Quality in High-Deductible Plans

As high-deductible plans, particularly those coupled with Health Savings Accounts, spread, there is a need to understand the impact of those plans on use of preventive and other services and on the health status of enrollees and their health outcomes.  A new brief from the Employee Benefit Research Institute examines this issue.  (EBRI Brief)  The study looked at 18,000 enrollees from one large employer who did a full replacement of all health coverage with a high-deductible plan coupled with an HSA.  The employer contributed a significant, but not overly large amount of money to the HSA and the worker could add more.  This group of enrollees was matched with a control group that had traditional coverage.  The study period was a long five-year period, which allows time for enrollees to become familiar with the plan and how best to use it.  The variables looked at were HEDIS-type measures.

In regard to office visits, well-child visits, and preventive visits, there was a modest decline in use in the CDHDP in the first year, compared to the control group.  There was essentially no difference in the remaining years of the study period.  There was less LDL testing in the CDHDP group in the first year, but that difference also subsequently disappeared.  There was also slightly less use of services that monitor the effect of medications and that persisted through the study period.  antibiotics and low back pain imaging services are viewed as often used too much, and by the end of the study period, CDHDP enrollees were using less of each service than those persons in the control group.  Cancer screenings showed mixed effects, with colorectal cancer ones being slightly lower throughout the study period, while breast and cervical cancer screening showed less of an effect and breast cancer screenings were actually slightly higher in the study group.

So at most, there was a minor impact on use of preventive services.  It is important to note that health savings accounts, unlike HRAs, roll over from year to year, so there is no spend it or lose it incentive.  They also may not be funded by the employer, meaning money is available to pay for services in some cases only if the employee funds the account.  The research did not segment the study population by how much money was in their HSA, which may have affected utilization of services.  It is also worth considering that preventive services, while generally recommended, may or may not actually provide value to a particular patient.  So consumers could appropriately decide they didn’t need the service.  And this study did not measure any effect on health status or health outcomes from receiving or not receiving the studied services.  That is a more important piece of research than just whether someone is getting the service.