Healthcare Spending and Preventive Care in High-Deductible and Consumer-Directed Health Plans | Page 2
Published Online: March 22, 2011
Melinda Beeuwkes Buntin, PhD; Amelia M. Haviland, PhD; Roland McDevitt, PhD; and Neeraj Sood, PhD
The employers entered the study from 2 routes. One group of employers was recruited because they offered an HDHP or a CDHP during the period from 2003 to 2007. These employers were selected to encompass a range of geographic regions, employee income levels, proportion of employees enrolling in HDHPs or CDHPs, and HDHP or CDHP characteristics. The other group of employers was from the Thomson Reuters (New York, New York) MarketScan database. These employers were selected to match the geographic, size, and industry distribution of the recruited employers. In the 2004-2005 cohort used for this analysis, employers from both sources contributed to the treatment and control samples (83% of HDHP or CDHP–enrolled families are from recruited firms). The enrollment and claims data from insurers were standardized into a modified MarketScan format. An expert independent of the study organizations certified that the analysis data files received by the research team were deidentified, and the Human Subjects Protection Committee at RAND Corporation approved the study.
Families are the unit of analysis, with additional variables indicating a single employee, employee plus spouse, and additional tiers. For the effect of HDHP or CDHP enrollment analysis, treatment families were those who first enrolled in an HDHP or a CDHP in 2005. For the effect of HDHP or CDHP offer analysis, the treatment families included all insured families in firms that first offered an HDHP or a CDHP in 2005. In both cases, the treatment group was restricted to those who worked for employers where at least 3% of employees enrolled in an HDHP or a CDHP. Control families worked for employers that did not offer high-deductible plans.
High-deductible health plans are classified into the following 4 types by individual deductible and by employer contribution to personal medical accounts: (1) moderate deductible ($500-$999), (2) high deductible (>$1000) with no account, (3) high deductible with low employer account contribution of less than $500, and (4) high deductible with generous employer account contribution of at least $500 (the last 2 are also known as CDHPs); the types represented 44%, 11%, 33%, and 13% of the treatment sample, respectively. Almost all of these high-deductible plans waived the deductible for preventive care, as established by employer survey and interview data.
We derived plan cost-sharing provisions for all plans based on payment patterns in the claims data combined with employer survey data if available. We included in our analysis only plans with at least 100 employees to ensure sufficient observations to make reliable estimates of the deductible, which is used to assign treatment status. We validated our claimsbased cost-sharing provisions by comparing them with survey responses from 27 employers about 138 plans they offer with a total enrollment of 1.1 million members in 2005. Comparing the treatment classification based on the 2 sources, we found agreement for 93% of enrollees. In addition, all high-deductible plans identified for this analysis were confirmed by survey data or other communication with the employer.
We calculated annual family costs for medical care (insurance and patient payments for care received) and divided these by 12 to obtain the mean monthly expenditures. Parallel calculations resulted in the mean monthly expenditures in each of the following 4 healthcare settings: outpatient, inpatient, emergency department, and prescription drugs.
The following 6 preventive care outcomes were created based on Healthcare Effectiveness Data and Information Set (HEDIS) measure definitions15: 2 child immunization
measures, receipt of mammography, cervical and colorectal cancer screening, and glycosylated hemoglobin (A1C) testing for patients with diabetes mellitus. Dichotomous measures were created at the annual family level indicating whether some or none of the eligible family members had obtained the recommended care. We adapted HEDIS 2008 specifications to conform to the single-year windows in our analysis framework (discussed further in the eAppendices, available at www.ajmc.com). We created 2 child immunization measures indicating whether a child was on track to obtain the full set of recommended immunizations. Counting only care received in the current year caused these measures to be lower than typical HEDIS measures but consistently so in each year and across the treatment and control groups.
Covariates for analyses were derived from enrollment, claims, and geocoded location. Enrollment files provided family type, age of head of household, family size, geographic region, metropolitan statistical area status, and employer’s industry type. Claims data supplied prospective relative risk scores based on diagnostic cost group16,17 summed to the family level and indicators for whether a family received care in each of 23 major diagnostic categories. Actuarial values (percentage of allowed charges paid by the plan) were calculated for each plan using the plan provisions to simulate payment of claims for a standard population. The zip code–level geocoded characteristics are the median household income, percentage of adults with high school and college degrees, percentage unemployed, and percentage of Hispanic, black, and non- Hispanic white race/ethnicity.
For the cost-outcome models of the effects of enrollment in HDHPs or CDHPs, we used propensity score weighting to balance the distributions of numerous characteristics observed in 2004 between treatment and control families.18,19 Logistic regression analysis was used to model the odds of being a treatment family as a function of characteristics that predict both health plan selection and healthcare use (discussed further in the eAppendices). Predicted probabilities (propensity scores) were used to derive individual family weights for control families proportional to the conditional probability of being a treatment family. To check the adequacy of the propensity score model, we evaluated the balance of the weighted means of the measured characteristics. When balance is obtained, weighted analyses adjust for potential confounding owing to measured characteristics.
When estimating the effects for different types of high-deductible plans, treatment families were divided into different subgroups. Each subgroup was propensity score weighted to match the distribution of characteristics of the entire treatment sample (discussed further in the eAppendices).
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