How does enrollment in CDHPs impact
on consumerist behaviours?
Anna Dixon, Jessica Greene
and Judith H Hibbard
University of Oregon
Funding provided by The Changes in Health Care Financing and Organization
(HCFO) initiative, a program of The Robert Wood Johnson Foundation, and the
Commonwealth Fund
Research questions


Do consumer directed health plans influence
enrollees health and health care behaviors?
Compared to employees who remained in a
PPO are employees who enrolled in CDHPs
more likely to begin to
–
–
–
use health and cost information,
make cost-sensitive utilization decisions and
undertake regular healthy activities?
Analysis

Dependent variables: self reported behaviors
–
–
–



Information seeking
Cost sensitive decisions
Healthy behaviors
Cross sectional analysis of behaviors in 2003 by
plan type
Analysis of behaviors in 2004 & 2005 among those
who were not doing the behaviors in the previous
year by plan type (bivariate and multivariate)
Control variables: health status, chronic conditions,
age, income, ethnicity, gender, work type, and survey
mode
Information seeking
pre-enrollment year by plan type (bivariate)
High
Deduct
CDHP
Lower
Deduct
CDHP
PPO
%
sample
(N)
Used any website for health
information other than their plan’s
48.3%
51.8%
39.8%***
45.8%
Used website or booklet that
compares the quality of hospitals
6.2%
7.7%
5.6%
6.4%
Used website or book that helps you
figure out how to handle symptom or
problem
40.1%
46.3%
36.0%***
40.1%
Used website or booklet that
compares prescription drug costs
15.7%
22.0%
15.7%***
17.5%
*p<.10 **p<.05 ***p<.01
Initiated information seeking
during first 6 months enrollment by plan type in
2004 (multivariate)
High
Deduct
CDHP
Lower
Deduct
CDHP
PPO
%
sample
(N)
Used any website for health
information other than their plan’s
1.31
2.20***
(1.0)
6.6%
(1123)
Used website or booklet that
compares the quality of hospitals
0.71
4.23***
(1.0)
1.8%
(1944)
Used website or book that helps you
figure out how to handle symptom or
problem
0.71
1.49
(1.0)
10.4%
(1237)
2.22**
3.42***
(1.0)
4.8%
(1711)
Used website or booklet that
compares prescription drug costs
Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode.
Denominator in each case is those who did not report doing the behavior in 2003
*p<.10 **p<.05 ***p<.01
Initiated information seeking
during 2nd year of enrollment by plan type in 2005
(multivariate)
Lower
High Deduct
Deduct
CDHP
CDHP
PPO
%
sample
(N)
Used any website for health
information other than their plan’s
1.06
1.18
(1.0)
21.0%
(637)
Used website or booklet that
compares the quality of hospitals
0.98
0.80
(1.0)
5.7%
(1084)
Used website or book that helps you
figure out how to handle symptom or
problem
0.80
1.12
(1.0)
25.0%
(713)
Used website or booklet that
compares prescription drug costs
0.57*
0.88
(1.0)
9.1%
(957)
Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode.
Denominator in each case is those who did not report doing the behavior in 2004
No statistically significant relationship
*p<.10 **p<.05 ***p<.01
Summary of findings: Information



