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Cliff BQ, Eddelbuettel JCP, Meiselbach MK, Eisenberg MD. Deductible imputation in administrative medical claims datasets. Health Serv Res 2024; 59:e14278. [PMID: 38233373 DOI: 10.1111/1475-6773.14278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVE To validate imputation methods used to infer plan-level deductibles and determine which enrollees are in high-deductible health plans (HDHPs) in administrative claims datasets. DATA SOURCES AND STUDY SETTING 2017 medical and pharmaceutical claims from OptumLabs Data Warehouse for US individuals <65 continuously enrolled in an employer-sponsored plan. Data include enrollee and plan characteristics, deductible spending, plan spending, and actual plan-level deductibles. STUDY DESIGN We impute plan deductibles using four methods: (1) parametric prediction using individual-level spending; (2) parametric prediction with imputation and plan characteristics; (3) highest plan-specific mode of individual annual deductible spending; and (4) deductible spending at the 80th percentile among individuals meeting their deductible. We compare deductibles' levels and categories for imputed versus actual deductibles. DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS All methods had a positive predictive value (PPV) for determining high- versus low-deductible plans of ≥87%; negative predictive values (NPV) were lower. The method imputing plan-specific deductible spending modes was most accurate and least computationally intensive (PPV: 95%; NPV: 91%). This method also best correlated with actual deductible levels; 69% of imputed deductibles were within $250 of the true deductible. CONCLUSIONS In the absence of plan structure data, imputing plan-specific modes of individual annual deductible spending best correlates with true deductibles and best predicts enrollees in HDHPs.
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Affiliation(s)
- Betsy Q Cliff
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
| | | | - Mark K Meiselbach
- Health Policy and Management, Johns Hopkins University, Baltimore, Maryland, USA
| | - Matthew D Eisenberg
- Health Policy and Management, Johns Hopkins University, Baltimore, Maryland, USA
- Johns Hopkins University, Baltimore, Maryland, USA
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Freed MC, Humensky JL, Arean PA. PERSPECTIVE: A Path to Value-Based Insurance Design for Mental Health Services. THE JOURNAL OF MENTAL HEALTH POLICY AND ECONOMICS 2024; 27:23-31. [PMID: 38634395 PMCID: PMC11062318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 03/02/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Aligning cost of mental health care with expected clinical and functional benefits of that care would incentivize the delivery of high value treatments and services. In turn, ineffective or untested care could still be offered but at costs high enough to offset the delivery of high value care. AIMS The authors comment on Benson and Fendrick's paper on Value-Based Insurance Design (VBID) for mental health in the September 2023 special issue of this journal. The authors also present a preliminary framework of key ingredients needed to consider VBID for mental health treatments and services. METHODS The authors briefly review current and past efforts to contain costs and improve quality of mental health care, which include (for example) use of carve-out and carve-in programs, evaluation of cost sharing models, impact of accountable care organizations, and studying other benefit designs and impact of federal and state policies. RESULTS Using PTSD as an example, key ingredients of VBID for mental health services were identified and include the following: tools for case identification and monitoring progress over time at the population level; specific treatments and services with evidence of clinical effectiveness, cost-effectiveness, and health equity; and an approach to document the specific treatment or service was delivered (versus another treatment or service that may lack evidence). DISCUSSION The inability to afford mental health care is a top barrier to treatment seeking. People who do elect to spend time and money on mental health care are further disadvantaged by accessing care that is not well regulated and the quality at best is questionable. VBID could be an important lever for increasing access to and use of high value mental health care. Partnerships among the research, practice, and policy communities can help ensure research solutions meet needs of these two communities. IMPLICATIONS FOR HEALTH CARE VBID holds promise to make high value mental health care more affordable while discouraging low value treatments and services. IMPLICATIONS FOR HEALTH POLICIES While evidence gaps remain, these gaps can be filled concurrently with pursuit of VBID for mental health services. IMPLICATIONS FOR FUTURE RESEARCH This paper identifies important research opportunities to help make VBID a reality for mental health care.
