To the Editor:

A greater part of the cost of medical care has shifted from insurance companies to the individual patient because of increases in co-pays and deductibles. A consequence of these increases is a change in patient behavior, which is rarely to his or her medical advantage. Below are some examples of how these behaviors have impacted care of hematology patients:

Follow-up physician office visits: A 20-year-old female with sickle cell disease has started on hydroxyurea. She should return for evaluation and blood work in several months but now that her co-pay has risen from $10 to $50, she does not want to come in. She proposes that she be given a prescription for hydroxyurea for 12 months (including refills) and a yearly doctor visit. She will go to the emergency room (ER) with any problems because there is no co-pay if admitted from the ER. Experience has taught us that more frequent patient monitoring can avoid unnecessary and costly hospitalizations, but the patient doesn’t buy it.

Phone calls to physician offices have increased:  Patients, aware of their cost increase, are also aware that phone calls are free. A patient who is in remission from Hodgkin disease presents for evaluation of a new “lump.” Physical exam reveals something palpable and a PET/CT is performed. The results are equivocal. The patient calls for the results, refusing to come back to the office because her co-pay has increased from $10 to $25. The physician is then faced with trying to explain the subtleties of the scan and match them up with the physical findings of the patient. With the patient unable to see the scan and the doctor unable to see the patient, care takes longer than average and is not paid for by anyone.

Less frequent visits to the office for blood work: Patients now are asking that they be given a lab request slip to take to another participating laboratory. The location may not be convenient, but the perception is that the co-pay in the office is higher than the co-pay at the lab. Sometimes this is true, but often it’s not. Unlike many lab “draw stations,” our office staff is trained specifically to maximize the viability of chemotherapy-weakened veins, trying with great care to preserve them and avoid the need for venous access placements. Without this diligence, there is a rise in surgical costs, an increased risk of infections, and patient discomfort, from both a medical and financial standpoint.

Whether or not the change in patient behavior due to increased co-pays and deductibles is an intended consequence, the net result could be a reduced standard of patient care. Hematologists need to help educate both our patients and their insurance companies regarding the danger of the new behavior.

-Thomas A. Bensinger, MD, from Hematology Oncology Consultants, P.A., Greenbelt, MD