The problem of care avoidance

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Care avoidance can increase mortality rates.

That’s not meant to be shocking or scary. But it’s a fact. People routinely avoid care in the U.S. and that has real consequences. According to Surest Chief Health Officer Marcus Thygeson, "Prior to the implementation of the Affordable Care Act (ACA), at least 300,000 Americans died every year because of complications of not getting health care. So, care avoidance is a problem."

Care avoidance remains a big, widespread problem. While the ACA has improved access to healthcare, care avoidance is still a factor in tens of thousands of deaths every year—not to mention unnecessary complications to illnesses that could be averted with earlier care. According to a 2018 study commissioned by CarePayment, two-thirds of Americans delayed or avoided seeking medical attention during the previous 12 months.

People may avoid care at all points along the development of a disease. They avoid preventive care. They avoid the doctor even after they notice symptoms. In one study, according to the National Institute for Health (NIH), 17% of patients diagnosed with rectal tumors delayed seeking care for a year or more, even after they noticed symptoms. Some delayed seeking care for five years!

Once they’re diagnosed, people avoid follow-up visits to manage chronic disease. They avoid taking medications, or they take half-doses or take a dose half as often to make a prescription last twice as long.

Research and reasons

Why? Research indicates that people avoid health care for all kinds of reasons. Some don’t like the hospital or the clinic. They don’t like dealing with health care organizations or they had negative experiences with their health insurance company. Some people don’t like to hear bad news, even if they suspect it’s coming.

Many people avoid care because they may not like the interaction they have with their doctors. That NIH study found that, outside of traditional barriers like lack of health insurance and high costs, the biggest reason for avoiding care was interpersonal problems with the doctor.

So, people downplay symptoms they’re experiencing, telling themselves it’s not that bad. It’s not the kind of bad you need to see a doctor for. Or they couldn’t get an appointment until weeks after they were sick. Or they feel like certain conditions are embarrassing. Or they’re afraid of needles. They’re too busy, or it’s too hard to get to the doctor’s office, or they can’t afford to take time off work.

These are some of the ways and whys that people avoid seeing their health care providers.

And, of course, there’s the big one: medical bills.

Care avoidance and medical debt

A 2020 Gallup poll found that 33% of Americans avoided medical care because of cost. That’s a 50% increase since Gallup started asking the question in 2001.

A fundamental driver of care avoidance is the access to affordable care—or lack thereof. And that starts with access to some kind of health insurance coverage.

Prior to the enactment of the Affordable Care Act, about 50,000 people died every year as a result of not having health insurance. - Dr. Marcus Thygeson, Surest Chief Health Officer

That number may be lower now, but it’s still in the tens of thousands, because even with the ACA in place, studies have found that inadequate health insurance, high co-pays and out-of-pocket costs like high-deductibles remain strong deterrents to seeking care. That’s true for people with private insurance, as well. Research indicates that people with private insurance plans through their employers routinely delay or avoid care due to high medical bills.

In 2019, research indicated that 137 million Americans faced financial hardship because of medical bills. Another study found that 66% of personal bankruptcies in the US were related to medical debt.

The role of health insurance

But soaring medical bills and the specter of crushing medical debt are not the only factors in play. Even when people have access to coverage, the complexity of the health insurance industry creates a great deal of confusion. In one study, over a third of the people surveyed who had health insurance did not know their plan covered the entire cost of an annual check-up, a cornerstone of disease prevention.

Insurance plans with deductibles can add to the opacity when it comes to knowing how far into the deductible amount a member is. Surest Chief Clinical Officer Tara Bishop says many insurance plans, particularly those with high deductibles and co-pays, are not solving many problems.

"If someone has a plan with a deductible of $5,000, every visit they have is essentially not covered by insurance until they hit that $5,000. You can imagine people do not want to see the doctor because it’s all out-of-pocket cost to them," Bishop says. "They’re behaving the same as people who don’t have insurance. Part of the reason I joined Surest is to address these perverse incentives that happen with high deductible plans." (Surest health plans have no deductibles.)

Prevention and chronic disease

The irony of avoiding care because of cost is that care avoidance generates more cost. Without the prevention piece, the risk of disease increases. If you don’t catch developing issues early, they worsen, which eliminates a lot of the treatment options that could have stemmed or limited the course of the disease. Disease prevention is almost always less expensive than treatment of a worsening condition.

Managing chronic disease also depends on routine scheduled interaction with caregivers. Avoiding care allows complications to arise. "Diabetes is the perfect example," Bishop says. "If we can manage blood sugar levels in someone with chronic diabetes, we can avoid blindness or amputation of a limb—plus the addition of more debt from those complications."

Thygeson also pointed to the Surest model as means of addressing care avoidance. “As we get people access to the right tools—whether that’s technology or telemedicine or just clearer information or lower cost barriers—we’re helping them understand how to manage their disease and reduce their burden of care.