Individual Health Accounts Can Bring Health Savings to More People in the US

This JAMA Forum discusses health savings accounts and introduces the concept of individual health accounts that could enhance the ability of people in the US to save for their own health care expenses.

Alleviating Financial Hardships Associated with High-Deductible Health Plans for Adults with Chronic Conditions Through Health Savings Accounts

BACKGROUND

High-deductible health plans (HDHPs) are becoming increasingly common, but their financial implications for enrollees with and without chronic conditions and the mitigating effects of health savings accounts (HSAs) are relatively unknown.

OBJECTIVE

Our aim was to compare financial hardship between non-HDHPs and HDHPs with and without HSAs, stratified by enrollees' number of chronic conditions.

DESIGN

We used data from 2015 to 2018 Medical Expenditure Panels Surveys (MEPS) to compare rates of financial hardship across individuals with HDHPs and non-HDHPs using linear and logistic regression models.

PARTICIPANTS

A nationally representative sample of 30,981 adults aged 18-64 enrolled in HDHPs and non-HDHPs.

MAIN MEASURES

We examined several measures of financial hardship, including total yearly out-of-pocket medical spending as well as rates of delaying medical care or prescriptions in the past year due to cost, forgoing medical care or prescriptions in the past year due to cost, paying medical bills over time, or having problems paying medical bills. We compared rates using the non-HDHP as the control.

KEY RESULTS

On most measures, HDHPs are associated with greater financial hardship compared to non-HDHPs, including average annual out-of-pocket spending of $637 for non-HDHPs, $939 for HDHPs with HSAs, and $825 for HDHPs without HSAs (p < 0.01). However, for HDHP enrollees with multiple chronic conditions, having an HSA was associated with less financial hardship (p < 0.05).

CONCLUSIONS

Our findings suggest that HSAs may be most beneficial for those with chronic conditions, in part due to the tax benefits they offer as well as the fact that those with chronic conditions are more likely to take advantage of their HSAs than their younger, healthier counterparts. However, as HDHPs are more likely to be correlated with worse financial outcomes regardless of health status, recent trends of increasing participation may be a reason for concern.

Health-related debt and Health Savings Accounts over time

This study examines Health Savings Account (HSA) effects on health-related debt outcomes. Applying the health lifestyles theory, a subset of 12,686 respondents from three years (2010, 2012, and 2014) of secondary quantitative data from the National Longitudinal Surveys of Youth (NLSY) was drawn. The sample included respondents who answered survey questions about owning an HSA, chronic disease status, health behavior, and health-related debt. Descriptive, bivariate, and generalized estimating equation (GEE) analyses were conducted. Results indicate HSA ownership status (p = .76) is not significantly associated with reporting health-related debt. Implications for social work practice are discussed.

Early Effects of an Accountable Care Organization Model for Underserved Areas

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) developed the Accountable Care Organization (ACO) Investment Model (AIM) to encourage the growth of Medicare Shared Savings Program (MSSP) ACOs in rural and underserved areas. AIM provides financial support to eligible MSSP ACOs by means of prepayment of shared savings. Estimation of the performance of AIM ACOs on measures of spending and utilization in their first performance year would be useful for understanding the viability of ACOs located in these areas.

METHODS

We analyzed Medicare claims and enrollment data for a group of fee-for-service beneficiaries who had been attributed to 41 AIM ACOs and for a comparable group of beneficiaries who resided in the ACO markets but were served primarily by non-ACO providers. We used a difference-in-differences study design to compare changes in outcomes from the baseline period (2013 through 2015) to the performance period (2016) among beneficiaries attributed to AIM ACOs with concurrent changes among beneficiaries in the comparison group. The primary outcome of interest was total Medicare Part A and B spending.

RESULTS

Provider participation in AIM was associated with a differential reduction in total Medicare spending of $28.21 per beneficiary per month relative to the comparison group, which amounted to an aggregate decrease of $131.0 million. Over the same period, CMS made $76.2 million in prepayments and paid an additional $6.2 million in shared savings to ACOs in which shared savings exceeded the prepayments. After we accounted for this $82.4 million in CMS spending, the aggregate net reduction was $48.6 million, which corresponded to a net reduction of $10.46 per beneficiary per month. Decreases in the number of hospitalizations and use of institutional post-acute care contributed to the observed reduction in overall spending.

