Joseph Heller’s 1961 satirical novel Catch-22 pulls us into the life of Captain John Yossarian, a U.S. Army Air Force bombardier in World War II. The plot wheels around the frustrating experiences of Yossarian and his fellow airmen as they try to complete their service and get home from the war alive. The “Catch-22” refers to a regulation that airmen deemed mentally unfit to fly are not required to go on missions, but anyone who claims a lack of fitness in order to avoid a mission is considered rational – and therefore fit to fly.
Mounting evidence shows there’s a new Catch-22 in health care. A growing trend in health insurance is “consumer-directed” health plans, which often link high deductible coverage with a health saving account or other health reimbursement arrangement. The idea behind these high deductible health plans (HDHPs) is that such plans ensure that consumers have “skin in the game” by requiring them to pay for a significant portion of their care so that they will make better and more informed choices.
There is enormous growth in the use of this type of plan. A Health Affairs blog published in October 20151 notes that the proportion of all workers enrolled in HDHPs increased from 8 percent in 2009 to 24 percent in 2015. While employers offering this type of plan did initially experience reduced health care costs, the blog also highlighted some very concerning statistics. Average out-of-pocket costs per worker more than doubled between 2006 and 2015, and one in five people avoided preventive care due to cost concerns2.
Here’s the Catch-22. When these findings are paired with recent information from the Agency for Healthcare Research and Quality (AHRQ) that states “only 12 percent of U.S. adults have the health literacy skills needed to manage the demands of our complex health care system, and even these individuals' ability to absorb and use health information can be compromised by stress or illness,”3 we find the fundamental illogic to this type of approach. Restating AHRQ’s findings in a slightly simpler way, even the small proportion of people with the capacity to make informed choices about their care may lose that ability when their health is severely compromised. Joseph Heller would be proud.
A recent working paper describing a large employer’s transition to a high deductible plan found that even their select group of highly educated, well compensated employees reduced their health care spending by getting fewer health care services across the board, including avoiding high-value, preventive services, rather than by selectively avoiding care with less value4.
In fact, even medical professionals often don’t have the tools they need to make the kind of informed decisions for themselves that these plans hope to elicit. A physician friend who works for a small organization with a HDHP recently told of trying to choose a provider for a recommended screening procedure that has some risks associated with it. When she asked her own doctor where to go to ensure the best cost and quality value with the least risk of unintended side effects like an infection, her doctor couldn’t provide an answer. My friend then used every publicly available tool to get her questions answered but was unable to find the information she needed.
It’s unlikely that the movement toward HDHPs is going to slow down anytime soon, but there are some ways to tackle the challenges they present. There are tools that can help patients so that they’re not asked to understand information that is too complicated, make decisions they are ill-equipped to make, or struggle to find data about cost and quality that will help them to make informed choices. AHRQ’s newly updated “ Health Literacy Universal Precautions Toolkit ” provides guidance to health care practices so that they can simplify communications and improve patient understanding, make office environments and the health care system easier to navigate, and support patients’ efforts toward health improvement. Cost and quality data are made available through tools such as the Maine Health Management Coalition’s Get Better Maine website and the Maine Health Data Organization’s Compare Maine website. None of these tools is perfect (as shown by my friend’s experience), but they are big steps in the right direction. Patients and providers will need to work together even more closely in the future to be sure that everyone has the information needed to make good decisions.
Let’s not perpetuate the Catch-22 when people’s health and lives are at stake.
2 For Maine-specific information about premiums and deductibles, go to the Maine Health Management Coalition’s website and look under the Member Resources tab for the MHMC Healthcare Data Book Supplement.
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