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In this episode, we sit down with Shirin Hund, an internal medicine physician, to explore the impact of high-deductible health plans on individuals with chronic medical conditions like diabetes. Shirin discusses the financial barriers these patients face, the consequences for medication adherence and health outcomes, and the need for legislative changes to improve access to essential care.

Shirin Hund is an internal medicine physician.

She discusses the KevinMD article, “High-deductible health plans: a barrier to care for chronic conditions.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Shirin Hund. She’s an internal medicine physician. Today’s KevinMD article is “High-deductible health plans: a barrier to care for chronic conditions.” Shirin, welcome to the show.

Shirin Hund: Thank you for having me, Kevin.

Kevin Pho: So I know you’re joining us from Switzerland. Just briefly share your story and journey to where you are today.

Shirin Hund: Absolutely. So I’m originally from the US, and right now I’m a practicing doctor in Switzerland. I’m from Connecticut. I studied literature in college but married my love of writing, of narrative, with my love of medicine. I went to medical school at the University of Connecticut and trained at Cambridge Health Alliance in internal medicine.

And after that my husband got a job in Switzerland, so he persuaded me to make this big journey after my residency was complete. And I’ve had the pleasure and challenge of learning how to practice in a different country in a different language.

Kevin Pho: So tell me, what are the main differences between practicing in Switzerland versus the United States?

Shirin Hund: I think for me the biggest shock was actually the understanding of what an attending physician’s role is. Because in the US, when one is finished with their residency and is licensed, you are independent. You’re not presenting your plan to anyone. You always have backup, you always have your mentors or your chief if you want to discuss something, but you’re on your own.

And what I was surprised by here is, in Europe there’s more of a hierarchical structure with the way medicine is practiced. So even a doctor who is finished with their training still has a responsibility to present their patient and their plan to the doctors that are above them in this hierarchy. And it’s meant to be in a collaborative environment, that one learns from the expertise of their chief, that one can have this dialogue back and forth. But of course, for me coming from the US, I was very surprised at this.

Kevin Pho: All right, so today we’re going to talk about high deductible health plans, which is very common in a lot of American health insurance plans. Your KevinMD article is titled “High-deductible health plans: a barrier to care for chronic conditions.” Now, for those who didn’t get a chance to read your article, tell us what it’s about.

Shirin Hund: Absolutely. So this article is actually the response to a study that my colleagues and my resident and I published.

So I did my residency at Cambridge Health Alliance, which is a Harvard teaching hospital but very much focused on the foundation of social justice. And in my third year of residency I had the privilege of participating in a course which we call the advocacy course. And our task as a cohort was actually to look at a matter of social justice, publish an original study on it, and then learn how to take the results of that study to the mainstream media through a press release and through an opinion editorial.

And I found that to be a wonderful exercise in how we translate science to voice. This is where that article comes from. And our study was actually published in the Journal of General Internal Medicine, and I was responsible for publishing the op-ed, which was graciously accepted by you.

Kevin Pho: All right, tell us what the study is.

Shirin Hund: Yes. So the study is quite interesting. For those of you in the audience who may not know what high deductible health plans are, it’s very, very common in the US, and it’s quite deceiving what that entails for the patient.

A lot of patients, especially those of lower socioeconomic means, choose to enroll in high deductible health care plans because they have a lower monthly premium. But what they don’t realize is that at the end of the year they are responsible for a much, much higher out-of-pocket cost, the average being $7,000. This is quite an enormous cost for someone that might be just scraping by.

And what we found was, we wanted to look at how patients with chronic conditions who are enrolled in these high deductible health care plans, how they take their medicines compared to those in more traditional health care plans. And not surprisingly, we found that patients who are taking medicines for diabetes have a much higher cost related nonadherence to their medications. And of course with diabetes, the consequences of not taking your medicine as prescribed has tremendous mortality and morbidity.

And we were very pleased that this was accepted in the Journal of General Internal Medicine, it was published in 2022. And then we wanted to learn how to take that message to the public, because this is actually a message that serves our patient at the greatest. It doesn’t serve anyone by just staying in the journal’s pages and not being understood by the patient.

Kevin Pho: So give us a sense, you don’t have to give us exact numbers, but in terms of medication nonadherence, how much of a difference did high deductible health insurance make?

Shirin Hund: So the numbers were that 20 percent of those enrolled in high deductible health care plans had cost related non-adherence, compared with 16 percent in a standard health care plan. And with patients taking insulin, 25 percent were unable to afford their medication, and they had a 31 percent higher rate of missing their medicines.

Kevin Pho: And when you saw these patients, say at the Cambridge Health Alliance, did they just simply say that they couldn’t afford their medications because of the out-of-pocket cost?

Shirin Hund: Yes. And I don’t think that they realized what the consequences of enrolling in these plans were. I don’t think that all of them realized this was the link. I never heard a patient come to me and say, I skipped my medicine because I couldn’t afford it because I’m enrolled in this plan.

Kevin Pho: I think that gives us a greater mission to educate the patient on what the choice of their insurance means for their health, and the decisions that they’re forced to make. Because I’m sure a lot of patients, when they browse through the list of plans, a lot of them are just going to pick the one with the lowest monthly premium, right?

Shirin Hund: Exactly, exactly. That’s the whole point. And one doesn’t think, what does that mean at the end of the year? Especially when one has to submit their receipts to the insurance, one doesn’t know what other hospitalization bills might come up, especially for those suffering from conditions.

Kevin Pho: Now, did you just look at diabetes, did you look at, say, blood pressure or other chronic conditions as well?