CONCLUSIONS

With up-front investments, participation in ACO shared savings contracts by providers serving rural and underserved areas was associated with lower Medicare spending than that among non-ACO providers. (Funded by the Centers for Medicare and Medicaid Services.).

Cancer History, Health Insurance Coverage, and Cost-Related Medication Nonadherence and Medication Cost-Coping Strategies in the United States

OBJECTIVES

To evaluate the relationship between cancer history and cost-related medication nonadherence (CRN) as well as cost-coping strategies, by health insurance coverage.

METHODS

We used the 2013 to 2016 National Health Interview Survey to identify adults aged 18 to 64 years with (n = 3599) and without (n = 56 909) a cancer history. Cost-related changes in medication use included (1) CRN, measured as skipping, taking less, or delaying medication because of cost, and (2) cost-coping strategies, measured as requesting lower cost medication or using alternative therapies to save money. Separate multivariable logistic regressions were used to calculate the adjusted odds ratios (AORs) of CRN and cost-coping strategies associated with cancer history, stratified by insurance.

RESULTS

Cancer survivors were more likely than adults without a cancer history to report CRN (AOR 1.26; 95% confidence interval [CI] 1.10-1.43) and cost-coping strategies (AOR 1.10; 95% CI 0.99-1.19). Among the privately insured, the difference in CRN by cancer history was the greatest among those enrolled in high-deductible health plans (HDHPs) without health savings accounts (HSAs) (AOR 1.78; 95% CI 1.30-2.44). Among adults with HDHP and HSA, cancer survivors were less likely to report cost-coping strategies (AOR 0.62; 95% CI 0.42-0.90). Regardless of cancer history, CRN and cost-coping strategies were the highest for those uninsured, enrolled in HDHP without HSA, and without prescription drug coverage under their health plan (all P<.001).

CONCLUSIONS

Cancer survivors are prone to CRN and more likely to use cost-coping strategies. Expanding options for health insurance coverage, use of HSAs for those with HDHP, and enhanced prescription drug coverage may effectively address CRN.

Health Savings Account Ownership and Financial Barriers to Health Care: What Social Workers Should Know

Over a decade ago, Health Savings Accounts (HSAs) were deemed contrary to social work values, leading to greater inequality in access to health care. Using data from the 2015 National Health Interview Survey (NHIS) (n= 12,265), we examine whether HSA ownership is associated with unmet need for health care due to cost (financial barrier). HSA ownership was significantly associated with reduced financial barriers to health care (p< .001) in the regression model. Owning an HSA may be related to reducing financial barriers to health care access, which could inform improvements in HSA policy provisions for social work practice.

The high-deductible plan trap

Republicans seem intent on pursuing a disastrous Obamacare replacement plan that couples catastrophic coverage with subsidized health savings accounts.

Evaluating the Investment Potential of HSAs in Benefit Programs

Despite its complexities, the health savings account (HSA) is a powerful and growing element of the U.S. financial landscape. In the future, employers will likely be expected to provide tax-advantaged savings programs for employees' current and future medical expenses. This article discusses investment lineup issues that must be addressed in order to optimize HSAs to help participants achieve successful outcomes. Plan sponsors at the forefront of addressing these issues (and perhaps others) will be in a better position to help their employees maximize both the health benefits and the wealth benefits provided for a secure retirement.

Health Insurance for "Humans": Information Frictions, Plan Choice, and Consumer Welfare

Traditional models of insurance choice are predicated on fully informed and rational consumers protecting themselves from exposure to financial risk. In practice, choosing an insurance plan is a complicated decision often made without full information. In this paper we combine new administrative data on health plan choices and claims with unique survey data on consumer information to identify risk preferences, information frictions, and hassle costs. Our additional friction measures are important predictors of choices and meaningfully impact risk preference estimates. We study the implications of counterfactual insurance allocations to illustrate the importance of distinguishing between these micro-foundations for welfare analysis.

CDHPs: as enrollment goes up, a time to tune up

One of the clearest findings of Mercer's annual National Survey of Employer-Sponsored Health Plans is that more companies are thinking of adopting a consumer-directed health plan (CDHP) approach, and more employees are enrolling in CDHPs at the companies that offer them. The authors discuss the advantages for organizations that offer CDHPs, as well as outline key considerations for companies looking to update, optimize and align their CDHPs with the realities of health care reform. They also explain how CDHPs go hand in hand with wellness and health management strategies, both of which increase collaboration between employees and employers to control costs and give employees more personal responsibility for better outcomes.

