The role of plan choice in health care utilization of high-deductible plan enrollees

Choice of high-deductible health plans among enrollees with a substance use disorder

INTRODUCTION

High-deductible health plans (HDHPs) expose enrollees to increased out-of-pocket costs for their medical care, which can exacerbate the undertreatment of substance use disorders (SUDs). However, the factors that influence whether an enrollee with SUD chooses an HDHP are not well understood. In this study, we examine the factors associated with an individual with an SUD's decision to enroll in an HDHP.

METHODS

Using de-identified administrative commercial claims and enrollment data from OptumLabs (2007-2017), we identified individuals at employers offering at least one HDHP and one non-HDHP plan. We modeled whether an enrollee chose an HDHP using linear regression on plan and enrollee demographic characteristics. Key plan characteristics included whether a plan had a health savings account (HSA) or a health reimbursement arrangement (HRA). Key demographic variables included age, race/ethnicity, census block income range, census block highest educational attainment, and sex. We separately investigate new enrollment decisions (i.e., not previously enrolled in an HDHP) and re-enrollment decisions, as well as decisions among single enrollees and families of differing sizes. The study also adjusted models for additional plan characteristics, employer and year fixed effects, and census division. Robust standard errors were clustered at the employer level.

RESULTS

The sample comprised 30,832 plans and 318,334 enrollees. Among enrollees with new enrollment decisions, 24.6 % chose an HDHP; 93.8 % of HDHP enrollees chose to re-enroll in an HDHP. The study found the presence of a plan HRA to be associated with a higher probability of new and re-enrollment in an HDHP. We found that older enrollees with SUD were less likely to newly enroll in an HDHP, while enrollees who were non-White, living in lower-income census blocks, and living in lower educational attainment census blocks were more likely to newly enroll in an HDHP. Higher levels of health care utilization in the prior year were associated with a lower probability of newly enrolling in an HDHP but associated with a higher probability of re-enrolling.

CONCLUSION

Given the emerging evidence that HDHPs may discourage SUD treatment, greater HDHP enrollment could exacerbate health disparities.

A systematic review of strategies used for controlling consumer moral hazard in health systems

Background

Consumer moral hazard refers to an increase in demand for health services or a decrease in preventive care due to insurance coverage. This phenomenon as one of the most evident forms of moral hazard must be reduced and prevented because of its important role in increasing health costs. This study aimed to determine and analyze the strategies used to control consumer moral hazards in health systems.

Methods

In this systematic review. Web of Sciences, PubMed, Scopus, Embase, ProQuest, Iranian databases(Magiran and SID), and Google Scholar engine were searched using search terms related to moral hazard and healthcare utilization without time limitation. Eligible English and Persian studies on consumer moral hazard in health were included, and papers outside the health and in other languages were excluded. Thematic content analysis was used for data analysis.

Results

Content analysis of 68 studies included in the study was presented in the form of two group, six themes, and 11 categories. Two group included “changing behavior at the time of receiving health services” and “changing behavior before needing health services.” The first group included four themes: demand-side cost sharing, health savings accounts, drug price regulation, and rationing of health services. The second approach consisted of two themes Development of incentive insurance programs and community empowerment.

Conclusion

Strategies to control consumer moral hazards focus on changing consumer consumptive and health-related behaviors, which are designed according to the structure of health and financing systems. Since “changing consumptive behavior” strategies are the most commonly used strategies; therefore, it is necessary to strengthen strategies to control health-related behaviors and develop new strategies in future studies. In addition, in the application of existing strategies, the adaptation to the structure of the health and financing system, and the pattern of consumption of health services in society should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08613-y.

Demand-side Interventions to Control Moral Hazard in Health Systems, Beneficial or Detrimental: A Systematic Review Study

Background: Moral hazard is one of the main reasons for health market failure where supply-side and demand-side interventions are used for its control and prevention. This study aimed to identify the effects of demand-side interventions on moral hazards in health systems. Methods: For this systematic review, electronic databases, including Scopus, PubMed, Web of Science, Embase, ProQuest, Google Scholar's search engine, and Iranian databases such as SID and Magiran, were investigated. No time limitation was considered in the search process. The narrative synthesis approach was used for data analysis. Results: Out of 7484 retrieved papers, 61 papers were included in the study. The Identified effects were divided into 2 categories: health services consumption effects and financial effects, which were summarized in the form of advantages and disadvantages. The most important advantages included a decrease in the utilization of different services and a reduction in health expenditures. Also, the most important disadvantages included lower quality of care, shifting financing burden to the consumers, and limited access to necessary care. Conclusion: The results showed that the most benefits of interventions, especially in cost-sharing and waiting list interventions, are for insurance organizations, where the disadvantages also affect consumers more. Therefore, it is necessary to pay more attention to these effects and their management because a lack of attention in this regard may impair the performance of insurance financial protection and health provision as one of the major goals of the health system.

