By Mark Zdechlik

Ruth Skoog will undergo her second hip replacement of the year later this week.

She’s calling it a “Christmas miracle” that her doctor could squeeze in the operation before year’s end. Skoog has already spent enough money on care this year to satisfy her health plan’s out-of-pocket maximum, so her insurer will cover the surgery’s entire cost.

But if she has the same procedure with the same doctor after Jan. 1, it would cost her thousands of dollars.

Just like retailers, doctors, hospitals, pharmacies and health plans see a jump in business around the holidays, and it’s due to policies actually designed to slow health spending.

High-deductible health plans that Skoog and many Americans now have push people who’ve met their deductible to scramble for appointments of all kinds during the end of the year.

That keeps health care providers busy.

“We have our physicians doing elective operations on the weekends and into the evening and really kind of stressing the resources we have available for anesthesia and other pieces,” said Abbott Northwestern Hospital president Ben Bache-Wiig.

November and December are 20 percent busier than the average month at Bache-Wiig’s hospital, and he said it’s because of cost-sharing provisions like deductibles.

Cost sharing can be painfully expensive, but it helps bring down monthly premiums.

The moment a policyholder reaches their out-of-pocket maximum, their price of care goes from expensive to free — insurance covers 100 percent.

Insurance broker Heidi Mathson said dramatic increases in out-of-pocket costs have brought the financial incentives into sharp focus for consumers.

“If you are going to have a procedure or a surgery or you’re going to have some kind of event that causes you to meet your deductible,” she said, “then it’s really beneficial to you to maximize and use up all of the health services that you can in that calendar year.”

When 35-year-old Brian Ernste hit his deductible in May, he said, “it’s like I won the lottery!”

He’s a financial planner who kept his bottom-line in mind when scheduling an elective surgery for early this year, knowing he’d hit his maximum payments. Since Ernste’s care became free in spring, he’s seen his doctor five or six times.

“I had a few minor concerns,” he said, “and I thought, ‘Hey, I don’t have to pay anything to go talk to her so why not go in?’”

Insurance companies take the hit in instances like that.

Health insurer Medica said it pays out 16 percent more for care in December than during the average month.

The purpose of deductibles and other-cost sharing provisions is to encourage people to think twice about getting care in hopes of cutting down on unnecessary doctor visits.

It can have the opposite effect, though.

Doug Campbell of Bloomington said his family reached their deductible halfway through 2016, and they’re taking advantage of the less-expensive care.

He said today’s health plans have conflicting and perverse incentives.

“During that deductible period there is an incentive not to go seek care because you have to pay for it and it’s hugely expensive,” Campbell said. “Once that deductible’s satisfied the incentive is reversed. Now it’s use it or lose it and you may as well go to the doctor everyday just because you like the lobby.”

Health insurance companies are realizing that when some of their customers avoid care because of high out-of-pocket costs, they can end up getting sicker and wind up costing a lot more, said University of Minnesota health economist Jean Abraham.

The industry is exploring smarter approaches, she said, including value-based insurance design.

Caring for the chronic illnesses like asthma and diabetes sucks up the vast majority of health care spending in the United States.

Value-based insurance covers maintenance care for expensive chronic conditions, Abraham said.

The goal is to ensure those patients get the care they need so their health problems don’t get worse.

“It’s essentially saying we need to think differently about patients based on their health status,” Abraham said. “We don’t want them skimping on their medications that help them manage that conditions because doing so might put them in the hospital if they’re not taking care of themselves.”

The value-based approach is gaining traction, she said, and some employers are testing it out.

“There is an increasing body of literature that’s showing that consumers do respond to it,” she said. “I do think it’s an innovation that tries to make insurance a bit more patient-centric.”

Bache-Wiig, the Abbott hospital president, had a different idea for changing how health insurance works.

He’s talked to health insurance companies about staggering the start and end dates of policies in hopes of taking some pressure off of the last two months of the year.

But he said he’s gotten nowhere with the idea.

“Our employees would like to have time off around the holidays as well,” he said, “and instead we’re asking them to work extra to be able to meet the needs.”