Consumers’ Use of
Preventive Care in CDHPs
Jessica Greene PhD
Judith Hibbard DrPH
Department of Planning, Public Policy & Management
The University of Oregon
Prevention & Cost Sharing
• Little is known about consumers’ use of
preventive care in CDHPs
• Generally co-pays, co-insurance & deductibles
have lowered rates of preventive care (Blustein
95, Karter 00, Solanki 00, Liang 04,)
• There have been recent calls for targeted cost
sharing (Fendrick 06, Chernew 07)
– Alcoa increased cost sharing and exempted
prevention, resulting in no change in
preventive care (Busch et al 2006)
Research Question
Do consumers alter use of preventive
care in a CDHP, when prevention is
excluded from the deductible?
Methods
Three year cohort study (2003-2005)
• Employees of a large company offered CDHPs
alongside traditional coverage in 2004 and 2005
• 18,025 adults (employees & spouses)
• Use medical claims to examine 3 NCQA
prevention measures
– Cervical Cancer Screening
– Colorectal Cancer Screening
– Breast Cancer Screening
• Fixed effects analysis used to examine the
estimated impact on prevention from enrolling in
a CDHP
Plan Details
Family Coverage 2004
Premium
Hourly
Salaried
Deductible Level
Personal Care Account
Gap (Deductible-PCA)
Enrollment
2004
2005
High
Deductible
CDHP
Lower
Deductible
CDHP
$1,260
$420
$420-$1,128 $1,260-$2,600
$3,000
$1,500
$1,500
13%
13%
$2,000
$1,500
$ 500
23%
41%
PPO
$1,260
$1,260-$3,600
$600/$1,050
n/a
n/a
60%
43%
Cervical Cancer Screening
(Percentage of women 21-64 who had screen during year)
70
60
50
40
30
20
10
0
2003
High Deductible 04 & 05
2004
Lower Deductible 04 & 05
2005
PPO 04 & 05
Colorectal Cancer Screening
(Percentage of people 51-80 who had screen during year)
50
40
30
20
10
0
2003
High Deductible 04 & 05
2004
Lower Deductible 04 & 05
2005
PPO 04 & 05
Breast Cancer Screening
(Percentage of women 52-69 who had screen during year)
70
60
50
40
30
20
10
0
2003
High Deductible 04 & 05
2004
Low Deductible 04 & 05
2005
PPO 04 & 05
Odds Ratios from
Fixed Effects Models
Cervical
Cancer
Screening
Colorectal
Cancer
Screening
Breast
Cancer
Screening
High
Deductible
CDHP
1.1
0.9
0.5*
Lower
Deductible
CDHP
1.0
1.0
0.6***
Year 2
0.9**
1.0
1.1
Year 3
0.9*
1.0
1.1
*p<.05, **p<.01, ***p<.001
Summary
• Those who selected CDHPs were equally likely
to receive preventive care in the baseline year
as those remaining in PPO
• Enrollment in a CDHP, which exempted
prevention from the deductible:
– did not impact rates of colorectal or cervical
cancer screening
– appears to have reduced breast cancer
screening
Strengths & Limitations
Strengths
• Fixed effects technique addresses selection
bias by controlling for all individual
characteristics that do not change over time
Limitations
• One employer, offering a Health
Reimbursement Account model
• Company changed information systems and
we were unable to include ~1/3 of the sample
in the third year (2005)
Implications
• Targeted cost sharing (exempting prevention from
deductibles) has potential to maintain preventive care
rates, but it requires consumers to understand greater
detail about their health plan
• Monitoring of preventive care in CDHPs that do not
exempt prevention- as well as other quality care
indicators in all CDHPs- is warranted
– Only 22% of CDHP enrollees have prevention exempted
(Claxton, 2006)
• CDHP providers and employers should consider
exempting prevention from the deductible- and
examine its impact on utilization
Acknowledgements
The authors wish to acknowledge both the
participating employer and CDHP for their
openness and commitment to research.
We also would like to thank “The Changes in
Health Care Financing and Organization”
(HCFO), a program of The Robert Wood Johnson
Foundation, for providing support for this
research.