Impact of High Deductible Health Plans on Continuous Buprenorphine Treatment for Opioid Use Disorder

BACKGROUND

Long-term, continuous treatment with medication like buprenorphine is the gold standard for opioid use disorder (OUD). As high deductible health plans (HDHPs) become more prevalent in the commercial insurance market, they may pose financial barriers to people with OUD.

OBJECTIVE

To estimate the impact of HDHPs on continuity of buprenorphine treatment, concurrent visits for counseling/psychotherapy and OUD-related evaluation and management, and out-of-pocket spending.

DESIGN

Difference-in-differences analysis comparing trends in outcomes among enrollees whose employers offer an HDHP (treatment group) to enrollees whose employers never offer an HDHP (comparison group).

PARTICIPANTS

Enrollees with OUD from a national sample of commercial health insurance plans during 2007-2017 who initiate buprenorphine treatment.

MAIN MEASURES

Number of days of continuous buprenorphine treatment; probabilities of continuous buprenorphine treatment ≥30, ≥90, ≥180, and ≥365 days; probability of concurrent (i.e., within the same month) behavioral therapy (i.e., counseling or psychotherapy); probability of concurrent OUD-related evaluation and management visits; proportions of buprenorphine treatment episodes with counseling/psychotherapy and evaluation and management visits; and out-of-pocket (OOP) spending on buprenorphine, behavioral therapy, and evaluation and management visits.

KEY RESULTS

HDHPs were associated with an average increase of $98 (95% CI: $48, $150) on OOP spending on buprenorphine per treatment episode but no change in the number of days of continuous buprenorphine treatment or concurrent use of related services.

CONCLUSIONS

HDHPs do not reduce continuity of buprenorphine treatment among commercially insured enrollees with OUD but may increase financial burden for this population.

On the Relative Importance of Different Factors Explaining Health Plan Choices: Evidence From Mandatory Health Insurance in Switzerland

Many factors influence health plan choices. Classical individual-level determinants include socioeconomic and health-related characteristics, and risk attitudes. However, little is known to what extent personality traits can determine insurance choices. Using representative survey data from Switzerland, we investigate the associations between choices of health plans and traditional individual factors as well as personality traits. We employ dominance analysis to explore the relative importance of the different predictors. We find that personality traits play an at least equally important role in predicting health plan choices as common factors like age, health status, and income. Our results have implications regarding recent efforts to empower people in making better health plan choices and support theoretical models that integrate insights from behavioral sciences.

Deductible Status in the Pediatric Population: A Barrier to Appropriate Care?

OBJECTIVE

The objective of this study is to evaluate the impact of high-deductible health plans on elective surgery (tonsillectomy) in the pediatric population.

STUDY DESIGN

Cross-sectional study.

SETTING

Health claims database from a third-party payer.

METHODS

Data were reviewed for children up to 18 years of age who underwent tonsillectomy or arm fracture repair (nonelective control) from 2016 to 2019. Incidence of surgery by health plan deductible (high, low, or government insured) and met or unmet status of deductibles were compared.

RESULTS

A total of 10,047 tonsillectomy claims and 9903 arm fracture repair claims met inclusion and exclusion criteria. The incidence of tonsillectomy was significantly different across deductible plan types. Patients with met deductibles were more likely to undergo tonsillectomy. In patients with deductibles ≥$4000, a 1.75-fold increase in tonsillectomy was observed in those who had met their deductible as compared with those who had not. These findings were not observed in controls (nonelective arm fracture). For those with met deductibles, those with high deductibles were much more likely to undergo tonsillectomy than those with low, moderate, and government deductibles. Unmet high deductibles were least likely to undergo tonsillectomy.

CONCLUSIONS

Health insurance plan type influences the incidence of pediatric elective surgery such as tonsillectomy but not procedures such as nonelective repair of arm fracture. High deductibles may discourage elective surgery for those deductibles that are unmet, risking inappropriate care of vulnerable pediatric patients. However, meeting the deductible may increase incidence, raising the question of overutilization.

The role of plan choice in health care utilization of high-deductible plan enrollees

OBJECTIVE

To study whether the negative association between enrollment in high-deductible plans and health care utilization is driven by reverse moral hazard or favorable selection, by examining adults with and without a choice of plans.

DATA SOURCE

2011-2016 Medical Expenditure Panel Survey Household Component data on nonelderly adults enrolled in employer-sponsored insurance.

STUDY DESIGN

Four types of plans were examined: high-deductible health plans (HDHPs), consumer-directed health plans (CDHPs), low-deductible health plans (LDHPs), and no-deductible health plans (NDHPs). Multivariate logistic regressions of various measures of health care utilization were conducted to estimate the differences in utilization across plan types among those who had a choice of plans and those who did not.

PRINCIPAL FINDINGS

Among adults with a choice of plans, HDHP enrollees had lower levels of utilization compared with those of the NDHP enrollees for any ambulatory visit, any specialist visit, and most preventive services. Among adults without any choice of plans, the differences between HDHP enrollees and NDHP enrollees were not statistically significant.

CONCLUSIONS

The differences between those with and without choice of plans in the relationship between HDHP enrollment and health care utilization might possibly be explained by favorable selection.