Medication utilization and adherence in a health savings account-eligible plan

OBJECTIVES

To evaluate the impact of a consumerdirected health plan with a health savings account (CDHP-HSA) on utilization of and adherence to medications among individuals with chronic disease.

STUDY DESIGN

Pre-post comparison study with matched control group (difference-in-differences analysis).

METHODS

Data on workers and dependents with 1 or more of 5 chronic conditions--hypertension, dyslipidemia, diabetes, asthma/chronic obstructive pulmonary disease (COPD), and depression--were obtained from an employer that fully replaced its preferred provider organizations (PPOs) with a CDHP-HSA in 2007. A control group of participants from an employer that maintained its PPO throughout the 3-year study period (2006-2008) was created by matching on preperiod (2006) individual characteristics. Difference-in-differences estimates of the impact of the CDHP-HSA were derived by chronic condition for number of prescriptions, proportion of days covered (PDC), and an indicator for a PDC of 0.80 or higher.

RESULTS

During the first year after implementation, enrollees with hypertension, dyslipidemia, and diabetes had significantly less medication utilization (by 1-2 prescriptions) and lower adherence rates (by 0.05-0.09 in PDC; 0.04-0.13 in the proportion adherent). These reductions abated, yet remained, after 2 years among hypertension and dyslipidemia patients. The PDC was significantly lower in patients with depression by 0.07 and 0.05 after 1 and 2 years under the new plan, respectively. No statistically significant impacts were detected on enrollees with asthma/COPD.

CONCLUSIONS

A CDHP-HSA full replacement was associated with reduced adherence for 4 of 5 conditions. If this reduced adherence is sustained, it could adversely impact productivity and medical costs.

Findings from the 2011 EBRI/MGA Consumer Engagement in Health Care Survey

SEVENTH ANNUAL SURVEY: This Issue Brief presents findings from the 2011 EBRI/MGA Consumer Engagement in Health Care Survey. This study is based on an online survey of 4,703 privately insured adults ages 21-64 to provide nationally representative data regarding the growth of consumer-driven health plans (CDHPs) and high-deductible health plans (HDHPs), and the impact of these plans and consumer engagement more generally on the behavior and attitudes of adults with private health insurance coverage. Findings from this survey are compared with EBRI's findings from earlier surveys. ENROLLMENT CONTINUES TO GROW: The survey finds continued growth in consumer-driven health plans: In 2011, 7 percent of the population was enrolled in a CDHP, up from 5 percent in 2010. Enrollment in HDHPs increased from 14 percent in 2010 to 16 percent in 2011. The 7 percent of the population with a CDHP represents 8.4 million adults ages 21-64 with private insurance, while the 16 percent with a HDHP represents 19.3 million people. Among the 19.3 million individuals with an HDHP, 38 percent (or 7.3 million) reported that they were eligible for a health savings ccount (HSA) but did not have such an account. Overall, 15.8 million adults ages 21-64 with private insurance, representing 13.1 percent of that market, were either in a CDHP or were in an HDHP that was eligible for an HSA but had not opened the account. When their children are counted, about 21 million individuals with private insurance, representing about 12 percent of the market, were either in a CDHP or an HSA-eligible plan. MORE COST-CONSCIOUS BEHAVIOR: Individuals in CDHPs were more likely than those with traditional coverage to exhibit a number of cost-conscious behaviors. They were more likely to say that they had checked whether their plan would cover care; asked for a generic drug instead of a brand name; talked to their doctor about treatment options and costs; talked to their doctor about prescription drug options and costs; developed a budget to manage health care expenses; checked a price of service before getting care; and used an online cost-tracking tool. CDHP ENROLLEES MORE ENGAGED IN WELLNESS PROGRAMS: CDHP enrollees were more likely than traditional plan enrollees to report that they had the opportunity to fill out a health risk assessment, and they were also more likely to report that they had access to a health promotion program. CDHP enrollees were also more likely to report that they had been offered a cash incentive or reward to participate in a wellness program when a program was offered. HDHP enrollees were less likely to report having the opportunity to fill out a health risk assessment and to have access to a health promotion program. FINANCIAL INCENTIVES MATTER: When it comes to participating in a wellness program, CDHP enrollees were more likely than traditional plan enrollees to take advantage of the health risk assessment but not the health promotion program. Among those participating, the reasons they gave were that they were offered incentive prizes and reduced premiums. Among those not participating, the reasons they gave were that they could make changes on their own; they lacked time; and they were already healthy. Financial incentives were more a factor for CDHP enrollees than for traditional plan enrollees when it came to participating in wellness programs. CONSUMER USE OF TECHNOLOGY: A significant portion of the population reported using a smartphone, and 1 in 5 reported using a tablet. Among them, about one-quarter reported using an app for health-related purposes. Among those not using an app, nearly one-half were interested in using one.