Shirin Hund: Our study was specifically focused on diabetes. We wanted to limit it to that population. It was done with 7,000 adults from the National Health Interview Survey. So if we wanted to do more comorbidities, more diseases, it would have been a much, much bigger study.

But we did see ties with similar themes, for example with patients with asthma, patients with high blood pressure. And there were also many articles written on this subject in the times of COVID, and the changes that Congress made in response to patients not receiving care, not being able to afford care in the COVID times.

Kevin Pho: Now, high deductible health plans can be a fit for a subset of patients. Now, for those patients who are listening to you here and they’re browsing through the choices that they have, tell us what kind of questions they should ask themselves in order to choose whether a high deductible health plan is right for them or not.

Shirin Hund: I would be very introspective, and I would say, how many times do I go to the doctor, how many times have I been hospitalized, how many comorbidities, other conditions, do I have that might warrant a trip to the emergency room or hospitalization?

These high deductible health care plans could very well be a great option for a young person who perhaps goes to see their health care provider once a year and never has any other reason to go to the doctor, the hospital. But for this subset of patients it really, really is detrimental to their financial health and ultimately their own physical and mental health.

Kevin Pho: Now, from a policy standpoint, just tell us broadly, why are high deductible health plans a thing? Why are they so popular?

Shirin Hund: Exactly for the reason you said, because in the US we have employment health care plans, and most of us, myself included, we skim through and we look at what will cost us the least each month, and that’s the most enticing.

But one doesn’t generally think, how does this accumulate over the course of a year, how does my health evolve over the course of a year, what is my status with my health currently? They don’t ask you this when you’re choosing your health plans when you start a new job.

Kevin Pho: And again, from a policy standpoint, is there any movement to perhaps limiting these high deductible health plans, precisely because of the out-of-pocket expenses that people with chronic conditions may face?

Shirin Hund: That I’m not currently aware of. What we did find was that, in response to the cost related non-adherence, the pharmaceutical companies are making measures to put cost restrictions on insulin, and that has been a positive step in the right direction. But in terms of actions from the insurance companies, to my knowledge we’ve not seen that step.

Kevin Pho: How about the role of the physician? Is there a role for clinicians in the exam room to educate patients when it comes to choosing a health insurance plan, and working with patients to see what the right plan for them is?

Shirin Hund: Absolutely. And that was my biggest learning point from writing the article that was published on your website. I found myself thinking, if I truly didn’t understand the implications of what my insurance plan means for me and my health, how can I expect my patient to?

And when we all ask our patients, how often do you take your medicines, are you taking it correctly, and then we put that label on them, non-compliant, what does that mean? Are they non-compliant because they don’t understand how to take the medicine, or are they non-compliant because of an external factor that’s limiting their ability to afford that medicine? These are two entirely different subjects, and we have an obligation to broach that subject with them.

The same way that, in an ideal consultation, we discuss, where do you get your food, are you living in a food desert, or are you going to a bodega, are you eating from a farm? It’s the same principle. But it’s not one that the current restrictions of our consultation time allow, and it’s also not something that we have as much education on, I hate to say.

Kevin Pho: Now, tell us the response to both your study and the article. What are some of the spectrum of responses you received?

Shirin Hund: I think it was very positive. What I really enjoyed working with my colleagues from Cambridge on was that we had the privilege of working with people that are incredibly involved in the policy space.

Dr. Adam Gaffney, who was also listed on the study, he was the former president for Physicians for a National Health Program. Dr. Gaurab Basu, Dr. Danny McCormick, these are leaders of the Health Equity course at Harvard Medical School. And I credit them with teaching us how to broach topics of social justice within the framework of medicine.

And I believe that the people who read the study are now greater educated and empowered to advocate for their patients in a different way than perhaps we’ve been trained.

Kevin Pho: When you say physicians should advocate for, for instance, lower drug costs, what are some ways they can do that?

Shirin Hund: A great question. So this is exactly what our teachers at the advocacy and equity course at Cambridge Health Alliance taught us.

We learned so much about community organizing, how to frame a narrative behind the mission you are trying to achieve, whether that’s the power of your written voice. So an example is learning how to write an op-ed, learning which newspapers or media outlets might be the greatest avenue for you to share your mission, ranging to having a fundraiser or a community event.

What we also found was how to lobby Congress itself. How does a physician go about writing a bill? How does a physician go about raising awareness for a change in reform? And these were all things that we had the privilege of learning, and I really wish more residencies considered this role as important as all the other things we have to learn in medicine.

Kevin Pho: We’re talking to Shirin Hund. She’s an internal medicine physician. Today’s KevinMD article is “High-deductible health plans: a barrier to care for chronic conditions.” So let’s end off with sharing your take-home messages to the KevinMD audience.

Shirin Hund: My ask of everyone who has read my article and who is listening to me today is to think of yourself not just as the physician in the room talking to one person, but a physician who has a voice, that has agency to affect many voices.

And I think all of us, myself included, sometimes we get a little bit exhausted or burnt out by the administrative, logistical hassles of practicing medicine in its current age. But if there’s a topic that you feel strongly about, something that raises a fire inside of you, whether it’s a food desert, whether it’s health literacy, whether it’s prison reform, whether it’s insurance plans, I would ask my audience to really educate yourself on that topic and see, how does my agency as a physician move that topic forward, and how can I teach a greater population about that topic?

I think by thinking of ourselves not just as a practicing physician but as a teacher, as an advocate in the community, as a quasi parent figure, we have a moral obligation to the people that we serve, to not just treat high blood pressure or diabetes but think, how do all the aspects of their life and their community affect their general health?

Kevin Pho: Shirin, thank you so much for sharing your time and insight, and thanks for coming on the show.

Shirin Hund: Thank you for having me.