital experience a good one. A few years back hospitals started offering amenities such as Internet access, parenting classes, and concierge services all in the name of making patients happy. Lately the patient experience debate has centered on process-driven metrics such as reducing emergency department wait times or improving the time it takes to get a patient from registration to a bed, or from a bed to the front door.
While the ACA has tipped its hat in favor of measureable goals, Jason Wolf, executive director at the Bedford, Texas-based Beryl Institute, argues that while improving the patient experience “should take some process into account, it really needs to be broader and more strategic. Successful organizations see improving the patient experience not as an initiative but as something that becomes intrinsic to the organization.”
The Beryl Institute, which consults with hospitals about patient experience, recently released a survey about what hospitals are doing to improve the patient experience. Wolf noted that for all the talk about the importance of the patient experience, more than 40% of the respondents said a committee has the primary responsibility and accountability for the patient experience and that such committees meet on average about once a month.
He doesn’t think that is the ideal model. “We’re talking about systemic change from top to bottom. Someone with power, like the CEO or COO, has to take ownership.”
I asked Wolf to cook his advice down to the five most important tips a hospital can use to improve its patient experience. Here are his suggestions:
1. Be clear on what you are doing and why.
Healthcare reform has introduced new market pressures and opportunities. It’s okay to admit that you are implementing this change or that process because there’s money involved. In 2013 the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAPHS, will be used not only to measure performance on quality measures but also to establish how much a hospital will be paid for meeting the performance standards. Everyone in the hospital, from the mailroom to the boardroom, needs to understand that patient perceptions are directly related to meeting standards and earning quality payments.
2.Establish leadership vision and support
According to the Beryl Institute survey, 72% of the respondents cited strong, visible support from the top as a critical to the success of improving the patient experience. There needs to be a dedicated lead with the power and the ownership to move the process forward.
3.Cultural alignment is systemic
Understanding what a patient values or needs is a systemic process. Wolf tells the story of one medical center that looked at its surgery process and discovered that each surgical patient came into contact with 30 different departments. “The patient is only having one experience but the medical center needed to align the interests and culture of those 30 different departments into that single experience.”
4.Get everyone engaged
One of his clients told Wolf that the key to their success was helping staff rediscover the passion that brought them to healthcare in the first place – care and service to others. It’s a simple message that resonates across departments and job titles. Cold hard cash can motivate, too. About 60% of the survey respondents said patient experience efforts are tied to individual performance reviews and bonuses.
5.It takes relentless commitment and continuous action.
The current thinking is that there is a ‘there’ that you get to with the patient experience. Wolf says there is not a ‘there.’ Improving the patient experience take continuous effort and relentless commitment by everyone. Hospitals want to get to a point where improving the patient experience isn’t a goal, it is simply the nature of the organization.
Ninety percent of American families living above the federal poverty level ($22,350 for a family of four) will be able to afford health insurance thanks to the Affordable Care Act, according to a Commonwealth Fund report released Wednesday. But families with high out-of-pocket medical costs may continue to struggle.
The report, "Will The Affordable Care Act Make Health Insurance Affordable?" finds that new subsidies available through health insurance exchanges established under the ACA will make premiums affordable for most families.
The exchanges, which are scheduled to begin in 2014, will offer a federally determined essential benefits package. Health plans in the exchanges must cover, on average, 60% of the costs of the insurance. In addition, the out-of-pocket limit for enrollee spending can't exceed the regulated level for health savings accounts or about $6,000.
The Commonwealth Fund report uses consumer spending data to analyze family budgets across income levels, and compares them to the costs of purchasing health insurance through HIEs and typical out-of-pocket healthcare spending. The analysis shows that the majority of families, even lower-income families, have room in their budgets for premiums and typical out-of-pocket costs.
Households between 100% and 150% of the FPL (up to $33,525 for a family of four) spend 75 percent of their resources on necessities—including child care, food, housing, taxes and transportation—leaving most families in that income range able to afford some health-related expenses.
While the families had room in their budgets for necessities, health insurance premiums, and moderate levels of out-of-pocket costs, that was not the case with high levels of out-of-pocket costs. In each income range examined, some families would struggle to afford all their healthcare expenses because of high out-of-pocket costs.