Healthcare spending and preventive care in high-deductible and consumer-directed health plans

OBJECTIVE

To investigate the effects of high-deductible health plans (HDHPs) and consumer-directed health plans (CDHPs) on healthcare spending and on the use of recommended preventive care.

STUDY DESIGN

Retrospective study.

METHODS

We analyzed claims and enrollment data for 808,707 households from 53 large US employers, 28 of which offered HDHPs or CDHPs. We estimated the effects of HDHP or CDHP enrollment on healthcare cost growth between 2004 and 2005 using a difference-in-difference method that compared cost growth for families who were enrolled in HDHPs or CDHPs for the first time in 2005 with cost growth for families who were not offered HDHPs or CDHPs. Control families were weighted using propensity score weights to match the treatment families. Using similar methods, we examined the effects of HDHP or CDHP enrollment on the use of preventive care and the effects of HDHP or CDHP offering by employers on the mean cost growth.

RESULTS

Families enrolling in HDHPs or CDHPs for the first time spent 14% less than similar families enrolled in conventional plans. Families in firms offering an HDHP or a CDHP spent less than those in other firms. Significant savings for enrollees were realized only for plans with deductibles of at least $1000, and savings decreased with generous employer contributions to healthcare accounts. Enrollment in HDHPs or CDHPs was also associated with moderate reductions in the use of preventive care.

CONCLUSIONS

The HDHPs or CDHPs with at least a $1000 deductible significantly reduced healthcare spending, but they also reduced the use of preventive care in the first year. This merits additional study because of concerns about enrollee health.

Prospects for account-based health plans under the Patient Protection and Affordable Care Act

Account-based health plans (ABHPs), which combine high-deductible plans with either health reimbursement arrangements (HRAs) or health savings accounts (HSAs), have gained popularity in recent years. Because there is growing evidence these plans are indeed engaging consumers and moderating cost increases, employers will need ABHP design options as they strive to bring costs under control in coming years. Some observers, however, are now concerned that benefits standards introduced by federal health care reform will undermine these plans, and many in the business community anticipate new health benefits mandates will drive up employers' total health care costs. The authors show that although the Patient Protection and Affordable Care Act (PPACA) of 2010 includes numerous provisions that will likely increase costs for employers, the law also accommodates, and may even foster, HSAs and HRAs.

Helping your patients want to pay you

Back in the day when deductibles and copayments represented a relatively small share of your accounts receivable, you might have been able to get away with relegating patient-balance collections to your secondary list of practice management priorities. But in today's world of flat or declining medical revenue--coupled with burgeoning consumer-driven health plans--collecting those patient dollars has become a significant part of revenue cycle management.

Consumer-driven healthcare: what is it?

Consumer-driven health plans continue to emerge and grow across the country. The intent of these plans is to increase patient control and thus the free-market variables, increasing competition and quality, with a side effect of better patient health through improved service, improved patient self-management of regimens, and overall health awareness. Healthcare costs will be lower overall as a result. But more action is required from providers, patients, and payers alike when dealing with these plans. The products and benefits are not always understood, and the education to make the system work is lacking.

