Currently Viewing:
The American Journal of Managed Care January 2011
Hypertension Treatment and Control Within an Independent Nurse Practitioner Setting
Wendy L. Wright, MS; Joan E. Romboli, MSN; Margaret A. DiTulio, MS, MBA; Jenifer Wogen, MS; and Daniel A. Belletti, MA
Relationship Between Short-Acting -Adrenergic Agonist Use and Healthcare Costs
Harris S. Silver, MD; Christopher M. Blanchette, PhD; Shital Kamble, PhD; Hans Petersen, MS; Matthew A. Letter, BS; David Meddis, PhD; and Benjamin Gutierrez, PhD
Healthcare Costs and Nonadherence Among Chronic Opioid Users
Harry L. Leider, MD, MBA; Jatinder Dhaliwal, MBA; Elizabeth J. Davis, PhD; Mahesh Kulakodlu, MS; and Ami R. Buikema, MPH
A System-Based Intervention to Improve Colorectal Cancer Screening Uptake
Richard M. Hoffman, MD, MPH; Susan R. Steel, RN, MSN; Ellen F. T. Yee, MD; Larry Massie, MD; Ronald M. Schrader, PhD; Maurice L. Moffett, PhD; and Glen H. Murata, MD
Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days
William Boulding, PhD; Seth W. Glickman, MD, MBA; Matthew P. Manary, MSE; Kevin A. Schulman, MD; and Richard Staelin, PhD
Currently Reading
Effects of Health Savings Account Eligible Plans on Utilization and Expenditures
Mary E. Charlton, PhD; Barcey T. Levy, PhD, MD; Robin R. High, MBA, MA; John E. Schneider, PhD; and John M. Brooks, PhD
Telephone-Based Disease Management: Why It Does Not Save Money
Brenda R. Motheral, PhD
Economic Model for Emergency Use Authorization of Intravenous Peramivir
Bruce Y. Lee, MD, MBA; Julie H. Y. Tai, MD; Rachel R. Bailey, MPH; Sarah M. McGlone, MPH; Ann E. Wiringa, MPH; Shanta M. Zimmer, MD; Kenneth J. Smith, MD, MS; and Richard K. Zimmerman, MD, MPH
High-Deductible Health Plans and Costs and Utilization of Maternity Care
Katy Backes Kozhimannil, PhD, MPA; Haiden A. Huskamp, PhD; Amy Johnson Graves, MPH; Stephen B. Soumerai, ScD; Dennis Ross-Degnan, ScD; and J. Frank Wharam, MB, BCh, MPH
High-Deductible Health Plans and Costs and Utilization of Maternity Care
Katy Backes Kozhimannil, PhD, MPA; Haiden A. Huskamp, PhD; Amy Johnson Graves, MPH; Stephen B. Soumerai, ScD; Dennis Ross-Degnan, ScD; and J. Frank Wharam, MB, BCh, MPH
Telephone-Based Disease Management: Why It Does Not Save Money
Brenda R. Motheral, PhD
Economic Model for Emergency Use Authorization of Intravenous Peramivir
Bruce Y. Lee, MD, MBA; Julie H. Y. Tai, MD; Rachel R. Bailey, MPH; Sarah M. McGlone, MPH; Ann E. Wiringa, MPH; Shanta M. Zimmer, MD; Kenneth J. Smith, MD, MS; and Richard K. Zimmerman, MD, MPH

Effects of Health Savings Account Eligible Plans on Utilization and Expenditures

Mary E. Charlton, PhD; Barcey T. Levy, PhD, MD; Robin R. High, MBA, MA; John E. Schneider, PhD; and John M. Brooks, PhD

The health savings account-eligible design may decrease costs and utilization, but it also may decrease use of preventive services.

Average utilization totals by time period are expressed PMPY or as the rate per 1000 members (Table 1). Although median values varied minimally, mean utilization generally increased over time for the traditional group, with the exception of ED visits. In contrast, mean utilization in the HSA-eligible group generally decreased or remained unchanged following implementation of the HSA-eligible design in 2005, with the exception of outpatient visits and prescription fills.