For example, 10.8% to 17.5% of families with incomes between 100% and 200% of the FPL could not afford all their necessities plus health-related costs when they had high out-of-pocket medical costs. At 200% to 300% of FPL high out-of-pocket medical costs meant about a quarter of families could not afford all their necessities plus health-related costs. Families with incomes over 500% of FPL ($111,750 for a family of four) were found to have room in their budgets for healthcare even with high out-of-pocket costs.
"Our analysis is promising, as the vast majority of people will be better off because of the premium subsidies and cost-sharing limits in the Affordable Care Act," said Jonathan Gruber, an economics professor at MIT and the lead author of the report. "However, the concerns about high out-of-pocket costs are notable and should be addressed so that people who become very sick don't face out-of-pocket costs that they are unable to afford."
Employers will continue to shift healthcare benefit costs to employees either by increased contributions or plan design, according to the 2011 Benefit Options Survey released by Indianapolis-based United Benefit Advisors, an employee benefits advisory firm.
The good news is that employers are committed to providing healthcare benefits to active employees and their dependents. Almost 77% said they recognized the value of the benefits while 96% responded that good benefits help attract and retain employees. More significantly, more than half the employers continue to believe they should shoulder the brunt of future health plan premium increases.
Looking at what might happen to health plans in the next five years, 87% of respondents expect to see more healthcare benefit costs shifted to employees. Among the cost-sharing strategies, 5% of respondents said they planned to implement a high-deductible health plan with a health reimbursement arrangement; 6% said they planned to implement an HDHP with a health savings account this year.
In considering plan design changes in 2011, 22% of employers expect to increase deductibles; 21% are looking at increases for office visits and emergency room copays; 17% will increase prescription drug copays; and 13% expect to increase copays for specialists. Only 5 % are looking at value-based plan design.
There is continued employer interest in incorporating programs that stress prevention and personal health management, such as wellness programs with health risk assessments and disease management programs to help employees with chronic conditions. After wellness and disease management, the component most likely to be added is a cost differential for smokers vs. non-smokers.
The majority of employers recognize the potential impact of employee health management on future plan costs with 57% willing to offer healthcare incentives, including lower deductibles to employees who make a reasonable effort to manage their chronic conditions.
Looking at safety and quality outcomes, only 44% of respondents believe physicians, hospitals, or the government should establish the standards. More than 33% said employers and employees should set the safety and quality requirements.
That said, 75% of employers believe the federal government should require hospitals, physicians, and insurers/health plans to publicly disclose all quality and cost information to provide employers and employees with the critical information needed to make informed decisions. Employers would also like the government to require insurers to disclose actual network discounts for claims.
Almost 1,300 employers responded to the on-line survey, which was conducted in February, 2011. Firms with fewer than 50 employees represent 87% of the respondents. Government and manufacturing industry categories each account for around 14% of the responses.
The survey looks at employer opinions and strategies in these areas: health benefits philosophy, health plan management, personal health management, scope of benefits and employee communications.
Physicians are participating in Medicare pay-for-reporting programs in growing numbers, according to the 2009 Physician Quality Reporting System and e-Prescribing Experience Report from the Centers for Medicare & Medicaid Services.
More than 119,800 physicians and other eligible professionals received incentive payments totaling more than $234 million in 2009—well above the $92.4 million and $36 million paid in 2008 and 2007, respectively, for the physician quality program. Under the e-prescribing incentive program, CMS paid $148 million to 48,354 physicians and other eligible professionals in 2009, the first payment year for that program.
Participation in the physician quality reporting system is optional, but has increased by 50% each year, the report shows. The number of quality measures increased from 55 in 2007 to 74 in 2009 and now stand at 194.
The measures capture evidence-based practices that are shown to improve patient outcomes, such as providing preventive services, taking steps to reduce health care disparities, planning care for patients with chronic conditions to keep them healthy for as long as possible and integrating health information technology solutions into care delivery. Not all of the measures apply to all physicians.
For doctors, much of the data represents clinical performance measures, for example, asthma assessment, melanoma counseling on self-examination, blood pressure management for patients with chronic kidney disease, and assessment of mental status for community-acquired bacterial pneumonia.
The e-prescribing incentive program has one quality measure: HIT-adoption/use of e-prescribing.
