Behavioral Healthcare Services
Utilization between
Health Savings Account Members and
Traditional Health Plan Members
Nancy A. Hardie*, Anthony Lo Sasso** and
Regina A. Levin*
* United Healthcare, Minneapolis, MN
** University of Illinois at Chicago, Chicago, Ill
Objective
To estimate the effects of switching from
traditional health plans to health savings
accounts (HSAs) on:
• Initiation of behavioral health treatment
• Intensity of behavioral health outpatient
treatment once initiated
2
Study Design
•
Quasi-Experimental (difference-in-differences)
•
Retrospective
•
Pre - Post Study (pre/post offer of HSA)
•
Cohorts
1. Traditional plan take-up (“Stayers”)
2. HSA plan take-up (“Switchers”)
3
Study Design
Cohorts
2005
Pre HSA Offer
Stayers
2006
Post HSA Offer
2007
Post HSA Offer
Traditional Plans
Traditional Plans
HSAs
HSAs
Traditional
Plans Only
Switchers
All Cohort Members:
36 Months Continuous Enrollment
4
Data Source
• All data were extracted from the data repository of
UnitedHealthcare, which provides a full complement of
traditional plan designs in addition to being the leading
provider of consumer driven healthcare plans in the
country.
• The data contain linkable datasets of member, employer,
medical and pharmacy claims information.
• Data have been aggregated to the person-year level.
5
Employer Criteria
• Employed between 2 and 4,999 persons
• Offered medical and pharmacy coverage
• 2005: offered only traditional plans (Pre-year)
• 2006 & 2007: offered an option to choose
• CDHP with HSA or
• Traditional health plan
• Coverage started on January 1st in all study years
(2005, 2006 and 2007)
 This resulted in 251 employers
6
Member Criteria
• Members and subscribers age < 65 on last day of
study
• No coordination of benefits
• 36 months of continuous membership in
commercial insurance plan
• Remained in traditional plans in 2006 and or2007
(Post-years) or switched to an HSA in 2006 and
remained in HSA in 2007

This resulted in 60,294 members
7
Study Design
Cohorts
2005
Pre HSA Offer
2006
Post HSA Offer
Traditional Plans
N =50,316
Stayers
2007
Post HSA Offer
Traditional Plans
N =50,316
Traditional
Plans Only
N=60,294
Switchers
All Cohort Members:
(251
Employers)
HSAs
N=9,978
HSAs
N=9,978
36 Months Continuous Enrollment
8
Methods
• Employer and member selection
• Data Extraction
• Data Verification
• Descriptive data summaries
• Multivariate analyses
9
Methods
Dependent variables:
• Behavioral health treatment (0/1) in each year [Logistic
regression]
• First primary ICD9 codes (290-314) per year
• Log of outpatient treatment visits in each years conditional
on initiation [OLS regression]
• Primary ICD9 codes (290-314)
10
Methods
Independent variables:
•
•
•
•
•
•
•
•
•
Post year variables (2006 & 2007)
Cohort
Post year variables & cohort interaction terms
Health risk score (Symmetry ETG Grouper)
Age (2005)
Gender
Region (2005)
Employer size (2005)
Seven psychiatric disorder indicators
(for intensity regression)
•
•
•
•
•
•
Anxiety disorders,
Major depression,
Schizophrenia and bipolar disorders,
Alcohol and substance abuse disorders,
Conduct disorders, personality disorders and
Other behavioral disorders
11
Dependent Variables
Percent (%) Initiating Behavioral Health Treatment per Year
12.0%
10.0%
9.7%
9.5%
8.4%
7.5%
8.0%
7.4%
7.5%
6.0%
4.0%
2.0%
0.0%
Stayers
N=50,316
Switchers
N=9,978
2005
2006
2007
12
Dependent Variables
Behavioral Health Intensity
(Among Members Who Received Outpatient Treatment)
Mean
Outpatient
Visits PMPY
2005
2006
2007
2005
2006
2007
Mean
6.52
6.62
6.34
6.07
6.18
5.76
SD
9.53
9.36
9.17
8.45
8.89
8.14
4,202
4,872
4,751
744
739
747
N
Stayers
Switchers
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Independent Variables
Pre-Offer of HSA: 2005
Variables
Mean (SD) Retrospective Risk Score
Stayers
Switchers
1.09 (1.7)
0.93 (1.6)
32.7 (17.6)
32.0 (17.5)
% Female
50.7%
49.3%
% Northeast (reference)
10.9%
6.6%
% South
47.8%
43.2%
% Midwest
29.1%
41.4%
% West
12.2%
8.8%
% Large Firm (vs. small)
93.6%
65.6%
N
50,316
9,978
Mean (SD) Age
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Initiation of Behavioral Health Treatment
Logistic Regression
Coeff
SE
OR
Post Year 2006 * Switcher
-0.043
0.015
0.96
0.0037
Post Year 2007 * Switcher
-0.032
0.015
0.97
0.0306
Post Year 2006
0.022
0.015
1.02
0.1343
Post Year 2007
0.018
0.015
1.02
0.2272
-0.132
0.016
0.88
<.0001
Switcher (Stayer reference)
P-value
N = 60,291 members
Model also controls for age, gender, risk score, region, large/small firm
15
Intensity of Behavioral Health Treatment
(Log of Days in Outpatient Treatment)
OLS Regression
Variable
β
Post Year 2006 * Switcher
-0.018
0.056
0.750
Post Year 2007 * Switcher
-0.039
0.056
0.480
Post Year 2006
0.006
0.021
0.761
Post Year 2007
-0.041
0.021
0.049
0.017
0.040
0.673
Switcher (Stayer reference)
SE β
Probability-value
N = 16,053 members
Model also controls for age, gender, risk score, region, large/small firm, and
indicators for type of behavioral health disorder.
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Conclusions
• Our results indicate that there is a relative decline in
behavioral treatment initiation associated with enrollment
in an HSA, though this was driven by an increase in
initiation among stayers not a decline in use among
switchers.
• Conditional on behavioral health treatment, we did not
observe a significant difference in outpatient visit
intensity between HSA and traditional plan enrollees.
• Importantly, our results are not sensitive to the
inclusion/exclusion of explanatory variables such as the
Ingenix retrospective risk score, supporting our quasiexperimental design
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Implications for Policy Delivery or Practice
• Our findings support the notion - dating back to the RAND Health
Insurance Experiment - that greater demand side cost sharing
affects initiation into treatment, but has more modest effects on
intensity of treatment
• The logic of this is that consumers have more discretion over the
decision to initiate treatment while providers have more discretion over
the intensity of treatment
• For a serious chronic condition like a behavioral health disorder, our
results are a mixed message
• While treatment initiation does not decline in absolute terms, it falls
modestly in relative terms
• However, conditional on any use, we find little differences in outpatient
mental health treatment use compared to traditional plan enrollees
• Future work will explore the type of care mental health received
(outpatient vs. pharmacy), costs, and quality
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Collaborators
• Mona Shah, Health Services Research
Manager
• Grace Shen, SAS Programmer
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Psychiatric Disorders
(in OLS Regression)
7
Percent
6
5
4
3
2
1
0
2005
2006
2007
Stayers
2005
2006
2007
Switchers
Anxiety Disorders
Major Depression
Schizophrenia & Bipolar Disorders
Alcohol and Substance Abuse Disorders
Conduct Disorders
Personality Disorders
Other Behavioral Disorders
20