Table 2 shows the impact of the HSA-eligible design on expenditures. After controlling for age and prospective risk, the positive versus zero expenditure models yielded negative   estimates, indicating that the HSA-eligible design implementation was associated with a lower likelihood of positive expenditures in the following categories: total, office, outpatient, pharmacy, and amount per drug. The Expenditure Models on Positive Values Only columns contain coefficients for the effect of HSA on positive expenditure measures, where  individuals with zero expenditure were excluded. The estimates are the log percent differences between study groups. In these models based only on positive values, the implementation of the HSA-eligible design was associated with significantly lower total expenditures (-17.4%), office expenditures (-20.3%), pharmacy expenditures (-29.2%), and amount per drug (-27.9%), and significantly higher outpatient expenditures (5.1%) than the traditional group. Inpatient expenditure was not significantly different between groups. A total of 24 distinct people (0.7% of total sample) were excluded from at least 1 expenditure model.

The utilization model coefficients are displayed in Table 3. These estimates are interpreted as the log percent difference between the traditional group and the HSA-eligible group. The implementation of the HSA-eligible design was associated with significantly fewer office visits (-13.6%) and ED visits (-20.1%). No other significant differences were detected, but measures such as inpatient and outpatient facility visits were used at substantially lower frequencies than measures such as office visits and prescription. A total of 16 people  (0.5% of total sample) were excluded from at least 1 expenditure model.

Use of Preventive Services

Table 4 shows the number of individuals meeting age and sex eligibility criteria for each preventive service. This table also illustrates the percentage of eligible individuals who used each service at least once from January 1, 2003, through December 31, 2004, and from January 1, 2005, through December 31, 2006, as well as the change in percentage of eligible individuals receiving preventive services before 2005 and after 2005. McNemar’s tests showed that the proportion of HSA-eligible group members receiving mammograms significantly decreased (-14%, P <0.05) after 2005. In contrast, the traditional group had a significant increase in prostate screening exams after 2005 (8.9%, P <.05).

Stratified logistic regression models demonstrated that the HSA-eligible plan was associated with significantly lower odds of receiving mammograms, and nearly significantly lower  odds of receiving Papanicolaou tests and routine health maintenance exams compared with the traditional plans after controlling for age and prospective risk (Table 4). There was no difference between the 2 groups in changes in use for prostate cancer screening.

DISCUSSION

In our analysis, the HSA-eligible plan was associated with significantly lower total expenditures, fewer and less costly office visits, fewer ED visits, less costly prescription fills and amount per drug, and a reduction in the likelihood of mammograms, Papanicolaou tests, and possibly routine physical exams. There was no difference in inpatient facility cost or utilization, but there was a significant increase in outpatient facility expenditures for those in the HSA group. These findingssuggest that members of the HSA-eligible group  restrictedutilization of nonemergent face-to-face services, including some preventive services, due to increased out-of-pocket office expenses. Pharmacy expenditures decreased significantly without a significant decrease in prescription fills, indicating that individuals with the HSA-eligible plan did not discontinue their prescriptions, but rather sought out lower-cost options such as generic medications to reduce out-of-pocket pharmacy expenses. The significant increase in outpatient facility expenditures, given no change in outpatient utilization and decreased ED utilization, indicated that once individuals with the HSA-eligible plan did seek services in an outpatient facility, the expenses related to those services were substantial. However, this phenomenon was not observed for inpatient services. Of note, outpatient and inpatient facility analyses were based on small utilization numbers and widely varying expenditures.

Our results are consistent with the RAND Health Insurance Experiment, which indicated that members consumed fewer services when faced with higher cost sharing.15 However, the RAND experiment found significant decreases in cost and utilization in all places and types of services, whereas our results showed that office, preventive, and pharmacy  services may have been more heavily impacted than hospitalrelated services. This difference may be related in part to the differences in the benefit designs studied. The RAND designs involved straight coinsurance, but the plans in our study involved a combination of coinsurance, copayments, deductibles, and OPM amounts.