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Affiliation(s)
- Michael C Freed
- Division of Services and Intervention Research; National Institute of Mental Health; 6001 Executive Boulevard, Bethesda, MD 20892, USA,
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Kennedy-Hendricks A, Eddelbuettel JCP, Bicket MC, Meiselbach MK, Hollander MAG, Busch AB, Huskamp HA, Stuart EA, Barry CL, Eisenberg MD. Impact of High Deductible Health Plans on U.S. Adults With Chronic Pain. Am J Prev Med 2023; 65:800-808. [PMID: 37187443 PMCID: PMC10592566 DOI: 10.1016/j.amepre.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/08/2023] [Accepted: 05/08/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Chronic pain affects an estimated 20% of U.S. adults. Because high-deductible health plans have captured a growing share of the commercial insurance market, it is unknown how high-deductible health plans impact care for chronic pain. METHODS Using 2007-2017 claims data from a large national commercial insurer, statistical analyses conducted in 2022-2023 estimated changes in enrollee outcomes before and after their firm began offering a high-deductible health plan compared with changes in outcomes in a comparison group of enrollees at firms never offering a high-deductible health plan. The sample included 757,530 commercially insured adults aged 18-64 years with headache, low back pain, arthritis, neuropathic pain, or fibromyalgia. Outcomes, measured at the enrollee year level, included the probability of receiving any chronic pain treatment, nonpharmacologic pain treatment, and opioid and nonopioid prescriptions; the number of nonpharmacologic pain treatment days; number and days' supply of opioid and nonopioid prescriptions; and total annual spending and out-of-pocket spending. RESULTS High-deductible health plan offer was associated with a 1.2 percentage point reduction (95% CI= -1.8, -0.5) in the probability of any chronic pain treatment and an $11 increase (95% CI=$6, $15) in annual out-of-pocket spending on chronic pain treatments among those with any use, representing a 16% increase in average annual out-of-pocket spending over the pre-high deductible health plan offer annual average. Results were driven by changes in nonpharmacologic treatment use. CONCLUSIONS By reducing the use of nonpharmacologic chronic pain treatments and marginally increasing out-of-pocket costs among those using these services, high-deductible health plans may discourage more holistic, integrated approaches to caring for patients with chronic pain conditions.
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Affiliation(s)
- Alene Kennedy-Hendricks
- Department of Health Policy and Management, Matthew Eisenberg's, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Johns Hopkins Center for Mental Health and Addiction Policy, Matthew Eisenberg's, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Mental Health, Matthew Eisenberg's, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Julia C P Eddelbuettel
- Department of Health Policy and Management, Matthew Eisenberg's, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mark C Bicket
- Department of Anesthesiology and Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Mark K Meiselbach
- Department of Health Policy and Management, Matthew Eisenberg's, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mara A G Hollander
- Department of Public Health Sciences, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, North Carolina
| | - Alisa B Busch
- McLean Hospital, Belmont, Massachusetts; Department of Health Care Policy, Harvard Medical School, Cambridge, Massachusetts
| | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, Cambridge, Massachusetts
| | - Elizabeth A Stuart
- Department of Health Policy and Management, Matthew Eisenberg's, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Johns Hopkins Center for Mental Health and Addiction Policy, Matthew Eisenberg's, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Mental Health, Matthew Eisenberg's, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Colleen L Barry
- Cornell Jeb E. Brooks School of Public Policy, Cornell University, Ithaca, New York
| | - Matthew D Eisenberg
- Department of Health Policy and Management, Matthew Eisenberg's, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Johns Hopkins Center for Mental Health and Addiction Policy, Matthew Eisenberg's, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Mental Health, Matthew Eisenberg's, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Gupta R, Yang L, Lewey J, Navathe AS, Groeneveld PW, Khatana SAM. Association of High-Deductible Health Plans With Health Care Use and Costs for Patients With Cardiovascular Disease. J Am Heart Assoc 2023; 12:e030730. [PMID: 37750565 PMCID: PMC10727247 DOI: 10.1161/jaha.123.030730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/23/2023] [Indexed: 09/27/2023]
Abstract
Background By increasing cost sharing, high-deductible health plans (HDHPs) aim to reduce low-value health care use. The association of HDHPs with health care use and costs in patients with chronic cardiovascular disease is unknown. Methods and Results This longitudinal cohort study analyzed 57 690 privately insured patients, aged 18 to 64 years, from a large commercial claims database with chronic cardiovascular disease from 2011 to 2019. Health care entities in which all or most beneficiaries switched from being in a traditional plan to an HDHP were identified. A difference-in-differences design was used to account for differences between individuals who remained in traditional plans and those who switched to HDHPs and to assess changes in health care use and costs. Among the 934 individuals in the HDHP group and the 56 756 in the traditional plan group, switching to an HDHP was not associated with statistically significant changes in annual outpatient visits, hospitalizations, or emergency department visits (-8.3% [95% CI, -16.8 to 1.1], -28.5% [95% CI, -62.1 to 34.6], and 11.2% [95% CI, -20.9 to 56.5], respectively). Switching to an HDHP was associated with an increase of $921 (95% CI, $743-$1099) in out-of-pocket costs but no statistically significant difference in total health care costs. Conclusions Among commercially insured patients with chronic cardiovascular disease, switching to an HDHP was not associated with a change in health care use but was associated with an increase in out-of-pocket costs. Although health care use by individuals with chronic cardiovascular disease may not be sensitive to higher cost sharing associated with HDHP enrollment, there may be a significant increase in patients' financial burden.
