Patients often find out about a high deductible not from their insurer or employer, but from a registrar — and many of these high-dollar accounts go unpaid. Now, multiple recent studies show that people are avoiding care because they cannot pay their high deductibles.

“It is not unusual to hear from patients that they are struggling to afford medications or not taking them as prescribed. As deductibles continue to rise, we’re only going to hear this more,” says Adam Gaffney, MD, MPH, an instructor in medicine at Harvard Medical School.

People with COPD and high-deductible plans were more likely to delay care compared to those with traditional health plans, according to the authors of a recent study.1 Researchers compared 803 people with high-deductible plans to 1,334 people with traditional plans. They fully expected high deductibles to cause nonadherence with medications and greater financial strain. They did find both of these things.

“However, one surprising finding was just how many patients are affected,” says Gaffney, lead author of the study. Most people with high deductibles faced financial hardships despite being employed. They also recorded more ED visits and hospitalizations, something that seems counterintuitive.

Typically, deductibles keep people away from the hospital. “But this may not be the case for chronically ill patients who deteriorate when they don’t take needed controller medications,” Gaffney observes.

When people avoid medical care because they cannot afford the deductibles, they may end up in the hospital because of it. “The current system is simply not working for those with expensive, chronic illnesses like COPD,” Gaffney concludes.

Cancer survivors with high-deductible plans were more likely to delay or avoid care compared to those with traditional plans, according to recent research.2 The authors of a third study found that people with consumer-driven health plans (a type of high-deductible plan) use fewer services than those enrolled in traditional plans.3

“Perhaps most interestingly, this was even the case among those with chronic conditions,” says Bill Johnson, PhD, the study’s lead author and a senior researcher at the Health Care Cost Institute.

Here, three patient access leaders report on how they are addressing the problems caused by high deductibles:

Kaylin Fogarty, director of patient access and financial coordination at Tufts Medical Center, a 415-bed Boston-based academic medical center: The majority of commercial plans we see have a deductible as part of their cost-sharing. Some plans have tiered benefits, with different deductible, copay, and co-insurance amounts, depending on the provider or facility. It can be difficult for patients to understand which tier their provider falls in — and therefore, what their cost-sharing will be.

The best thing we can do to help patients is to communicate their expected out-of-pocket costs. Many patients do not understand their benefits fully. The more we can do to educate them on their plan, the more empowered they will be.

If a patient has a deductible, we offer no-interest payment plans to help manage these costs. Our customer service team will work with the patient to agree upon a monthly amount based on the total outstanding balance.

We reach out to patients to inform them of their expected out-of-pocket costs for certain services, such as surgeries and radiology exams. We hope to expand that proactive outreach to more patients who are receiving less expensive services, but would still benefit from understanding costs preservice.

Financial conversations can be sensitive. We strive to communicate this message so as to educate patients about the impending costs, but not deter them from receiving the care they need.

When patients are able to plan ahead, the hospital is more successful in obtaining payment. Patients are grateful to know the costs prior to receiving the services. Nobody wants to receive an unexpected, surprise bill weeks after receiving healthcare services.

Pamela Carlisle, MHA, FHAM, director of revenue cycle management at Zanesville, OH-based Genesis HealthCare System: We are seeing an increase in retiree benefit plans with high deductibles, as well as small employer plans. High deductibles are often hidden from the patients. They do not understand the changes that have occurred with their specific plan.

We have found that it is critical to have conversations with the patient prior to their service date. We not only work with the patient, we conference in the employer so everyone can remain on the same page and we all understand the cost moving forward. This allows the patient to ask pointed questions to the employer, keeping the provider out of the discussion.

We have found that truly reviewing the details with the patient has been essential. It is not just giving them a number. We explain how we got to that number, and how we can help them satisfy their portion. We have, in turn, seen an increase in employee payroll deductions and payment plan options.

Timing is everything. Obviously, it is best to do all the prework, but there are many situations where that cannot occur — ED visits, walk-ins, and add-on procedures.

We pride ourselves in timely follow-up for financial screening. Early on, we identify patients who need follow-up calls. We then make every effort to ensure we provide them with the tools needed to take care of their financial commitment. It could be a phone call post-appointment or speaking to an approved family member on the day of service.

We start by saying, “We want to review the details of your insurance plan with you. Your insurance has confirmed that, through your employer, these are the benefits assigned.”

As providers, we are processors of information. We do not determine the factors involved in benefits. But that is a hard concept for our patients to understand. It is our role to assist them with understanding their plan benefits, the cost of the procedure and their out of pocket, and to be able to identify any finance assistance that can be provided. As the revenue cycle, we take care of the financial health of the patient.

Julie Johnson, CHAM, FHAM, director of health information management and patient access at Mount Graham Regional Medical Center, a 49-bed acute care hospital in Safford, AZ: We are seeing an increase of outstanding balances that go to bad debt. Most patients are unable to pay the high deductibles. They will always owe the full amount when obtaining exams such as ultrasound or MRI.

The cost of the test is often less than the deductible. A patient may come in toward the end of the year, and owes $3,000 on their deductible. The price of an MRI could be $2,100. All of that would go to the deductible, and they would be responsible for payment.

This is why we offer the choice of a self-pay radiology discount. We do inform patients that with this option, it does not go toward their deductible. Instead of paying $2,100 for the MRI, the patient elects to pay the cash price, which is much less. The service is not submitted to insurance, saving them money.

Most patients want to be informed about the price prior to receiving services. Staff preregister scheduled patients, give estimates, and inform the patients of the different options available to them. All staff are knowledgeable on discount policies and our charity care program, and promote them to patients.

Some ask for discounts or cash pricing. They state, “We can’t afford this,” and ask if we will accept 50%. These requests go to the vice president and CFO for approval. We do have five insurances that do not allow discounts for their insured.

Our financial counselor is now located right in the patient access department. Previously, her office was in a building behind the hospital. To make payment arrangements or apply for charity or other programs, the patient would have to walk out of the hospital to their car and drive around to the back of the hospital.

We moved the financial counselor to the front end. She is now steps away from any registration area. At the same time, we moved our inpatient authorization employee to the patient accounting office, where they work closely with the billing personnel. This musical chairs approach has worked well for us. We assure the patient that we are willing to work with them. We show compassion and empathy, yet we are consistent and enforce the policies we have in place.


  1. Gaffney A, White A, Hawks L, et al. High-deductible health plans and healthcare access, use, and financial strain in those with COPD. Ann Am Thorac Soc 2020;17:49-56.
  2. Zheng Z, Jemal A, Banegas MP, et al. High-deductible health plans and cancer survivorship: What is the association with access to care and hospital emergency department use? J Oncol Pract 2019;15:e957-e968.
  3. Johnson W, Milewski A. Lower health care spending and use for people with chronic conditions in consumer-directed health plans. Health Care Cost Institute Brief; May 2019. Available at: Accessed Jan. 27, 2020.