Findings from the 2009 EBRI/MGA Consumer Engagement in Health Care Survey

FIFTH ANNUAL SURVEY: This Issue Brief presents findings from the 2009 EBRI/MGA Consumer Engagement in Health Care Survey, which provides nationally representative data regarding the growth of consumer-driven health plans (CDHPs) and high-deductible health plans (HDHPs), and the impact of these plans and consumer engagement more generally on the behavior and attitudes of adults with private health insurance coverage. Findings from this survey are compared with four earlier annual surveys. ENROLLMENT LOW BUT GROWING: In 2009, 4 percent of the population was enrolled in a CDHP, up from 3 percent in 2008. Enrollment in HDHPs increased from 11 percent in 2008 to 13 percent in 2009. The 4 percent of the population with a CDHP represents 5 million adults ages 21-64 with private insurance, while the 13 percent with a HDHP represents 16.2 million people. Among the 16.2 million individuals with an HDHP, 38 percent (or 6.2 million) reported that they were eligible for a health savings account (HSA) but did not have such an account. Overall, 11.2 million adults ages 21-64 with private insurance, representing 8.9 percent of that market, were either in a CDHP or were in an HDHP that was eligible for an HSA, but had not opened the account. MORE COST-CONSCIOUS BEHAVIOR: Individuals in CDHPs were more likely than those with traditional coverage to exhibit a number of cost-conscious behaviors. They were more likely to say that they had checked whether the plan would cover care; asked for a generic drug instead of a brand name; talked to their doctor about prescription drug options, other treatments, and costs; asked their doctor to recommend a less costly prescription drug; developed a budget to manage health care expenses; checked prices before getting care; and used an online cost-tracking tool. CDHP MORE ENGAGED IN WELLNESS PROGRAMS: CDHP enrollees were more likely than traditional plan enrollees to report that they had the opportunity to fill out a health risk assessment, whereas they were equally likely to report that they had access to a health promotion program. CDHP enrollees were more likely than traditional plan enrollees to participate when a program was offered. Among those not participating, they did not participate because they could make changes on their own; they lacked time; and they were already healthy. FINANCIAL INCENTIVES MATTER: Financial incentives for healthy behavior mattered more to CDHP enrollees than traditional plan enrollees. Financial incentives were a larger factor for CDHP enrollees than for traditional plan enrollees when it came to participating in wellness programs, choice of doctor, and the use of health information technology, as well as patient engagement using e-mail and the Web. HEALTH STATUS IS BETTER, INCOME HIGHER: Adults in CDHPs were significantly less likely to have a health problem than were adults in HDHPs or traditional plans. Adults in CDHPs and HDHPs were significantly less likely to smoke than were adults in traditional plans, and were significantly more likely to exercise. People in CDHPs were also less likely to be obese compared with adults enrolled in a traditional health plan. Adults in CDHPs were significantly more likely than those with traditional health coverage to have a high household income. CDHP and HDHP enrollees were also more likely than traditional plan enrollees to be highly educated.

Securing your financial future

Securing one's financial future requires dedication and planning. A clear plan must be implemented and continually re-examined to assure an individual remains on track to achieve this security. True success of the plan will be dependent upon taking the appropriate steps to protecting one's assets against unfortunate events along with building assets with a clear end goal in mind. This article will cover the fundamental steps an individual can take to secure their financial future.

Converging for coverage

Surprising coalitions have come together to demand solutions to the nation's uninsured crisis. When it comes time to work out the details, will these unlikely partners find common ground?

Medicare Program; revisions to the Medicare Advantage and Prescription Drug Benefit programs. Interim final rule with comment period

This interim final rule with comment period (IFC) revises the regulations governing the Medicare Advantage (MA) program (Part C), prescription drug benefit program (Part D) and section 1876 cost plans. This IFC makes conforming changes to the MA regulations to reflect new statutory requirements regarding special needs plans (SNP), private-fee-for-service plans (PFFS), regional preferred provider organizations (RPPO) plans, Medicare medical savings accounts (MSA) plans, and new statutory provisions governing cost-sharing for dual-eligible enrollees in the MA program prescription drug pricing, coverage, and payment processes in the Part D program. In addition, this IFC sets forth new requirements governing the marketing of Part C and Part D plans which by statute must be in place at a date specified by the Secretary, but no later than November 15, 2008. Both the conforming changes to the regulations to reflect new statutory provisions and the new marketing requirements are based on provisions in the Medicare Improvements for Patients and Providers Act (MIPPA), which became law on July 15, 2008.

Consumerism: forcing medical practices toward patient-centered care

Consumerism has been apart of many industries over the years; now consumerism may change the way many medical practices deliver healthcare. With the advent of consumer-driven healthcare, employers are shifting the decision-making power to their employees. Benefits strategies like health savings accounts and high-deductible insurance plans now allow the patients to control how and where they spend their money on medical care. Practices that seek to attract the more affluent and informed consumers are beginning to institute patient-centered systems designs that invite patients to actively participate in their healthcare. This article will outline the changes in the healthcare delivery system facing medical practices, the importance of patient-centered care, and six strategies to implement to change toward more patient-centered care.