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More Health Care Is Not Necessarily Better Health Care

More Health Care Is Not Necessarily Better Health Care Kullgren et al1 show that low-income families with high-deductible health plans report cost-related delayed or foregone care. However, the authors fail to show that the additional care consumed by the higher-income group was essential or that outcomes were superior in that group. In the well-known RAND study of free medical care vs cost sharing,2 the cost sharing group had one-third fewer ambulatory visits and one-third fewer hospitalizations than the free-care group, and yet there was no difference in health measures between either group for the average patient except for a trivial difference in corrected vision of 20/22 vs 20/22.5. In the subgroup of low-income high-risk patients, there was a significant 3.3 mm Hg difference in diastolic blood pressure, but there was no difference in smoking, weight, cholesterol level, or any of 5 self-assessed measures of health. In 1984, the Stanford health care economist Victor Fuchs estimated that 20% of all medical care was either harmful or low yield.3 Without evidence that the deferred care in the Kullgren study resulted in poorer outcomes, it is reasonable to posit that much excess care is either harmful or low yield and that the deferral of care was rational from a personal cost-benefit point of view. The value of any particular episode of care is situational and personal, and so decisions on what medical care to buy are best made at the level of patient and physician. If, however, Kullgren et al are correct in their observation of income-based health care utilization disparity, then leveling of the playing field between lower- and higher-income families could be accomplished with income-based progressive copayments, so that all patients may consider cost to benefit in their choices. Innovations of this type are a first and essential step toward rationalizing care, without the kind of 1 size fits all, top-down rationing that is on the minds of many. Correspondence: Dr Erlebacher, Division of Cardiology, Englewood Hospital and Medical Center, 177 N Dean St, Englewood, NJ 07631 (drerle@mac.com). Financial Disclosure: None reported. References 1. Kullgren JTGalbraith AAHinrichsen VL et al. Health care use and decision making among lower-income families in high-deductible health plans. Arch Intern Med 2010;170 (21) 1918- 1925PubMedGoogle ScholarCrossref 2. Brook RHWare JE JrRogers WH et al. Does free care improve adults' health? Results from a randomized controlled trial N Engl J Med 1983;3091426- 1434PubMedGoogle ScholarCrossref 3. Fuchs VR The “rationing” of medical care. N Engl J Med 1984;311 (24) 1572- 1573PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

More Health Care Is Not Necessarily Better Health Care

Archives of Internal Medicine , Volume 171 (12) – Jun 27, 2011

More Health Care Is Not Necessarily Better Health Care

Abstract

Kullgren et al1 show that low-income families with high-deductible health plans report cost-related delayed or foregone care. However, the authors fail to show that the additional care consumed by the higher-income group was essential or that outcomes were superior in that group. In the well-known RAND study of free medical care vs cost sharing,2 the cost sharing group had one-third fewer ambulatory visits and one-third fewer hospitalizations than the free-care group, and yet there was no...
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Publisher
American Medical Association
Copyright
Copyright © 2011 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2011.268
Publisher site
See Article on Publisher Site

Abstract

Kullgren et al1 show that low-income families with high-deductible health plans report cost-related delayed or foregone care. However, the authors fail to show that the additional care consumed by the higher-income group was essential or that outcomes were superior in that group. In the well-known RAND study of free medical care vs cost sharing,2 the cost sharing group had one-third fewer ambulatory visits and one-third fewer hospitalizations than the free-care group, and yet there was no difference in health measures between either group for the average patient except for a trivial difference in corrected vision of 20/22 vs 20/22.5. In the subgroup of low-income high-risk patients, there was a significant 3.3 mm Hg difference in diastolic blood pressure, but there was no difference in smoking, weight, cholesterol level, or any of 5 self-assessed measures of health. In 1984, the Stanford health care economist Victor Fuchs estimated that 20% of all medical care was either harmful or low yield.3 Without evidence that the deferred care in the Kullgren study resulted in poorer outcomes, it is reasonable to posit that much excess care is either harmful or low yield and that the deferral of care was rational from a personal cost-benefit point of view. The value of any particular episode of care is situational and personal, and so decisions on what medical care to buy are best made at the level of patient and physician. If, however, Kullgren et al are correct in their observation of income-based health care utilization disparity, then leveling of the playing field between lower- and higher-income families could be accomplished with income-based progressive copayments, so that all patients may consider cost to benefit in their choices. Innovations of this type are a first and essential step toward rationalizing care, without the kind of 1 size fits all, top-down rationing that is on the minds of many. Correspondence: Dr Erlebacher, Division of Cardiology, Englewood Hospital and Medical Center, 177 N Dean St, Englewood, NJ 07631 (drerle@mac.com). Financial Disclosure: None reported. References 1. Kullgren JTGalbraith AAHinrichsen VL et al. Health care use and decision making among lower-income families in high-deductible health plans. Arch Intern Med 2010;170 (21) 1918- 1925PubMedGoogle ScholarCrossref 2. Brook RHWare JE JrRogers WH et al. Does free care improve adults' health? Results from a randomized controlled trial N Engl J Med 1983;3091426- 1434PubMedGoogle ScholarCrossref 3. Fuchs VR The “rationing” of medical care. N Engl J Med 1984;311 (24) 1572- 1573PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jun 27, 2011

Keywords: smoking,seizures,cardiology,disclosure,episode of care,income,vision,cholesterol measurement test,diastolic blood pressure,health disparity,low income,health care use,play behavior,cost sharing,copayment,costs and benefits

References

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