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Affiliation(s)
- Ravi Gupta
- Division of General Internal MedicineJohns Hopkins University School of MedicineBaltimoreMD
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
- Hopkins Business of Health Initiative, Johns Hopkins UniversityBaltimoreMD
| | - Lin Yang
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
| | - Jennifer Lewey
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Amol S. Navathe
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Division of General Internal Medicine, Perelman School of MedicineUniversity of PennsylvaniaPAPhiladelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Peter W. Groeneveld
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of General Internal Medicine, Perelman School of MedicineUniversity of PennsylvaniaPAPhiladelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
| | - Sameed Ahmed M. Khatana
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
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Hollander MAG, Kennedy-Hendricks A, Schilling C, Meiselbach MK, Stuart EA, Huskamp HA, Busch AB, Eddelbuettel JCP, Barry CL, Eisenberg MD. Do High-Deductible Health Plans Incentivize Changing the Timing of Substance Use Disorder Treatment? Med Care Res Rev 2023; 80:530-539. [PMID: 37345300 PMCID: PMC10961140 DOI: 10.1177/10775587231180667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
A high-deductible health plan (HDHP) may incentivize enrollees to limit health care use at the beginning of a plan year, when they are responsible for 100% of costs, or to increase the use of care at the end of the year, when enrollees may have less cost exposure. We investigated both the impact of the deductible reset that occurs at the beginning of a plan year and the option to enroll in an HDHP on the use of substance use disorder (SUD) treatment services over the course of a health plan year. We found decreases in SUD treatment use following the increase in cost exposure related to a deductible reset. There was no variation in this behavior between HDHP offer enrollees and comparison enrollees who were not offered an HDHP. These findings reinforce that cost-sharing poses a barrier to SUD care and continuity of care, which can increase the risk of adverse clinical outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Alisa B Busch
- Harvard Medical School, Boston, MA, USA
- McLean Hospital, Belmont, MA, USA
| | | | - Colleen L Barry
- Cornell Jeb E. Brooks School of Public Policy, Ithaca, NY, USA
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Doty ME, Gil LA, Cooper JN. Association between high deductible health plan coverage and age at pediatric umbilical hernia repair. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000526. [PMID: 36969906 PMCID: PMC10030914 DOI: 10.1136/wjps-2022-000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/20/2023] [Indexed: 03/29/2023] Open
Abstract
Background High deductible health plans (HDHPs) are associated with the avoidance of both necessary and unnecessary healthcare. Umbilical hernia repair (UHR) is a procedure that is frequently unnecessarily performed in young children, contrary to best practice guidelines. We hypothesized that children with HDHPs, as compared with other types of commercial health plans, are less likely to undergo UHR before 4 years of age but are also more likely to have UHR delayed beyond 5 years of age. Methods Children aged 0-18 years old residing in metropolitan statistical areas (MSAs) who underwent UHR in 2012-2019 were identified in the IBM Marketscan Commercial Claims and Encounters Database. A quasi-experimental study design using MSA/year-level HDHP prevalence among children as an instrumental variable was employed to account for selection bias in HDHP enrollment. Two-stage least squares regression modeling was used to evaluate the association between HDHP coverage and age at UHR. Results A total of 8601 children were included (median age 5 years, IQR 3-7). Univariable analysis revealed no differences between the HDHP and non-HDHP groups in the likelihood of UHR being performed before 4 years of age (27.7% vs 28.7%, p=0.37) or after 5 years of age (39.8% vs 38.9%, p=0.52). Geographical region, metropolitan area size, and year were associated with HDHP enrollment. Instrumental variable analysis demonstrated no association between HDHP coverage and undergoing UHR at <4 years of age (p=0.76) or >5 years of age (p=0.87). Conclusions HDHP coverage is not associated with age at pediatric UHR. Future studies should investigate other means by which UHRs in young children can be avoided.
