II recently suggested to my patient Judy, "Why don't I see you again in six weeks? That way we can follow up on your diabetes and see how the new medication is working."

"How about four months?" she said. "I can't keep paying these $15 co-payments, $8 for parking, and taking time off from work."

My response should have been that I really need to see if the medicines are working and 16 weeks is just too long to wait. I suggested we compromise on 10 weeks; when she would have none of it, I suggested 12 weeks.

Nope, she said. No negotiations possible.

As health insurance premiums increase, people seem less willing to spend money out of pocket for any health care they feel isn't an emergency. Not surprisingly, this is exactly what the most famous of all health insurance studies – the Rand Insurance Study – showed.

As premiums increase, people go without non-urgent medical care, which often results in worse health outcomes (and more expensive care) over the long term.

The U.S. Bureau of Labor Statistics recently reported that on average, Americans spent $3,157 overall out of pocket on medical expenses in 2010, including $1,831 on insurance and $722 on medical services. That's an increase of nearly 3 percent.

Part of this is due to an additional 1 million people who now have no health insurance. Another part is due to people having higher deductibles, which means they need to shoulder all their health care costs until they reach some limit – often $2,500. In 2010 about 20 percent of Americans had a deductible above $1,000.

But even those of us with insurance are paying more for coverage, and in some cases the co-payment is increasing as a way for the insurance companies to decrease doctor visits. This really is penny-wise but pound-foolish.

Less than three weeks after I saw Judy, she went to the emergency department feeling tired, and concerned about stomach problems – all symptoms likely related to her new medication. That visit cost her insurance $650. My cost would have been one-tenth of that – even if you add in the co-payment.

Consumer Reports says that nearly half of prescription drug users put off visiting the doctor, decline obtaining lab tests or order their medicines from outside the United States because of increased costs.

As a result of all this decreased consumer spending, health insurance companies report paying out less for health care. Who wants to bet that that will translate into lower health care premiums any time in the foreseeable future?

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Michael Wilkes, M.D., is a professor of medicine at the University of California, Davis. Identifying characteristics of patients mentioned in his column are changed to protect their confidentiality. Reach him at drwilkes@sacbee.com.

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