Delayed health care has clinical and financial impacts

As out-of-pocket costs for health care continue to rise, many individuals are skipping or delaying health care services, a trend that could bring added health concerns for individuals as well as increased financial impacts for the health care system in the future.

One in four U.S. adults reported that they have put off getting needed medical services in the past year because of cost, according to a recent study from KFF. A recent Blue Cross Blue Shield of Massachusetts poll showed that about 40% of respondents delayed care because of expense.

Individuals most frequently delay dental and vision care, doctor visits, and mental health care, according to the KFF study, and members of marginalized groups and the uninsured are disproportionately affected.

Preventive screenings such as those for cancers and cardiovascular health are essential for early detection and treatment, while routine doctor visits and vision and dental checks can also uncover underlying medical conditions.

Hesitation over cost also impacts medication adherence. KFF finds that about 21% of U.S. adults say they have not filled a prescription because of the cost, and a similar proportion report they have chosen to use cheaper, over-the-counter solutions instead. About 50% of patients with chronic conditions do not take medications as prescribed, according to a TailorMed report.

“We understand more people abandon their medication at the pharmacy counter and do not adhere to prescriptions due to affordability issues, which can have an impact on their health care costs in the future,” said Jennifer Carioto, principal and consulting actuary with Milliman, a global risk management firm. “Impact models show that while it initially costs insurers more, these added prescription costs are offset later by lower medical costs and lower mortality rates.”

Medication non-adherence can not only exacerbate a patient’s medical condition — leading to more intense treatment and longer hospitalizations in the future — it also increases the financial toll on the U.S. health care system by more than $5 billion annually, according to a report from the Patient Access Network Foundation.

Possible solutions
Health care stakeholders have implemented strategies that help to alleviate affordability challenges, such as drug price negotiations, increasing availability of less-expensive biosimilar drugs, and offering health savings accounts. Carioto noted that a new Medicare Prescription Payment Plan, under Medicare Part D, is being rolled out in 2025 that will allow members to spread their $2,000 maximum prescription out-of-pocket costs into monthly installments, rather than paying a large amount upfront (depending on the benefit design). Although this is not currently a practice in commercial insurance, it has potential to be helpful, she said.

As employers continue to roll out higher deductible plans for their employees, Chris Bailey, director of MIIA’s Health Benefits Trust, noted that they should be sure that employees are well-educated on the use of these plans, especially when paired with a Health Savings Account.

HSAs allow employees to set aside pre-tax dollars for their out-of-pocket medical expenses. Some employers choose to add funding into their employee HSA plans to help employees with out-of-pocket medical expenses. These plans can be complicated, however, especially for employees enrolling for the first time. Employers are advised to connect with their plan managers or consultants to request education sessions for their employees, including webinars and on-site education meetings.

Bailey said municipal employers can also help by ensuring that employees are aware of every plan benefit and wellness program that is available to them. For example, some municipalities have leveraged diabetes management programs that increase medication adherence by providing cost waivers, leading to reduced medical claims and cost savings overall.

MIIA offers its Health Benefits Trust members a musculoskeletal program that provides at-home care instead of in-office physical therapy. This program has no out-of-pocket cost for the employee, a lower net cost for the employer’s medical plan, and better overall health outcomes when compared to traditional in-person care.

Individuals who have knowledge of and access to programs that improve health outcomes are not only healthier, but they reduce the need for higher levels of care and help to keep their costs down.

Written by Jennifer Ranz