November 15, 2019

Your Money Adviser: When Health Deductibles Rise, Men Delay Emergency Care

Frank Wharam, a doctor and researcher at Harvard Medical School, says he often hears these words, “My wife made me come.”

That gender dynamic may provide fodder for stand-up comics, but it can have serious health implications, especially given the increasing use of high-deductible health insurance plans.

Men, it turns out, are more likely to delay treatment for serious conditions under high-deductible plans, in contrast to women, who tend to be more selective and cut back care for minor ailments only.

That’s according to a recent study led by Katy Kozhimannil, a researcher at the University of Minnesota’s school of public health. (Dr. Wharam was a co-author.)

Such plans generally have lower monthly premiums than traditional health plans but higher out-of-pocket costs — sometimes, $4,000 or $5,000 for a family, or even higher. About a third of workers now have such plans. And that number is likely to grow, since lower-cost plans on the new health care marketplaces created by the Affordable Care Act are likely to have relatively high deductibles.

Other studies have shown that low-income people also tend to put off care under such plans. But Ms. Kozhimannil says her study is the first to examine the different impact of such plans on men and women.

The study compared emergency room visits for about 12,000 people — roughly half men and half women — for a year before, and two years after, they were involuntarily switched by their employers to a high-deductible plan.

For the first year after the switch, men’s use of the E.R. dropped across the board, even for severe conditions, like irregular heartbeat. Women cut back too, but mostly for less threatening symptoms, like headache or sore throats.

“It’s concerning that men were not going to the E.R.” for ailments like kidney stones and irregular heartbeats, Ms. Kozhimannil said. “That’s an urgent situation that requires medical care.”

Unfortunately, men also ended up with more hospitalizations in subsequent years, suggesting that they may have let a serious condition go untreated.

So, what is behind this approach? Other findings have suggested that “masculinity beliefs” make it harder for men to ask for help, Ms. Kozhimannil said, so the added worry of spending more on health care may reinforce that tendency.

Jim Kiefert, who runs an “Us Too” prostate cancer support group in Olympia, Wash., said men often worry that spending on their own care may lead to economic hardship for their families. “That is a reality with men,” he said, adding that with a costly illness and a high deductible, “You can deplete your savings in a very short period of time.”

Here are some questions to consider, if you’re a man on a high-deductible plan — or that man’s spouse.

How can I use my high-deductible plan wisely?

Understand your benefits. Not all high-deductible plans are the same, and many cover preventive care outside of the deductible. Under the Affordable Care Act, all plans sold on the new marketplaces and many others must offer many preventive services free, like colorectal cancer screenings.

How should I decide when to seek treatment?

No one expects you to be a physician, but health plans increasingly offer sound online information that can help you learn about symptoms of serious situations, like a heart attack. “It’s very useful to know what your risk factors are,” said Ms. Kozhimannil said. Most health plans also have nurse advice lines that can offer guidance, too.

What if I need care, but I’m worried I can’t pay for it?

Talk about this with your doctor, who might not know what cost burden you’re facing when you make decisions about proposed treatments. “Say to your doctor, ‘I have a high-deductible plan. Is there a different way to do this?’ ” suggests Alison Galbraith, a doctor at the Harvard Pilgrim Healthcare Institute who has studied the plans.

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Failure Rate of All-Metal Hips Is Increasing, Study Says

In a troubling development for people with all-metal artificial hips, a registry that tracks orthopedic implants in Britain reported on Thursday that the failure rate of the devices was increasing.

The National Joint Registry for England and Wales said that an all-metal artificial hip once sold by Johnson Johnson had failed in an estimated one-third of the patients who had been followed for the longest time. The device was recalled by the company last year.

The British registry also found that the early failure rate of some other “metal-on-metal” hips — ones in which both the ball and the socket components of an artificial joint are made of metal — was significantly higher than for those made from other materials, including a combination of metal and plastic.

While the patients tracked by the British registry are not in the United States, doctors and patients here pay close attention to the registry’s findings because no such body exists in this country, where there is far greater use of artificial hips and knees. Australia also keeps a registry.

There was already heightened concern in the United States about the all-metal hips. In the first six months of this year, the Food and Drug Administration received more reports about problems with the all-metal hips than it had in the previous four years combined, according to an analysis by The New York Times. In May, the F.D.A. took the unusual step of ordering producers of the devices to study how frequently they were failing and to examine the health implications for patients.

While traditional artificial hips typically last 15 years or more before they need to replaced, some of the all-metal models are failing in large numbers of patients within just a few years. Early failure rates for all-metal devices were far higher in women than in men, the British report found.

According to the report, the highest failure rates involved the Johnson Johnson device, which is known as the Articular Surface Replacement, or the A.S.R. The registry is following about 2,100 patients who received a version of the device that is used as a traditional hip implant. That is also how the A.S.R. was used in this country.

Of those patients in the British group who received the device six years ago, about 29 percent have since had it replaced.

The percentage is slightly lower, about 17 percent, in patients who got the device five years ago, but that number could rise over the next year.

Asked for a comment about the report, Lorie Gawreluk, a spokeswoman for DePuy, the division of Johnson Johnson that made the device, said in an e-mail that the six-year replacement rate “should be interpreted with caution because it is based on a small number of cases.”

DePuy officials recalled the A.S.R. last year around the time that the previous report of the British registry was released.

Along with a traditional hip model, another version of the device was sold outside this country for use in an alternative hip replacement technique known as “resurfacing.” It was also recalled.

While it is difficult to draw direct comparisons between device failure rates in Britain and in the United States, the new registry findings appear to bode ill for patients here who received an A.S.R. About 40,000 of the 90,000 units sold worldwide were used in this country.

The British data suggests that complaints will continue to grow in the United States in coming years because the A.S.R. was used overseas before its adoption here.

The British data also shows that the failure rate for all-metal devices as a group, even when the A.S.R. is excluded, is accelerating faster than for traditional hip replacements.

Though immediate problems with the hip implants are not life-threatening, some patients have suffered crippling injuries caused by tiny particles of cobalt and chromium that were shed by the metal devices as they wore.

Such debris generation is also believed to be a cause of earlier device failure.

Until a recent sharp decline in their use, all-metal hip implants accounted for nearly one-third of the estimated 250,000 replacements performed in this country each year. According to one estimate, some 500,000 patients in this country have received an all-metal replacement hip.

In the case of devices used for hip resurfacing, which is popular among younger patients, a model known as the Birmingham Hip Resurfacing device had the lowest replacement rate at five years, the registry found.

However, the report noted that further studies needed to be performed to determine whether hip resurfacing conferred true advantages over standard hip replacement.

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