Enrollment in high-deductible plans has plateaued, driven in part by concerns about the effect of such plans on receipt of needed health care. While it appears that this plan design may reduce health spending growth by putting more of the cost burden on patients, it may also cause longer term issues if, for example, people are avoiding preventive care or not using prescribed medications for chronic conditions because of the higher cost-sharing. A new study carried by Health Services Research attempts to elicit the reality of apparent utilization differences between people in high-deductible plans versus other designs. (HSR Article) The authors used MEPS data from 2011 to 2016 to divide people into four groups–those in a high deductible plan, those in a high-deductible plan with a health savings account, those in a low deductible plan and those with no deductible. They also ascertained whether the individuals had a choice of which plan they ended up in or was the plan the only one available. Using information from situations where the enrollee had no choice regarding the plan avoids selection issues. In particular, people who viewed themselves as healthy and having little need for health care services might be more likely to select a high-deductible plan if given the choice, because such plans generally have lower premiums. The outcomes of interest were various categories of outpatient utilization, including any outpatient visit, any visit to a specialist and receipt of certain preventive services.
Among adults with a choice of plans, 17% enrolled in a high-deductible one, 15% in a high-deductible with savings account one, 47% in a low-deductible plan and 21% in a no-deductible one. Among adults with no choice, 21% ended up in a high-deductible plan, 10% in a high-deductible with savings account one, 47.5% in a low deductible one and 21% in a no-deductible plan. The primary finding is that when a member has a choice of plan, those who select high-deductible plans appear to have lower levels of utilization of several types than do those people who choose no-deductible plans. However, if there is no choice, members in high-deductible plans have utilization that is no different than that of members who only had a no-deductible plan option. For example, among adults with a choice of plans, those who selected a high-deductible design were 5.1% less likely to have any outpatient visit compared to those who chose a no-deductible plan. But among adults who had no choice of plan, there was no difference in rates of ambulatory visits. The same was true for rates of specialist visits. Based on this study, apparent lower utilization by high-deductible plan enrollees is driven largely or exclusively by selection effects. As usual, it is worth recalling that MEPS is self-reported survey data, so probably some legitimate concerns exist about accuracy of information, but the results of this study are consistent with common sense.