Making Patients Pay won’t make the System more Affordable
Some people think that charging patients when they use the health system would help control health care costs and ensure that people were getting the care they need and not overusing the system. Others believe that user fees would bring in much-needed revenue.
Research to date suggests user charges for patients discourage patients from seeking both necessary and unnecessary care. When preventive care is discouraged and effective drug prescriptions are not filled, user charges can promote higher costs and poorer health.
But this doesn’t mean that money is saved. Nature abhors a vacuum, and the health care system detests unused capacity. As a result, any beds or doctors freed up because the sick are discouraged by charges, end up being used by the healthy for care they may not need.
Some claim that user fees are benign because they discourage only frivolous use. However, a US study involving fairly healthy adults showed that user fees led to a 20 per cent increase in risk of death for people with high blood pressure because they were less likely to see a doctor and get their blood pressure under control.1 The same study showed that user fees were just as likely to discourage appropriate care as inappropriate care.2
And, that’s a big problem with user fees. The average person doesn’t know whether their symptom warrants medical attention. When a child has a fever, most parents don’t know whether it’s the flu or the onset of meningitis. Do we really want them to make the decision about whether to seek health care on the basis of whether that will leave enough money to pay the rent?
The scientific evidence supporting publicly financed care is long and strong. So why do discredited ideas like user fees keep coming back? Dr. Bob Evans and his colleagues have repeatedly examined this issue and refer to user fees and related ideas as “zombies.”3 That’s because they have been killed off repeatedly by the scientific evidence, but, just like zombies, they keep bouncing back to life to wreak havoc with our public policy.
1. Brook RH, Ware JE, Rogers WH, et al. Does free care improve adults’ health? New England Journal of Medicine, 1983;309:1426–1434.
2. Siu AL, Sonnenberg FA, Manning WG, et al. Inappropriate use of hospitals in a randomized trial of health insurance plans, New England Journal of Medicine, 1986;315:1259–1266; Foxman B, Valdez RB, Lohr KN, et al., The effect of cost sharing on the use of antibiotics in ambulatory care: results from a population-based randomized controlled trial, Journal of Chronic Diseases, 1987;40:429–437.
3. Evans RG, Barer ML, Stoddart GL. User fees for health care: why a bad idea keeps coming back, Canadian Journal on Aging, 1995;360:360–390.