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Health Care Costs and Financing

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Studies reveal that patient cost-sharing influences patients' use of cancer screening and emergency department care

A growing number of health plans have adopted patient cost-sharing mechanisms to control use of health care services and costs. Two studies supported by the Agency for Healthcare Research and Quality reveal that cost-sharing does influence patients' use of care.

The first study (AHRQ grant HS10771 and HS10856) found that patient copayments, deductibles, and gatekeeper requirements for specialist referrals reduced men's likelihood of receiving the prostate cancer screening test, a somewhat controversial screening test, but did not influence women's use of mammography to detect breast cancer, a widely accepted screening test. The second study (AHRQ grant HS13902) demonstrated that patients' perceived copayment for emergency care was strongly associated with avoidance of or delays in such care. The two studies are discussed here.

Liang, S., Phillips, K.A., Tye, S., and others (2004, February). "Does patient cost sharing matter? Its impact on recommended versus controversial cancer screening services." American Journal of Managed Care 10(2), pp. 99-107.

The use of copayments, deductibles, and primary care gatekeepers may discourage controversial services, such as prostate cancer screening, but they may not discourage use of recommended and more widely accepted services, such as mammography screening for breast cancer, concludes this study. The investigators used data from the 1996 Medical Expenditure Panel Survey, a nationally representative sample of privately insured individuals, to examine whether there were differential impacts of patient cost-sharing and health plan organizational characteristics on the use of mammography and prostate cancer screening (PCS), after controlling for other factors such as socioeconomic status.

Men in private health plans with a copayment over $10 for an office-based physician visit or with deductibles over $250 were 62 percent less likely to receive PCS than men in plans with no or lower copayments and deductibles. Men in gatekeeper plans, which required a primary care provider referral for PCS, were 52 percent less likely to receive PCS than those without gatekeepers.

Neither higher copayments nor deductibles had a significant influence on whether or not women underwent mammography screening for breast cancer. Furthermore, use of primary care gatekeepers seemed to encourage use of mammography. The impact of cost-sharing on Medicare, Medicaid, and uninsured populations requires further investigation.

Hsu, J., Reed, M., Brand, R., and others (2004, March). "Cost sharing: Patient knowledge and effects on seeking emergency department care." Medical Care 42(3), pp. 290-296.

Patients are less aware of their copayment amounts for emergency department (ED) visits than for physician office visits and prescription drugs. However, perceived copayments for ED care can lead some patients to delay or avoid emergency care, according to this study. Further research is needed to determine whether these responses reflect greater efficiency (care could have been handled effectively elsewhere) or harmful decisions (needed emergency care was not received), note the researchers.

They studied a stratified random sample of 695 adult patients in an integrated delivery system, including many elderly and low-income patients. They asked those surveyed about perceived levels of copayments for ED visits, office visits, and prescription drugs and whether these copayments influenced their decisions to seek care. Only one-third of adults surveyed correctly reported their ED copayment, whereas three-fourths correctly reported their prescription drug and office visit copayments.

Over half (57 percent) of those surveyed underestimated their ED copayment by $20 or more. Perceived copayment level was strongly associated with behavior change. One-fifth (20 percent) of adults who thought their copayment was $20 or higher said they had delayed or avoided emergency care compared with only 6 percent who thought their copayment was less than $20. Among patients who reported having any ED copayment, 11 percent said they either delayed or avoided emergency care.

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