How does enrollment in CDHPs impact on consumerist behaviours?

Anna Dixon, Jessica Greeneand Judith H Hibbard

University of Oregon

Funding provided by The Changes in Health Care Financing and Organization (HCFO) initiative, a program of The Robert Wood Johnson Foundation, and the

Commonwealth Fund

Research questions

Do consumer directed health plans influence enrollees health and health care behaviors?

Compared to employees who remained in a PPO are employees who enrolled in CDHPs more likely to begin to– use health and cost information,– make cost-sensitive utilization decisions and– undertake regular healthy activities?

Analysis

Dependent variables: self reported behaviors – Information seeking– Cost sensitive decisions– Healthy behaviors

Cross sectional analysis of behaviors in 2003 by plan type

Analysis of behaviors in 2004 & 2005 among those who were not doing the behaviors in the previous year by plan type (bivariate and multivariate)

Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode

Information seekingpre-enrollment year by plan type (bivariate)

 High Deduct CDHP

Lower Deduct CDHP

PPO% sample (N)

Used any website for health information other than their plan’s 48.3% 51.8% 39.8%*** 45.8%

Used website or booklet that compares the quality of hospitals 6.2% 7.7% 5.6% 6.4%

Used website or book that helps you figure out how to handle symptom or problem

40.1% 46.3% 36.0%*** 40.1%

Used website or booklet that compares prescription drug costs 15.7% 22.0% 15.7%*** 17.5%

*p<.10 **p<.05 ***p<.01

Initiated information seekingduring first 6 months enrollment by plan type in 2004 (multivariate)

Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode. Denominator in each case is those who did not report doing the behavior in 2003

*p<.10 **p<.05 ***p<.01

 High Deduct CDHP

Lower Deduct CDHP

PPO%

sample (N)

Used any website for health information other than their plan’s

1.31 2.20*** (1.0)6.6%

(1123)

Used website or booklet that compares the quality of hospitals

0.71 4.23*** (1.0)1.8%

(1944)

Used website or book that helps you figure out how to handle symptom or problem

0.71 1.49 (1.0)10.4%(1237)

Used website or booklet that compares prescription drug costs

2.22** 3.42*** (1.0)4.8%

(1711)

Initiated information seekingduring 2nd year of enrollment by plan type in 2005 (multivariate)

Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode. Denominator in each case is those who did not report doing the behavior in 2004

No statistically significant relationship*p<.10 **p<.05 ***p<.01

 High Deduct CDHP

Lower Deduct CDHP

PPO%

sample (N)

Used any website for health information other than their plan’s

1.06 1.18 (1.0)21.0% (637)

Used website or booklet that compares the quality of hospitals

0.98 0.80 (1.0)5.7%

(1084)

Used website or book that helps you figure out how to handle symptom or problem

0.80 1.12 (1.0)25.0% (713)

Used website or booklet that compares prescription drug costs

0.57* 0.88 (1.0)9.1% (957)

Summary of findings: Information

Active information seekers more likely to select low deductible CDHP

Enrollees in low deductible CDHPs more likely to initiate health and quality information seeking than enrollees in either high deductible CDHP or PPO within first 6 months

Enrollees in both CDHPs more likely to initiate cost information seeking than enrollees in PPO within first 6 months

Cost sensitive behaviorspre-enrollment year by plan type (bivariate)

 High Deduct CDHP

Lower Deduct CDHP

PPO%

sample (N)

Decide not to go to the doctor when you thought you should have to save money

16.1% 18.1% 18.6% 17.7%

Not fill a prescription to save money 8.2% 9.8% 10.9% 9.8%

Take a lower dose of a prescription drug than was recommended in order to save money

3.7% 4.6% 4.8% 4.4%

Postpone or delay having a medical procedure or surgery to save money

9.2% 9.5% 10.3% 9.7%

Decide to have a less expensive diagnostic test to save money 4.9% 5.0% 4.7% 4.8%