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Affiliation(s)
- Morgan E Doty
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Lindsay A Gil
- Department of Surgery, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Jennifer N Cooper
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio, USA
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Meiselbach MK, Kennedy-Hendricks A, Schilling C, Busch AB, Huskamp HA, Stuart EA, Hollander MAG, Barry CL, Eisenberg MD. High deductible health plans and spending among families with a substance use disorder. Drug Alcohol Depend 2022; 241:109681. [PMID: 36370532 PMCID: PMC9976712 DOI: 10.1016/j.drugalcdep.2022.109681] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The United States faces an ongoing drug crisis, worsened by the undertreatment of substance use disorders (SUDs). Family enrollment in high deductible health plans (HDHPs) and the resulting increased cost exposure could exacerbate the undertreatment of SUD. This study characterized the distribution of health care spending within families where a member has a SUD and estimated the association between HDHPs and family health care spending. METHODS Using commercial claims and enrollment data from OptumLabs (2007-2017), we identified a treatment group of enrollees whose employers began offering an HDHP and comparison group whose employers never offered an HDHP. We used a difference-in-differences analysis that compared health care spending in families at firms that did vs. did not offer an HDHP before and after the HDHP offer. All models were adjusted for employer and year fixed effects, as well as family demographics, size, and chronic conditions. RESULTS Our sample was comprised of 317,353 family-years. Family members with a SUD, on average, contributed an outsized proportion of total family health care expenditures (56.9% in a family of three). Offering a family HDHP was associated with a 6.1% reduction (95% confidence interval [CI]: 9.7-2.6%) in the probability of families having any SUD-related expenditures. The HDHP offer was associated with a $1546 reduction in family total expenditures and a $1185 reduction for the individual with SUD (95% CI: -2272 to -821 and -1845 to -525, respectively). CONCLUSIONS The increased prevalence of family enrollment in HDHPs may further the existing issue of undertreatment of SUDs.
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Affiliation(s)
- Mark K Meiselbach
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; OptumLabs Visiting Fellow, USA.
| | - Alene Kennedy-Hendricks
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Cameron Schilling
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alisa B Busch
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA; McLean Hospital, Boston, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Elizabeth A Stuart
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mara A G Hollander
- Department of Public Health Sciences, University of North Carolina - Charlotte, Charlotte, NC, USA
| | - Colleen L Barry
- Cornell Jeb E. Brooks School of Public Policy, Ithaca, NY, USA
| | - Matthew D Eisenberg
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Johns Hopkins Carey Business School, Baltimore, MD, USA
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Huang TY, Togun A, Boese T, Dowd BE. Analysis of Affordable Health Care. Med Care 2022; 60:718-725. [PMID: 35866553 DOI: 10.1097/mlr.0000000000001755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lack of affordable health care affects the uninsured, commercially insured, and Medicare beneficiaries. Yet, the wide variation in providers' prices and practice styles suggests that more affordable care already may be available and data on low value and wasteful care suggest that lower cost care need not come at the expense of better quality. Although price variation has received the most attention in the literature and legislation, total cost of care is a function of both unit prices (fees) and the quantity of services. OBJECTIVE To partition provider-specific variation in total annual risk-adjusted per capita expenditures on health care services into variation in unit prices (fees) versus quantities of services, and to explore the relationship between low value, avoidable, discretionary, and recommended care to total health expenditures. The analysis is important because both prices and quantities of services can affect affordability and reductions in prices versus quantities have very different effects on providers' profits. SETTING 2018 data from the Minnesota State Employees Group Insurance Program (SEGIP) that offers a tiered cost-sharing health insurance benefit design to 130,000 State employees and their dependents (SEGIP "members"). EXPOSURE Each year during open enrollment, SEGIP members choose a primary care clinic (PCC). The PCC can make decisions regarding both unit prices and prescribed services. PCCs are placed in one of four cost-sharing tiers based on the total annual risk-adjusted per capita health expenditures for the SEGIP members who choose their clinic. Members choosing higher cost PCCs face higher deductibles, copayments, and maximum out-of-pocket spending limits. MEASURES Overall prices and use of inpatient, outpatient hospital, professional, and pharmaceutical services, total and avoidable use of emergency department visits and inpatient admissions, low value care, testing for patients with pneumonia, and recommended preventive care. RESULTS Differences in total risk-adjusted annual per capita health expenditures across the care systems were substantial. Higher cost providers had both higher unit prices and higher use of services. Variation in the quantity of health care services explained more of the variance in total spending than variation in prices. Prices for professional services and use of inpatient, outpatient hospital, and pharmaceutical services, and ambulatory care sensitive admissions, contributed significantly to high total expenditures. Lower cost PCCs in the lowest cost-sharing tier had higher rates of low value care and lower emergency department visits per capita. Neither the number of investigations for patients with pneumonia nor the receipt of recommended mammography screening varied systematically by tier. CONCLUSIONS Efforts to identify and expand sources of affordable care, including improved information and incentives for consumers, need to account for variation in both prices and quantities of services. Efforts to encourage more efficient use of health care services by providers need to consider the effect of those efforts on the provider's internal costs and thus their profits.
