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Consumer-Directed Health Plans: Do Doctors and Nurses Buy In?

Lucinda B. Leung, MD, MPH, and José J. Escarce, MD, PhD
Although clinical knowledge positions physicians and nurses well as consumer-directed health plan enrollees, they appeared less likely to choose these plans than nonmedical faculty and staff.
Because the catastrophic health plan also had a high deductible and may target similar consumers, we excluded it from sensitivity analyses and examined only the CDHP versus other noncatastrophic health plans. We estimated regression models for both faculty and staff cohorts without a Core Major Medical health plan and found that the point estimates were similar but slightly farther from statistical significance at the 0.05 level. Among faculty (n = 3340), physicians appeared less likely to choose these plans than nonmedical faculty, when all other covariates were fixed at their means, but the result was borderline statistically significant (ΔP, –1.6%; SE, 0.9%; P = .07). Among staff (n = 8230), nurses also appeared less likely to choose these plans than nonmedical staff, when all other covariates were fixed at their means, but the result was borderline statistically significant (ΔP, –1.8%; SE, 1.1%; P = .08). 

DISCUSSION

Overall, we observed low rates of CDHP selection in consumers both with and without medical knowledge in the study. Previous research has found an association between educational attainment and CDHP selection,14 but has not further investigated the content of expertise conferred by education. To our knowledge, this is the first study to specifically examine the role that medical knowledge plays in CDHP selection. After adjusting for sociodemographic characteristics and coverage type, physicians in our study were less likely to choose the CDHP over other health plans compared with nonphysician faculty. Nurses similarly appeared less likely to choose the CDHP compared with nonmedical campus staff, although this difference only approached statistical significance.

As medically knowledgeable consumers, physicians and nurses appear to be better CDHP enrollees than lay consumers. In addition to directly using their own medical knowledge, they can apply their knowledge to decision-support tools when making healthcare choices. On the other hand, they may be unwilling CDHP consumers because they are more cognizant of unforeseeable and high healthcare costs or they have unique insight into how cost sharing may discourage appropriate medical use. Our study findings showing their low rates of CDHP selection lead us to consider why this occurs.

Physicians and nurses may differ from their university counterparts for several reasons. First, consumers with medical knowledge, due to the aforementioned difficulties in making sound medical decisions, may be more risk aversive with their own healthcare needs than lay consumers. Second, physicians and nurses may place a higher value on healthcare than other consumers, making them wary of any supply-side restrictions (ie, high deductible) as CDHP enrollees. Third, UCLA physicians and nurses may not have taken the time to choose among new health plan offerings and were then assigned a default plan compared with other university employees. Of these explanations, we are unable to discern if any of these behaviors were more frequent among medically knowledgeable or lay employees.

Strengths and Limitations

A major strength of our study is the sample size of university-affiliated employees, which allows us to compare a large cohort of physicians and nurses against nonmedical faculty and staff of similar education level. Our sample is also uniquely diverse in age, gender, and race/ethnicity. However, our data is limited in external validity given that it is only from 1 large public university; for example, our UCLA employee cohort was able to choose a CDHP among many other health plans, unlike employees who have a limited array of health plan choices. Additionally, we did not have information on whether an employee chose a new plan or was defaulted to a new one similar to his or her previous plan choice. Future research may expand this study to several large universities or diversify the setting to large employers of health professionals.

Another limitation is that we lacked data on several factors that may influence CDHP selection, including health status, household income, and family structure. Nevertheless, we believe that not having data on health status probably biased our results toward the null hypothesis—that is, toward finding no difference in CDHP choice between physicians and nonphysician faculty and between nurses and nonmedical campus staff. Previous research indicates that better health is associated with a higher likelihood of choosing CDHPs.9 UCLA physicians and nurses were, on average, younger than their lay counterparts and, therefore, likely to be in better health. Consequently, it is likely that our findings would have been even stronger had we been able to control for health status. Finally, we used employee income as a proxy for household income and coverage type to approximate family structure. We lacked information on outside spousal coverage, however, which may have affected health plan selection.

CONCLUSIONS

To date, existing studies have done little to explore how cognitive factors affect CDHP selection. In our literature review, we were only able to identify 1 doctoral dissertation examining the relationship between employee health consumerism facilitated by a workplace health program (conceptually similar though not an actual CDHP) and social cognitive theory constructs, such as self-efficacy.16 Otherwise, we do not know how personality traits (eg, risk aversion, patient activation, self-efficacy, health locus of control) may influence consumer health plan choice. More importantly, we do not know what consumers are actually thinking (ie, the cognitive processes they used) when they chose their health plans. In understanding the thought processes of consumers, we believe we will be able to learn whether the conceptual underpinnings behind these plans are valid and, consequently, likely to accomplish their goals.

Although physicians and nurses may be better positioned to choose CDHPs and use them wisely, our study results suggest that they may not. Given their understanding of the unpredictability of healthcare needs and expenditures, as well as the difficulty of making good decisions in the face of anxiety or illness, physicians and nurses may reasonably be concerned about making the wrong choice. Under these conditions, they naturally do not want to partake in strong financial disincentives to use care. It is unclear if improving decision-support tools will necessarily ameliorate these concerns, because our study results insinuate that even highly sophisticated consumers with medical knowledge believe they may not be able to make good healthcare decisions with CDHPs. 

Physicians’ and nurses’ relative aversion to CDHPs may call to question the whole premise underlying these plans. Our data and analyses, however, limit the implications we can draw about the conceptual underpinnings of CDHPs in that we do not have data on cognitive factors that may affect decision making. No existing study offers insight into what employees are actually thinking, including their beliefs, concerns, fears, and the tradeoffs they make when they chose CDHPs. Future research should address major gaps in understanding the cognitive processes that surround choosing these plans, especially regarding a consumer’s ability to make good decisions and his or her worries about potentially forgoing needed care.

Acknowledgments

The authors would like to thank Lydia Oller (UCLA Benefits Services director), University of California Office of the President Human Resources and the University Committee on Faculty Welfare’s Health Care Task Force for their support of this research.

Author Affiliations: Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA (LBL); Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (LBL, JJE), Los Angeles, CA.

Source of Funding: Support for this article was provided by the Robert Wood Johnson Foundation Clinical Scholars program and the US Department of Veterans Affairs. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Author Disclosures: The authors 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 (LBL, JJE); acquisition of data (LBL); analysis and interpretation of data (LBL, JJE); drafting of the manuscript (LBL, JJE); critical revision of the manuscript for important intellectual content (LBL, JJE); statistical analysis (LBL, JJE); provision of patients or study materials (LBL); obtaining funding (LBL); administrative, technical, or logistic support (LBL); and supervision (JJE).

Address Correspondence to: Lucinda B. Leung, MD, MPH, UCLA Robert Wood Johnson Foundation VA Clinical Scholars Program, 10940 Wilshire Blvd, Ste 710, Los Angeles, CA 90024. E-mail: lleung@mednet.ucla.edu. 
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