allan brett, journal watch: increased copays disproportionately “dissuade” elders from seeking timely & necessary medical care resulting in more hospitalizations (0127)

Consequences of Increasing Co-Payments for Ambulatory Care
by Allan S. Brett, MD
January 28, 2010

Even small increases in cost-sharing were associated with fewer outpatient visits and more inpatient admissions among elders.

Recently, many health plans have increased co-payments for outpatient visits. Although the rationale presumably is to minimize unnecessary ambulatory care, the strategy could backfire if higher co-payments dissuade patients from obtaining necessary clinical services.

To examine this issue, researchers analyzed data from 36 Medicare managed care plans with nearly one million enrollees. In 18 plans, mean co-payments for outpatient visits increased during the study period (2001–2006), from a mean of US$7 to $14 for primary care visits and from $13 to $22 for specialist visits. In 18 “control” plans, co-payments stayed the same during the study interval.

During the year after outpatient co-payments increased, 20 fewer outpatient visits occurred per 100 enrollees (compared with plans that did not change co-payments). However, annual inpatient admissions increased by 2 per 100 enrollees and inpatient days increased by 13 per 100 enrollees after co-payments increased. Annual outpatient expenditures fell by an estimated $7150 per 100 enrollees, but this savings was negated by inpatient expenditures, which increased by an estimated $24,000 per 100 enrollees annually.

Comment: The authors note that lack of randomized assignment of patients to health plans is a limitation of their analysis. But the findings are worrisome: Even relatively small increases in outpatient co-payments might deter some patients from seeking timely medical attention. In the long run, the result could be poorer health and higher costs — precisely the opposite of what health care reform should accomplish.

Allan S. Brett, MD

Published in Journal Watch General Medicine January 28, 2010


Trivedi AN et al. Increased ambulatory care copayments and hospitalizations among the elderly. N Engl J Med 2010 Jan 28; 362:320.

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