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Affiliation(s)
- Tsan-Yao Huang
- Health Policy and Management, University of Minnesota, Minneapolis, MN
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Glied SA, Remler DK, Springsteen M. Health Savings Accounts No Longer Promote Consumer Cost-Consciousness. HEALTH AFFAIRS (PROJECT HOPE) 2022; 41:814-820. [PMID: 35666974 DOI: 10.1377/hlthaff.2021.01954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Two decades ago Congress enabled Americans to open tax-favored health savings accounts (HSAs) in conjunction with qualifying high-deductible health plans (HDHPs). This HSA tax break is regressive: Higher-income Americans are more likely to have HSAs and fund them at higher levels. Proponents, however, have argued that this regressivity is offset by reductions in wasteful health care spending because consumers with HDHPs are more cost-conscious in their use of care. Using published sources and our own analysis of National Health Interview Survey data, we argue that HSAs no longer appreciably achieve this cost-consciousness aim because cost sharing has increased so much in non-HSA-qualified plans. Indeed, people who have HDHPs with HSAs are becoming less likely than others with private insurance to report financial barriers to care. In sum, promised gains in efficiency from HSAs have not borne out, so it is difficult to justify maintaining this regressive tax break.
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Affiliation(s)
- Sherry A Glied
- Sherry A. Glied , New York University, New York, New York
| | - Dahlia K Remler
- Dahlia K. Remler, Baruch College, City University of New York, New York, New York
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Cliff BQ, Avanceña ALV, Hirth RA, Lee SYD. The Impact of Choosing Wisely Interventions on Low-Value Medical Services: A Systematic Review. Milbank Q 2021; 99:1024-1058. [PMID: 34402553 DOI: 10.1111/1468-0009.12531] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Policy Points Dissemination of Choosing Wisely guidelines alone is unlikely to reduce the use of low-value health services. Interventions by health systems to implement Choosing Wisely guidelines can reduce the use of low-value services. Multicomponent interventions targeting clinicians are currently the most effective types of interventions. CONTEXT Choosing Wisely aims to reduce the use of unnecessary, low-value medical services through development of recommendations related to service utilization. Despite the creation and dissemination of these recommendations, evidence shows low-value services are still prevalent. This paper synthesizes literature on interventions designed to reduce medical care identified as low value by Choosing Wisely and evaluates which intervention characteristics are most effective. METHODS We searched peer-reviewed and gray literature from the inception of Choosing Wisely in 2012 through June 2019 to identify interventions in the United States motivated by or using Choosing Wisely recommendations. We also included studies measuring the impact of Choosing Wisely on its own, without interventions. We developed a coding guide and established coding agreement. We coded all included articles for types of services targeted, components of each intervention, results of the intervention, study type, and, where applicable, study quality. We measured the success rate of interventions, using chi-squared tests or Wald tests to compare across interventions. FINDINGS We reviewed 131 articles. Eighty-eight percent of interventions focused on clinicians only; 48% included multiple components. Compared with dissemination of Choosing Wisely recommendations only, active interventions were more likely to generate intended results (65% vs 13%, p < 0.001) and, among those, interventions with multiple components were more successful than those with one component (77% vs 47%, p = 0.002). The type of services targeted did not matter for success. Clinician-based interventions were more effective than consumer-based, though there is a dearth of studies on consumer-based interventions. Only 17% of studies included a control arm. CONCLUSIONS Interventions built on the Choosing Wisely recommendations can be effective at changing practice patterns to reduce the use of low-value care. Interventions are more effective when targeting clinicians and using more than one component. There is a need for high-quality studies that include active controls.
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Affiliation(s)
- Betsy Q Cliff
- School of Public Health, University of Illinois Chicago
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