Physicians and electronic prescribers who satisfactorily reported data on the quality measures earned an incentive payment equal to 2% of their total estimated allowed charges for covered professional services under Medicare Part B. The average incentive was $2,000 per professional and $18,525 per medical practice for the physician program; for the e-prescribing program the average bonus payment was $3,000 per eligible professional and $14,501 per practice. Payments were received in the fall of 2010.
The three specialties accounting for the largest portion of the total incentive amount of $234 million were emergency medicine (11.9%), cardiology (11.6%) and ophthalmology (11.5%).
In 2009, a number of measures showed improvements from their 2007 rates:
The percent of professionals who reported that they communicated with patients with diabetes about potentially damaging eye-related complications of the disease jumped to 93% in 2009 from 52% in 2007.
The percent of professionals who reported that patients with left-ventricular systolic dysfunction (a specific form of heart failure) received recommended beta-blocker drugs increased to 95% in 2009 from 64% in 2007.
The percent of professionals who reported that care teams effectively stopped post-surgical antibiotics (to prevent overmedication and the formation of potentially drug-resistant “superbugs”) increased to 95% in 2009 from 54% in 2007.
Although participation is optional for now, providers who are eligible to participate in the e-prescribing program but choose not to will have their Medicare payments reduced beginning in 2012; the same rules will apply to the physician quality program beginning in 2015.
Thanks at least in part to healthcare reform initiatives, physician groups are beginning to hire again, the 2010 Physician Retention Survey from the American Medical Group Association shows.
Eighty-three percent of the responding medical groups said that they will hire more or significantly more primary care physicians, specialist and advanced practitioners in 2011. Nearly as many said they will be hiring more or significantly more specialists (79%) and advanced practitioners (78%).
The number one hiring priority over the next 12 months is internal medicine followed by family medicine.
Medical groups are also increasing their physician count by acquiring independent practices. Almost 60% of the survey respondents said they were actively seeking practices to acquire or integrate into their medical group.
The online survey of AMGA member organizations drew a small response from 62 medical groups employing an estimated 18,000 physicians. Survey size means some of the findings aren't statistically significant but some general trends affecting physician retention and recruitment may be identified. The survey will be available on-line from AMGA on May 1.
Medical groups with 51-500 physicians accounted for 69% of the respondents. Physician-owned groups accounted for 39%; integrated delivery systems (27%), hospitals (19%) and academic/foundation ownership represented 15% of the responding groups.
Among the findings:
Turnover rates have increased slightly. The average turnover rate for 2010 was 6.1%, which matches the 2008 rate before the economy began to freefall and is slightly ahead of 2009's 5.9%. Historically, physicians have been most likely to change practices after three years. The reasons vary and include career motivation and family satisfaction with the practice location. The 2010 survey found that almost 13% of responding groups were seeing turnovers after just one to two years of practice. That's a concern because it may reflect failures to adequately access physician prospects during the hiring process.
According to the survey, 78% of the turnovers were voluntary while retirement accounted for 10%. Turnover among physicians can cost a practice as much as $1.3 million per physician, including $990,000 in lost downstream revenue, $61,000 in recruiting costs and $211,000 in start up costs for the new hire.
Mentoring may reduce turnover. The majority of medical groups (73.8%) believe mentoring reduces turnover, but just more than half (56.1%) actually assign a mentor to newly hired physicians. The turnover rate was 5.3% for groups that have written mentor goals and guidelines compared to 6.3% for those who do not assign a mentor.
Working part-time is growing in popularity. Flexible work schedules are important. At least 21% of physicians were employed part-time in 2010 versus 13% in 2005. Female physicians are more likely than male physicians to be part-timers. Some 53% of the male physicians working part-time are at least 55 years of age and are probably reducing their work schedules in preparation for retirement. Female physicians working part-time are younger?56% are under age 44. That could reflect family responsibilities that make full-time work less attractive.
Physicians employed by hospitals want more say in hospital management, according to a survey by the consulting firm PricewaterhouseCoopers US. More than 90% of the physicians surveyed said they should be more involved in executive leadership and management of the hospital, including serving on the board of directors and outlining performance improvement initiatives.
Hospital leaders, however, think most physicians aren't ready for that big step.