No statistically significant relationship*p<.10 **p<.05 ***p<.01

Initiated cost sensitive behaviorsduring first 6 months of enrollment by plan type in 2004 (multivariate)

Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode. Denominator in each case is those who did not report doing the behavior in 2003

*p<.10 **p<.05 ***p<.01

 High Deduct CDHP

Lower Deduct CDHP

PPO% sample

(N)

Decide not to go to the doctor when you thought you should have to save money 3.47*** 1.67 (1.0)

3.8% (1715)

Not fill a prescription to save money 2.84** 1.04 (1.0)2.6%

(1873)

Take a lower dose of a prescription drug than was recommended in order to save money

3.25** 0.74 (1.0)1.6%

(1983)

Postpone or delay having a medical procedure or surgery to save money

2.73** 1.70 (1.0) 2.6% (1877)

Decide to have a less expensive diagnostic test to save money

2.16 0.79 (1.0)1.4%

(1949)

Initiated cost sensitive behaviorsduring 2nd year of enrollment by plan type in 2005 (multivariate)

 High Deduct CDHP

Lower Deduct CDHP

PPO%

sample (N)

Decide not to go to the doctor when you thought you should have to save money

1.99** 1.56 (1.0)9.2%

(1020)

Not fill a prescription to save money 1.25 0.71 (1.0)5.0%(725)

Take a lower dose of a prescription drug than was recommended in order to save money

1.44 2.89** (1.0)5.6%(750)

Postpone or delay having a medical procedure or surgery to save money 1.82 2.43** (1.0)

4.8% (1073)

Decide to have a less expensive diagnostic test to save money

2.08* 1.75 (1.0)5.0%

(1091)

Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode. Denominator in each case is those who did not report doing the behavior in 2004

*p<.10 **p<.05 ***p<.01

Summary of findings: Cost saving

Enrollees in high deductible CDHPs more likely to have started taking risky cost sensitive behaviors within 6 months of enrollment

Similar issues emerging for low deductible CDHPs during year 2 with drug use and procedures

Healthy behaviorsbaseline in 2004 by plan type in 2005 (bivariate)

 High Deduct CDHP

Lower Deduct CDHP

PPO% sample

(N)

Limit how much fat is in your diet on most days per week 50.5% 51.7% 43.5%***

47.9%(2094)

Exercise on most days per week56.2% 51.4% 48.3%***

51.6%(2102)

Eat 5 or more fruits or veggies a day on most days per week 36.6% 36.3% 35.2%***

35.9%(2101)

*p<.10 **p<.05 ***p<.01

Initiated healthy behaviorsduring 2nd year of enrollment by plan type in 2005 (multivariate)

 High Deduct CDHP

Lower Deduct CDHP

PPO%

sample (N)

Limit how much fat is in your diet on most days per week

1.69* 0.93 (1.0) 27.6%(580)

Exercise on most days per week1.47 0.92 (1.0) 30.2%

(569)

Eat 5 or more fruits or veggies a day on most days per week

0.76 0.82 (1.0) 18.3%(749)

Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode. Denominator in each case is those who did not report doing the behavior in 2004

*p<.10 **p<.05 ***p<.01

Summary of findings: Healthy behaviors

Enrollees in CDHPs more likely to do regular healthy activities than enrollees in PPO

Emerging trend that enrollees in high deductible CDHPs are more likely to regularly limit fat in diet compared to low deductible and PPO

Implications for US policy

Cost exposure may result in ‘bad’ decisions– Design of CDHPs is critical: size of ‘gap’– Monitor impact of HSAs/HRAs on utilization

Availability of information tools may result in greater use of health and cost information

– Do some people make greater use of tools than others? Information + financial incentives may increase level

of healthy activities– Who are these people? Are behaviors maintained?

Are people who select these plans predisposed to the behaviors already? Is there selection?