Faced with health plans that pay for less and less, more people who have insurance are beginning to act like those who don't -- skipping doctor's visits, putting up with chronic problems and hoping for the best.

A survey last month by the Deloitte Center for Health Solutions found that a quarter of the people who responded had skipped seeing the doctor as a result of economic uncertainty and higher out-of-pocket costs. About one in eight said they'd significantly reduced their health care spending.

"We've been living in a dream world, assuming this is somehow different from managing other aspects of our lives," said Dr. Lee Beecher, a St. Louis Park psychiatrist and president of the Minnesota Physician-Patient Alliance. "In economic hard times, people are pulling in their belts."

The trend is fattening the profits of health insurers. They set premiums this year on the theory that Americans who put off care during the worst of the recession would return to more normal patterns. But increased deductibles and other insurance provisions that require people to sometimes still pay thousands for procedures is depressing the use of medical services.

So the premiums still come in, but insurers have less medical care to pay for than they anticipated.

In the first quarter of the year, Blue Cross Blue Shield's system of 33 nonprofit insurers reported its highest profit margin since 2005. Analyst Carl McDonald of Citi Investments called the 4.8 percent margin an "unexpected windfall."

In Minnesota, where the nonprofit insurance plans are national leaders in keeping administrative costs low, both operating margins and reserves are up.

Holding out

With deductibles often ranging from $500 to $5,000 and a still-fragile economic recovery, people are often putting off care for anything they can.

"What you see in the office is the struggle that the patients have trying to figure out how to deal with their deductibles," Beecher said. He said that for a majority of people, their psychiatric issues are under control by the 10th session, just about the time patients have spent their deductibles and insurance kicks in.

Doug Fryer's doctor has been telling him for the past five years to buy an insulin pump to monitor his diabetes. But Fryer, who lives in Red Wing, says buying one doesn't make sense under his wife's insurance plan.

Fryer and his wife must meet a $6,000 deductible. After that, their insurance company pays 80 percent and they pay 20 percent of health expenses until they reach a $13,000 out-of-pocket maximum.

"It would benefit my health, but not enough to make that kind of investment," Fryer said.

Dr. David Holte, an orthopedic spine surgeon and president of Twin Cities Orthopedics, said people continue to postpone elective procedures until later in the year in the hope that by then they will have met their deductibles. His practice of 80 surgeons and 500 employees is putting more people on payment plans, including some who come in with fractures and other acute care issues that force them to see the doctor.

"It's true we want people to be more prudent for what they go to the doctor for so they don't overutilize medical services," he said. "But these nonprofit health insurance companies want to hold onto as much money as they can. They don't mind if people don't go to the doctor."

The problem for both patients and health plans is that delays in treatment of chronic problems often can result in the need for more drastic -- and expensive -- solutions when treatment is finally pursued.

Paul Keckley, executive director of the Deloitte Center for Health Solutions, says it's a flawed approach. Despite all the talk of the cost of health care, "there doesn't seem to be in the minds of most consumers a connection of the cost of the 'system' and their own habits," he said.

His Washington, D.C.-based group is studying whether the health care market will be able to transition from the current patient orientation -- which he says features disengaged, confused patients -- and a consumer market, where they have more responsibility.

"The jury's out," he said.

Some rebates

The better-than-expected profits come despite a new provision of federal health care reform law that requires insurers to put at least 80 cents of every premium dollar toward patient care. The law requires insurers to eventually pay rebates if they aren't spending enough on medical care.

"New regulations are having an impact," said David Heupel, a portfolio manager with Thrivent Financial. "But they're being dwarfed by an overall lackluster use of health care."

The law doesn't require companies to pay rebates until next year, but some are so flush they are acting now. In Connecticut, Aetna will drop premiums an average of 10 percent for 10,000 members starting in September. Blue Shield of California will hand back $180 million to policyholders from 2010 profits and also cap next year's earnings at 2 percent.

Closer to home, UCare wrote a $30 million check to the state of Minnesota from its excess reserves, money set aside to cover unexpected medical expenses. Shortly thereafter, UCare and the state's three largest insurers agreed to limit profits on public plans at 1 percent next year.

Sen. Al Franken, D-Minn., who championed the administrative caps and rebates, sees this as an early sign of the law's success.

"A lot of people were saying this wouldn't work, the insurance companies would be overburdened or wouldn't be able to make a profit or it wouldn't bring costs down," Franken said. "And every fear isn't happening."

When Minnetonka-based UnitedHealth Group reports second-quarter earnings Tuesday, it's expected to be the first in a line of publicly traded health care companies, including Aetna, Cigna and WellPoint, to show strong gains.

The company's insurance division, United Healthcare, posted $1.9 billion in operating profit in the first quarter on $23.9 billion in revenue, and United ended up raising its profit and revenue guidance for the year.

UnitedHealth officials say many factors are contributing to better-than-expected performance in its insurance division, including growing enrollment in commercial and public plans and better expense controls. 

Star Tribune staff writer Wendy Lee contributed to this report.

Jackie Crosby • 612-673-7335