Active information seekers more likely to select low
deductible CDHP
Enrollees in low deductible CDHPs more likely to
initiate health and quality information seeking than
enrollees in either high deductible CDHP or PPO
within first 6 months
Enrollees in both CDHPs more likely to initiate cost
information seeking than enrollees in PPO within first
6 months
Cost sensitive behaviors
pre-enrollment year by plan type (bivariate)
High
Deduct
CDHP
Lower
Deduct
CDHP
PPO
%
sample
(N)
Decide not to go to the doctor when
you thought you should have to save
money
16.1%
18.1%
18.6%
17.7%
Not fill a prescription to save money
8.2%
9.8%
10.9%
9.8%
Take a lower dose of a prescription
drug than was recommended in order
to save money
3.7%
4.6%
4.8%
4.4%
Postpone or delay having a medical
procedure or surgery to save money
9.2%
9.5%
10.3%
9.7%
4.9%
5.0%
4.7%
4.8%
Decide to have a less expensive
diagnostic test to save money
No statistically significant relationship
*p<.10 **p<.05 ***p<.01
Initiated cost sensitive behaviors
during first 6 months of enrollment by plan type in
2004 (multivariate)
High
Deduct
CDHP
Lower
Deduct
CDHP
PPO
% sample
(N)
Decide not to go to the doctor when you
thought you should have to save money
3.47***
1.67
(1.0)
3.8%
(1715)
Not fill a prescription to save money
2.84**
1.04
(1.0)
2.6%
(1873)
Take a lower dose of a prescription drug
than was recommended in order to save
money
3.25**
0.74
(1.0)
1.6%
(1983)
2.73**
1.70
(1.0)
2.16
0.79
(1.0)
Postpone or delay having a medical
procedure or surgery to save money
Decide to have a less expensive
diagnostic test to save money
2.6%
(1877)
1.4%
(1949)
Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode.
Denominator in each case is those who did not report doing the behavior in 2003
*p<.10 **p<.05 ***p<.01
Initiated cost sensitive behaviors
during 2nd year of enrollment by plan type in 2005
(multivariate)
High
Deduct
CDHP
Lower
Deduct
CDHP
PPO
%
sample
(N)
Decide not to go to the doctor when
you thought you should have to save
money
1.99**
1.56
(1.0)
9.2%
(1020)
Not fill a prescription to save money
1.25
0.71
(1.0)
5.0%
(725)
1.44
2.89**
(1.0)
5.6%
(750)
1.82
2.43**
(1.0)
4.8%
(1073)
2.08*
1.75
(1.0)
5.0%
(1091)
Take a lower dose of a prescription
drug than was recommended in
order to save money
Postpone or delay having a medical
procedure or surgery to save money
Decide to have a less expensive
diagnostic test to save money
Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode.
Denominator in each case is those who did not report doing the behavior in 2004
*p<.10 **p<.05 ***p<.01
Summary of findings: Cost saving


Enrollees in high deductible CDHPs more
likely to have started taking risky cost
sensitive behaviors within 6 months of
enrollment
Similar issues emerging for low deductible
CDHPs during year 2 with drug use and
procedures
Healthy behaviors
baseline in 2004 by plan type in 2005 (bivariate)
Limit how much fat is in your diet on
most days per week
High
Deduct
CDHP
Lower
Deduct
CDHP
PPO
% sample
(N)
50.5%
51.7%
43.5%***
47.9%
(2094)
56.2%
51.4%
48.3%***
51.6%
(2102)
36.6%
36.3%
35.2%***
35.9%
(2101)
Exercise on most days per week
Eat 5 or more fruits or veggies a day
on most days per week
*p<.10 **p<.05 ***p<.01
Initiated healthy behaviors
during 2nd year of enrollment by plan type in 2005
(multivariate)
Limit how much fat is in your diet on
most days per week
Exercise on most days per week
Eat 5 or more fruits or veggies a day
on most days per week
High
Deduct
CDHP
Lower
Deduct
CDHP
%
sample
(N)
PPO
1.69*
0.93
(1.0)
27.6%
(580)
1.47
0.92
(1.0)
30.2%
(569)
0.76
0.82
(1.0)
18.3%
(749)
Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode.
Denominator in each case is those who did not report doing the behavior in 2004
*p<.10 **p<.05 ***p<.01
Summary of findings: Healthy
behaviors


Enrollees in CDHPs more likely to do regular
healthy activities than enrollees in PPO
Emerging trend that enrollees in high
deductible CDHPs are more likely to
regularly limit fat in diet compared to low
deductible and PPO
Implications for US policy

Cost exposure may result in ‘bad’ decisions
–
–

Availability of information tools may result in greater
use of health and cost information
–

Do some people make greater use of tools than others?
Information + financial incentives may increase level
of healthy activities
–

Design of CDHPs is critical: size of ‘gap’
Monitor impact of HSAs/HRAs on utilization
Who are these people? Are behaviors maintained?
Are people who select these plans predisposed to
the behaviors already? Is there selection?