The report is the second in a two-part series on physician-hospital alignment. The findings are important because shifts toward healthcare reform, such as the move toward accountable care organizations make it financially attractive for physicians and hospitals to integrate their services. PwC's HRI's research focuses on three areas important to hospital-physician integration: Shared governance, aligned compensation, and changing physician-practice patterns.
The findings indicate that physicians and hospitals have more to work on as they explore ways to capitalize on health reform opportunities.
Governance
Hospital employment means physicians may have to give up control of how they practice to comply with standards that emphasize overall system quality and efficiency goals. Many physicians willing to make that transition, in return, want a seat at the management table.
Hospital leaders, however, aren't willing to cede to those demands just yet. Hospital leaders interviewed by PwC HRI for the report were of the opinion that most physicians lack the business management and leadership skills needed to be effective in positions of leadership and governance. The good news is that some hospital systems are providing continuing education to help physicians develop management skills.
About 66% of the physicians surveyed said they can devote time to leadership and management activities. To make sure they meet those obligations once they take them on, more providers are paying doctors to serve on committees and participate in administrative activities, especially to help create buy-in for new quality programs and cost reduction initiatives. Hospital leaders said they need physicians to not only help reduce supply and infrastructure cost, but also to generate additional revenue.
Compensation
Physicians are very aware that healthcare is moving toward a payment approach that rewards doctors and hospitals for quality results over volume. In looking at compensation, physicians said that half of their compensation should be fixed salary with the remainder based on meeting a combination of productivity, quality, patient satisfaction, and cost-of-care goals, with upside earning potential for performance.
In HRI interviews hospital leaders said they are developing compensation models that will benefit their overall system. They acknowledge that physicians will be the key drivers in meeting clinical quality standards set for ACO participation. Providing the right mix of compensation could help hospitals increase revenue and avoid financial penalties.
In other compensation findings:
Some 45% of physicians who are considering hospital employment would expect to be paid more than they are now with increases ranging from 1.7% to 4.7% percent.
Some 38% said they would expect no salary change.
Expectations for compensation varied by physician specialty, with pediatrics, psychiatry and cardiology expecting the largest increase at 4.7%, 3.6% and 3.5%, respectively. General surgery, oncology, and emergency medicine expect the least at 1.9%, 1.7% and 1.7%, respectively.
Changing Physician-Practice Patterns Physicians who have traditionally focused on volume will have to adjust to practice patterns that emphasize system quality and efficiency, the report suggests. Physicians also will be challenged to practice as part of a multidisciplinary team.
Hospitals are looking to develop clinical guidelines to help in this transition. While hospital executives expressed support for local guidelines, 62% of physicians surveyed preferred that nationally accepted physician practice guidelines be used. Only 30% preferred locally developed guidelines.
The report is based on a nationwide online survey of more than 1,000 physicians. Results are balanced by age, gender, practice type and specialty. In addition, HRI analysts conducted 28 in-depth interviews with thought leaders and executives representing healthcare providers, payers, and professional associations.
The call for deficit reduction has hit a fever pitch in Washington, D.C. First, Rep. Paul Ryan (R-WI) presented his so-called “Path to Prosperity: Restoring America’s Promise” plan, then President Obama countered with a speech offering his version of a deficit reduction strategy. The numbers both plans throw around are almost too large to imagine. Forget millions. The focus here is billions and even trillions.
Rep. Ryan has played his cards well. He jumped out of the gate with a proposal to revamp Medicare spending and put that entitlement program in play for massive cuts. Obama hedged his bets. He made it clear that he will oppose GOP efforts to reduce the deficit by recreating Medicare but proceeded to propose his own set of reductions to the program. The difference, he explained, is that “their plan lowers the government’s healthcare bills by asking seniors and poor families to pay them instead. Our approach lowers the government’s healthcare bills by reducing the cost of healthcare itself.”
Medicare is a complicated program, and so are the proposals to reduce its costs. Let's take a look at how Medicare would be affected by elements of each plan. The table below is much as possible an apples to-apples comparison, but in some cases the two plans use different years to report savings or to introduce program changes. The figures were gleaned from the Ryan budget and Obama deficit reduction proposals.
How Proposed Deficit Reduction Plans Would Affect Medicare
Age 65 until 2021; increase eligibility age by two months each year until it reaches age 67 by 2032.