Our results also are somewhat consistent with those of Parente et al, who compared the cost and utilization patterns of employees with employer-sponsored health coverage who were given a choice between traditional managed care plans and a CDHP (the latter involving a spending account rather than an HSA).4 Compared with traditional plans, the CDHP had lower costs associated with physician visits and pharmaceutical use, but higher hospital admission rates and costs.4 Selection bias could potentially explain the differences in findings, because individuals in the Parente et al study chose a CDHP over a traditional plan and therefore may have been more apt to delay seeking medical care, possibly leading to more serious medical conditions and high-cost hospitalizations.

Finally, our utilization results are similar to those of the aforementioned recent studies on HSAs/HRAs except that use of preventive services did not decrease in those studies.5-10 This difference may be explained by important design characteristics of prior studies, including waiving the deductible for preventive services in the CDHP and/or HDHP group and the fact that the study population was usually offered a choice between plans, did not have to be continuously enrolled for the entire study period, and/or was not limited to a particular industry. Other studies that have evaluated cost sharing related to preventive services have found decreased utilization with higher out-of-pocket costs.16-20

The strengths of this study include the reduction of selection bias due to the full replacement of the traditional plan with the HSA-eligible plan, a comparable control group, the use of a single industry category and geographic region, and the continuous enrollment of subjects, which allowed us to evaluate within-person variation over a 4-year period.

Our study has several potential limitations. The administrative database does not include variables such as education level, smoking status, or weight. We also did not have information related to job type (such as office-related job vs laborer or field worker) or salary. However, the fixed patientlevel effects models used to evaluate the utilization measures significantly reduced the impact of omitted variables by exclusively evaluating within-person variation; time-invariant variables were dropped from the model. Also, by selecting individuals receiving health insurance coverage from employer groups within the same general industry and headquartered in the same geographic area, we likely controlled for potentially confounding variables.

The administrative database also does not contain any information on the HSAs themselves, including contributions made to the HSAs by the employer or the employee. Therefore, while we knew the characteristics of the benefit plan, we did not know how the plans were funded and could not be certain that every employee opened a corresponding HSA. While this information would have been beneficial in interpreting behavioral changes, health plans do not typically administer the HSAs and therefore do not have access to detailed information. In addition, there is a possibility that employers in the traditional group could have added flexible spending accounts (FSAs) to their benefit offerings. FSAs are distinct from health insurance plans and therefore are not part of the administrative database of the health plan. While it is unlikely that the possible existence of FSAs confounded overall findings, it highlights the issue that this study compares bundles of characteristics between HSA-eligible plans and traditional plans. Further research in this area should focus on the effects of plan pieces that are generally different between HSA-eligible plans and traditional plans (eg, high deductibility, use of HSA accounts, different availability of FSAs).

Because we selected employer groups in the same industry and headquartered in the same geographic area, the study results may not be generalizable to populations in different  industries and locations. The findings also were limited to those individuals who obtained health insurance coverage through their employer, as this study addressed only employer-sponsored health insurance.

CONCLUSION

The results of this study support the notion that employer- sponsored HSA-eligible plans provide financial incentives for consumers to make cost-effective healthcare decisions (eg, choosing generics over brand prescription medications). One caveat is that these plans may discourage preventive care and thus could eventually cause medical costs to increase in the long term. In recent years, most employer-sponsored health plans have waived the deductible on preventive services.1,2,21 The current analysis provides a rationale for continued movement in this direction and will hopefully dissuade employers from reverting back to subjecting preventive services to the deductible in hopes of reducing short-term premium costs.

 
Copyright AJMC 2006-2017 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
x
Welcome the the new and improved AJMC.com, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up
×

Sign In

Not a member? Sign up now!