Further adventures in cost-sharing: An addendum via email

This post is jointly authored by Austin and Aaron.

The two of us puzzled over the findings of the paper on Mayo Clinic cost-sharing Aaron posted on earlier this morning. (Go read that post first, if you haven’t already.) We exchanged emails trying to get at why primary care visits were not responsive to a decrease in cost sharing, but specialist visits and imaging utilization were responsive to an increase in cost sharing. Here are lightly edited excerpts from our exchange:

Aaron:  I think it’s that people WANT to see specialists. They see an immediate good in it. They get a drug, or a test, or the feeling of solving a problem.

With primary care, there’s no immediate return. You may hear something you weren’t looking for. They may tell you to lose weight or exercise or stop smoking. If you’re healthy, there’s no immediate return. So you don’t WANT it. Making it cheaper may not matter.

Austin: That suggests something more though. Making primary care visits free at the point of service may not be enough. Maybe one has to pay people to do it. In fact, that’s essentially what the gatekeeper functions of HMOs do. They provide an additional incentive (payment, though not in dollars) to see the PC doc. You need it for the referral!

Retail clinics can also reduce the cost (in time, if not in dollars). The time factor may be relevant to a lot of folks.

Bottom line: There must be reasons why, according to the Mayo cost-sharing study, people don’t increase primary care visits when copays go down but they do decrease specialty use when copays go up. Understanding those reasons is crucial for building on the study and applying the results for policy. If primary care visits are important and if people are not receiving enough primary care, then the study suggests we need to do more than just lower copays. We may actually have to pay for people to use more primary care. That payment need not be in dollars. Other incentives may work too.

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