Beneficiary spending
Cap Medicare spending/beneficiary to GDP plus 0.50 of a percent
Premium supports by 2021; support will vary by health, age and income of beneficiary; coverage though private health plans
Medicare cuts
No specific amount noted for Medicare
$30 billion FY2012-FY2021
Total Medicare spending in 2012
$1.1 trillion (includes Medicaid)
$950 billion
Total reduction in healthcare spending
$480 billion by 2023; additional $1 trillion by 2033
$2.2 trillion FY2012-FY2021, including $1.4 trillion from not implementing the ACA, $771 billion from Medicaid and $30 billion from Medicare
Affordable Care Act
Continues to be enacted
Repealed
The big question is whether any of Ryan’s or even the President’s proposals will come to fruition and those trillion dollars in savings achieved. Increasing the age of eligibility doesn’t even begin until 2021 and then takes another 11 years to 2032 to actually reach the proposed eligibility age of 67. Premium supports are at least 10 years away. Even capping Medicare beneficiary costs is a couple of years away.
The Congressional Budget Office's analysis of Ryan's plan is here. The agency's analysis of the President's plan is here.
Ben Goldberg, CEO of the National Academy of Social Insurance, a Washington, D.C. healthcare think tank, says his main concern is that both proposals seem more concerned with reducing costs than improving healthcare. He acknowledges that the President’s cost reduction proposals are a little easier to understand because with the Affordable Care Act in place “the administration is already implementing measures that will reduce healthcare costs by looking at how healthcare is delivered and how that system can be improved to reduce costs.”
That opinion is shared by Marsha Proctor Killen, CEO at StrategyGen a Jacksonville, Fla-based healthcare benefits consultant. She sees premium supports as a windfall for private healthcare insurers. “Yes, they could produce a savings for the program because the beneficiaries will be purchasing their own coverage and private insurers will be paying for the medical procedures but how will privatizing the system improve healthcare?”
So what do we really have here? Are we looking to make meaningful policy or simply score some budget points? Ryan’s budget has already passed the House but will probably never see the light of day in the Senate. But once again the public debate about healthcare has been reduced to dollar and cents not long-term policies and good sense.
The medically vulnerable who enroll in high-deductible health plans are at no more risk for cutting back on needed healthcare than other people who enroll in HDHPs, according to a RAND Corporation study.
The findings are important because more low income and chronically ill people are likely to enroll in HDHPs over the next decade, the study says. Beginning in 2014, as mandated by the Affordable Care Act, Health Savings Account-based plans will be offered in health insurance exchanges to manage the individual and small group markets.
The lower premium plans may be attractive to the uninsured, and the concern has been that despite the lower premiums, high deductibles will make low-income families and the chronically ill more likely to skip needed medical treatments.
Amelia Haviland, lead author of the study and a statistician at RAND, a nonprofit research organization, explained in an interview that that is not the case. "We did not find greater cutbacks for medically vulnerable families. The evidence suggests that non-vulnerable families, low-income families, and high-risk families are equally affected under high-deductible plans."
The study examined the impact of HDHPs on families living in low-income areas where median income is below 200% of the federal poverty level or $44,700 for a family of four. Also examined were families with a member who had one of the five most costly chronic physical illnesses -? cancer, diabetes, heart disease, high blood pressure or kidney disease.
Researchers looked at data from 2003-2007, including medical claims information, for more than 360,000 families enrolled in HDHPs through 59 employers with at least 100 employees each. About 73% of the employers offered an HDHP as a health insurance option during the study. The study group used a traditional health plan in the first year and an HDHP in the second.
The study found that some of the chronically ill enrolled in HDHPs were more likely to receive certain types of preventive healthcare than low-income or non-vulnerable enrollees. The chronically ill were more likely, for example, to undergo all three recommended cancer screenings (cervical, colorectal and mammogram) but diabetics had lower rates of standard recommended tests such as HbA1c, lipid profile and microalbumin.
The study examined whether the size of the deductible affected inpatient, outpatient, or pharmacy services had an effect. The amount of the high deductible had a significant effect on all service categories for non-vulnerable families, but Haviland said the same was not generally true for the medically vulnerable. She explained that high-risk families reduced prescription drug spending only when deductibles were at least $1,000 per person.