The American Journal of Managed Care January 2011
High-Deductible Health Plans and Costs and Utilization of Maternity Care
Study groups were similar, with no statistically significant differences detected (Table 1). The average age at delivery was approximately 33 years. Between 15% and 18% lived in low socioeconomic status neighborhoods. More than 60% worked for small employers. Approximately one-third of women had a caesarean delivery, and between 20% and 30% experienced complications of high-risk pregnancy. Preterm deliveries accounted for fewer than 10% of births, and rates of gestational diabetes were low. Chronic disease scores were consistent across groups and indicate a generally healthy population.
Table 2 presents costs, quality, and utilization outcomes in the study groups as well as regression-based estimates of the impact of switching from an HMO to an HDHP on each of these outcomes. Regression coefficients for cost outcomes may be interpreted as the estimated percentage change in cost. Mean total maternity care costs for HDHP members were $9761 for women who delivered prior to the insurance transition and $9997 for those who delivered after the transition, compared with a change from $9731 to $10,434 for HMO members, a 12% (P = .114) relative reduction in the HDHP group, after adjusting for covariates. This occurred despite a significant increase in the underlying cost trend over time (8%, P <.001; see Appendix A). Further, the HDHP group experienced a 15% relative decline in delivery costs (P = .192).
In contrast to overall costs, out-of-pocket spending increased following the transition from an HMO to an HDHP. Average out-of-pocket maternity care expenditures among HDHP members rose from $356 before the HDHP transition to $942 for those who delivered after, compared with nearly constant values ($262 to $282) for women who remained inHMO plans, a relative increase of 106% (P <.001). Mean out-of-pocket costs for delivery care rose from $258 to $547 among HDHP members, compared with $188 to $218 among HMO members, a 45% relative increase (P <.001). Average insurer expenditures decreased for women who delivered babies after HDHP enrollment, falling from $9405 to $9055, while rising from $9469 to $10,152 for the control group, a 21% relative decrease (P = .005). The relative decrease in insurer expenditures for delivery care was similar (22%, P = .049).
Achievement of quality standards for early and frequent prenatal care as well as timely postpartum care did not vary significantly across study groups (Table 2). Nearly all women received early prenatal care, and the majority accessed recommended prenatal and postpartum care. Likewise, maternity care utilization was similar across groups, with an average of 9 to 10 prenatal visits and 7 to 8 sonograms (mode = 4; 25% of women had >10 sonograms) and an average delivery hospitalization stay of about 4 days (3 days for vaginal deliveries; 5 days for caesarean deliveries).
As expected, pregnancy and delivery complications, high chronic disease scores, and caesarean and preterm deliveries were generally associated with higher costs and utilization (Appendices A, B, and C).
This study is the first to characterize the impact of HDHPs on maternity care services. Our findings demonstrate that transitioning from an HMO to an HDHP was associated with increased out-of-pocket costs but stable utilization and quality for maternity and delivery care. Out-of-pocket costs represented a small percentage of total maternity costs for both HMO (4%) and HDHP (11%) members and were in the same range as national averages (6% of total costs).29 Nevertheless, HDHP members faced out-of-pocket costs 3 times higher than HMO members but received recommended prenatal and postpartum care at similar rates.
An overall reduction in costs associated with better consumer choice is one of the goals of HDHPs and other consumer-driven healthcare models.9,10 We found a 12% (nonsignificant) decrease in the average costs of maternity-related care following transition to an HDHP. This trend might result from reductions in expensive individualized services or elective tests and procedures (such as prenatal genetic counseling or early screening for chromosomal abnormalities). Transitioning from an HMO to an HDHP was not associated with adverse impacts on basic prenatal and postpartum quality measures, lending support to deductible exemptions for such services. Further, there was no measurable effect on prenatal visits, sonograms, or hospitalization following delivery. While a highly informed and “rational” consumer would not forgo any such services even if facing full cost sharing (because the expected delivery hospitalization essentially caps spending at the deductible level), immediate-term outof- pocket costs might remain important potential barriers to HDHP members, especially among lower-income women.
