Internists say Cost Sharing, Particularly Deductibles, May Cause Patients to Forgo or Delay Care

  • New ACP Position Paper Offers Five Recommendations


Washington, July 13, 2016 — The American College of Physicians (ACP) today said that cost sharing, particularly deductibles, may cause patients to forgo or delay care, including medically necessary services. “The effects are particularly pronounced among those with low incomes and the very sick,” said Nitin S. Damle, MD, MS, FACP, president of ACP.

 “Addressing the Increasing Burden of Health Insurance Cost Sharing,” ACP’s most recent position paper, was released today by the 148,000-member organization.

 “Underinsurance is emerging as a serious problem that may be more difficult to tackle than un-insurance,” Dr. Damle said. “Evidence shows that when cost sharing is imposed, consumers may respond by reducing their use of both necessary and unnecessary care.”

 ACP’s asserts that a different cost-sharing approach is needed to ensure that vulnerable people can afford medically necessary care in the face of rising health coverage costs and stagnant wages. 

 The five recommendations in the paper address ways cost sharing can be made more equitable in the private market by reducing overall health care spending, designing insurance plans that allow access to high-value services, enhancing financial subsidies for marketplace-based insurance plans, improving outreach and health insurance literacy and education, and advocating for updated research on the effects of patient cost sharing. They are:

Helping contain health insurance premiums and cost sharing, the health care system must accelerate its efforts to reduce overall health care spending in ways that do not rely principally on shifting the cost burden onto insured persons who cannot afford to pay more for their medical care.

Encouraging use of high-value health care:

Consider implementing value-based insurance design strategies that reduce or eliminate out-of-pocket contributions for services proven to offer the greatest comparative benefit, with higher cost-sharing for services with less comparative benefit. Such strategies should be based on rigorous comparative effectiveness research by independent and trusted entities that do not have a financial interest in the results of the research. The goal should be to ensure that high-value cost-sharing strategies encourage enrollees to seek items and services proven to be of exceptional quality and effectiveness and not just on the basis of low cost;

Consider implementing income-adjusted cost-sharing approaches that reduce or directly subsidize the expected out-of-pocket contribution of lower-income workers to avoid creating a barrier to their obtaining needed care.

Improving cost-sharing provisions under the Patient Protection and Affordable Care Act.

Working together among stakeholders to enhance health insurance literacy and promote better, more accessible, and objective information about cost-sharing requirements and health insurance plan design.

Implementing a large-scale demonstration to test the short- and long-term effects of cost sharing in different populations.

 “An alternative approach is needed to reduce spending through systemic reform of the health-care sector, protect low-income workers from overly burdensome out-of-pocket costs, enhance subsidies for marketplace Quality Health Programs, increase health care literacy, and direct shoppers to the right type of plan so that patients are shielded from financial ruin and insurance can function as intended,” Dr. Damle concluded. “ACP has provided that today with this position paper.”


The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 148,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on Twitter and Facebook.

Remember, health care spending drives premiums. Cost-sharing lowers premiums and shifts costs from all of the insured population to those actually using health care services. Health care costs are driven by the amount and type of health care received and the unit cost for each service provided. Health insurance premiums must cover the cost (unknown at the beginning) of all services received in a given year. A relatively small percentage of insured people incur the bulk of expenses, thus these people are subsidized by the rest of the insured, some who incur no health care services in a year … and that’s the truth‼️‼️

Categories: Healthcare

1 reply »

  1. I guess I am surprised that internists are so stupid. The internists reconfirm what a Rand study confirmed decades ago – people will forego or delay unnecessary AND necessary care when faced with a requirement to pay some/all of the cost of medical services. Surprise, surprise, surprise. According to your post, the internists recommend five options FOR SOMEONE ELSE TO PAY/SHOULDER THE BURDEN that would address the challenge:
    (1) Reducing overall health care spending,
    (2) Designing insurance plans that allow access to high-value services,
    (3) Enhancing financial subsidies for marketplace-based insurance plans,
    (4) Improving outreach and health insurance literacy and education, and
    (5) Advocating for updated research on the effects of patient cost sharing.

    They need to offer option #6 – a choice among:
    (A) Enrollment in a high cost plan (with undoubtetedly prohibitively expensive premiums and participant point of enrollment costs) with no point of purchase cost sharing,
    (B) A PPO option with a health care flexible spending account with a default funding equal to the anticipated point of purchase cost sharing, or
    (C) A PPO with a qualifying high deductible coupled with a health savings account with a default funding level set equal to the anticipated point of purchase cost sharing.

    I prefer option #6, Alternative (C) and have been in enrolled in that option every year since 2005. An individual enrolled on her date of birth in Option #6, Alternative (C) will, assuming a normal distribution of medical expense over the years, accumulate sufficient monies to cover her out of pocket expenses – whenever they come.

    Remember, monies in a health savings account need not be spent on out of pocket medical expenses – however, you lose the tax preference and may be subject to a penalty tax.

    But, why am I not surprised that the internists want YOU to pay more so that all of their patients will pay less out of pocket – and always be willing to use their service since there is minimal out of pocket cost.


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