Our findings have important implications for state and federal policy. Recently enacted healthcare reform legislation will establish state-sponsored health insurance exchanges, and policy makers must set minimum coverage criteria for included health plans. Given that previous studies have detected adverse impacts of cost sharing on the poor, further research is needed to investigate how HDHPs affect maternity care among lower-income employed women, who might increasingly be enrolled in HDHPs because of the Patient Protection and Affordable Care Act’s individual mandate for health insurance coverage and taxation of more generous “Cadillac” health plans.30
This study has a number of important limitations. Data on the prevalence of HRAs, employer contributions to such accounts, and employee premium payments were not available, limiting our ability to examine overall cost impacts on healthrelated expenditures. However, as above, we expect a very limited prevalence of HRAs among the small employers included in our cohort. Although it would be more broadly generalizable to include information on PPO members, we were not able to do so in this study. The primary differences compared with PPOs are that HMOs generally have a more limited provider network, lower potential out-of-pocket maternity costs, and higher acn tuarial values.4,31 These differences are important when interpreting study results in the national context, and future studies should include PPOs with and without high deductibles. Womenin our study were insured primarily through small employers. HDHP benefit structures and cost-sharing requirements may differ in the small, individual, and large employer group markets.
Some HDHP members who delivered babies after the insurance transition received maternity care prior to switching to an HDHP. Although coverage was identical for measured prenatal services under HMO and HDHPs (exempt from HDHP deductibles), we conducted sensitivity analyses that excluded HDHP members who received prenatal care prior to the index date, which revealed unchanged findings. Sample size might have constrained our ability to detect statistically significant differences in overall costs and utilization of care, although we had sufficient power to examine the highly policy- relevant association between HDHPs and out-of-pocket costs. Sample size also limited examination of differences among subgroups of interest (eg, caesarean vs vaginal deliveries, lower-income families, higher vs lower deductibles). We had access to medical claims but not laboratory data; HEDIS guidelines recommend assessing both when measuring timely postpartum care. Therefore, we may have undercounted the true rate of this measure, though not differentially by study roup. Also, for the small percentage of women whose employers did not offer pharmaceutical coverage, we assigned average chronic disease scores of women who do not use prescription drugs.
Enrollment in HDHPs has been growing rapidly and is likely to accelerate with the implementation of the Patient Protection and Affordable Care Act.7,32,33 Insurers, employers, and policy makers should pay careful attention to HDHP design and associated financial burdens. Recent health reform legislation contains extensive provisions to reduce out-of-pocket ost sharing for low-income individuals and families who obtain coverage through health insurance exchanges. However, out-of-pocket costs remain a concern if employers offer affordable” premiums but high deductibles to lowincome employees who are not eligible for subsidized health insurance through exchanges.
We found that the increased out-of-pocket costs associated with a transition from an HMO to an HDHP did not produce concerning changes in the utilization of recommended prenatal and postpartum care. In the future, larger studies should examine the impact of HDHPs on low-income families and on socioeconomic disparities in maternity and delivery care.
This study benefited greatly from data management and programming advice provided by Irina Miroshnik, MS, at Harvard Pilgrim Health Care Institute and Chantel Wilson-Chase, MA, at Harvard Pilgrim Health Care.
Author Affiliations: From the Department of Population Medicine (KBK, AJG, SBS, DR-D, JFW), Department of Health Care Policy (HAH), Harvard Medical School, Boston, MA; Harvard Pilgrim Health Care Institute (KBK, AJG, SBS, DR-D, JFW), Boston, MA; and the Division of Health Policy and Management (KBK), University of Minnesota, Minneapolis, MN.
Funding Source: Dr Kozhimannil's work on this study was supported by the Thomas O. Pyle Postdoctoral Fellowship and the Fellowship in Pharmaceutical Policy Research at the Department of Population Medicine, Harvard Medical School and the Harvard Pilgrim Health Care Institute. The study was funded in part by a Harvard Pilgrim Health Care Foundation grant to Dr Wharam, who is also supported by the Harvard Pilgrim Health Care Institute. Dr Soumerai is an investigator in the HMO Research Network Centers for Education and Research on Therapeutics, sponsored by the Agency for Healthcare Research and Quality (U18HS010391) and the Harvard Pilgrim Health Care Institute.
Author Disclosures: The authors (KBK, HAH, AJG, SBS, DR-D, JFW) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (KBK, HAH, DR-D, JFW); acquisition of data (AJG, JFW); analysis and interpretation of data (KBK, HAH, AJG, SBS, DR-D, JFW); drafting of the manuscript (KBK, JFW); critical revision of the manuscript for important intellectual content (HAH, AJG, SBS, DR-D, JFW); statistical analysis (KBK, SBS); obtaining funding (KBK, JFW); administrative, technical, or logistic support (AJG, SBS); and supervision (SBS, DR-D, JFW).
Address correspondence to: Katy Backes Kozhimannil, PhD, MPA, Division of Health Policy and Management, University of Minnesota, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455. E-mail: firstname.lastname@example.org.
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