How Valid are the Assumptions
Underlying ConsumerConsumer-Driven
Health Plans?
Judith H. Hibbard, DrPH
J
Jessica
i G
Greene, PhD
University of Oregon
Funding Provided by the RWJF HCFO
C O initiative
CDH Assumptions
Consumers will make more costeffective health care choices
 Consumers will become more
activated and engaged– seeking out
and
a
d us
using
g information
o at o a
and
d ta
taking
g
better care of their own health

Methods
Study setting--Large employer with
multiple worksites in Midwest.
 Employees offered high deductible
C
CDH,
lower deductible C
CDH and PPO.
O
 Medical and Pharmacy Claims data
obtained
bt i d for
f year prior
i to
t CDH
introduction and for 2 years after CDH
introduction.
introduction
 Surveys of employees in first year of
CDH 2 year and 3rd year
CDH,

Cost-effective Choices
CostInvestigated
Two
Different
Ways
 Does enrollment in CDH influence
chronic illness-related prescription
drug utilization? (pharmacy claims
only)
l )
 Generic substitution
 Reducing adherence
 Discontinuing drug

Does enrollment in CDH influence the
choice of evidence-based care?
(
(survey
data
d t and
d medical
di l claims
l i
d
data)
t )
Proportion of Claims in the Class
Th W
That
Were G
Generic
i
2nd Half of 2003 Compared with 2004
Antidepressants
High
Lower
Deductible Deductible
33-Tiered
Tiered
PV l
P-Value
CDHP
CDHP
Formulary
24% to 27% 28% to 34% 29% to 34% 0.31
Antidiabetics
32% to 52% 31% to 48% 26% to 48%
0 33
0.33
Antihypertensives
49% to 52% 42% to 43% 45% to 48%
0.71
Antiulcerants
26% to 23% 23% to 23% 19% to 19%
0 60
0.60
D
Drug
Cl
Class
Asthma Controllers
2% to 1%
3% to 2%
2% to 2%
0.72
Lipid
p Lower Drugs
g
4% to 3%
5% to 5%
5% to 4%
0.75
The p-value indicates how likely the change in generic use is the same across the three plans.
Percent of Enrollees that Discontinued
Prescriptions For Chronic Illness Medications
in 2004 (Year CDHPs Were Introduced)
Antidepressants
High
Deductible
CDHP
20.8% (221)
Lower
Deductible
CDHP
17.8% (824)
20.9% (1582)
0.19
Antidiabetics
19.4% (31)
7.5% (213)
7.3% (427)
0.05
Antihypertensives
13.2% (190)
6.3% (1005)
6.7% (1904)
< 0.01
Antiulcerants
40 2% (107)
40.2%
22 5% (637)
22.5%
21 9% (1228)
21.9%
< 00.01
01
Asthma Controllers
35.8% (81)
19.7% (264)
32.8% (491)
< 0.01
Lipid
p Lower Drugs
g
14.5% ((117))
8.2% ((612))
7.9% ((923))
0.05
Drug Classes
3-Tiered
Formulary
P-value
Summary of Findings

Neither CDHP:
◦ Stimulated greater generic use
◦ Influenced adherence to chronic illness medications
(
(among
th
those
who
h continued
ti
d medication)
di ti )

The high deductible CDHP:
◦ Increased likelihood of discontinuing several classes of
“essential” chronic illness medications, but not all

The lower deductible CDHP:
◦ Reduced the likelihood of discontinuing asthma
controllers
Operationalizing Cost
Cost--Effective
Ch i
Choices
Using
g a schema based on the Oregon
g
Health Plan priority list, ICD-9 codes
y office visits into
were used to classify
more effective (evidence for efficacy)
vs less effective ((little evidence for
efficacy)
 Acute
cu e a
and
dC
Chronic
o c visits
s s were
ee
categorized into HIGH PRIORITY OR
LOW PRIORITY.

Examples of the most common “low
priority”
i it ” acute
t and
d chronic
h i visits
i it

Acute
◦ Acute non-specific upper respiratory
infection
◦ Cough
◦ Acute pharyngitis
◦ Impacted cerumen (earwax)

C o c
Chronic
◦ Allergic Rhinitis
non specific
◦ Rotator cuff syndrome non-specific
Utilization by Plan Type:
Count
C
off the
h totall visits
i i per year
Low Priority Acute Visits
High Priority Acute Visits
Low Priority Chronic Visits
High Priority Chronic Visits
Fixed Effects Linear Regression Models of
High and Low Deductible CDHP Plan
Enrollment on Utilization Compared With PPO
Enrollment
1st year in
Low Deductible CDHP
(n = 6,839)
2nd year in
Low Deductible CDHP
(n = 3,046)
1st year in
High Deductible CDHP
(n = 2,234)
2nd year in
High Deductible CDHP
(n = 1,020)
-.19***
.00
-.46***
-.44***
(.02)
(.02)
(.03)
(.05)
Low Priority Acute
-.33***
-.18***
-.42***
-.39***
Visits
(.03)
(.04)
(.05)
(.07)
Low Priority Chronic
-.20***
-.01
-.60***
-.53***
Visits
( 04)
(.04)
( 05)
(.05)
( 07)
(.07)
( 10)
(.10)
High Priority Acute
-.23***
-.05
-.39***
-.47***
Visits
(.03)
(.04)
(.05)
(.07)
High Priority Chronic
-.14***
.04
-.63***
-.58***
Visits
(.03)
(.04)
(.06)
(.08)
Dependent Variable
Total Visits
Total Office Visits
Low Priority Visits
High Priority Visits
Summary
Utilization declined in the first year in a
CDH
 Reductions appear to be equal in high
and low priority care.
 Reductions were even greater for the
hi h d
high
deductible
d tibl plan--and
l
d th
the second
d
year reductions were largely sustained
 Cost
C t sharing
h i used
d iin CDH appears tto
stimulate indiscriminant reductions in
care

CDH increase Engagement and
A i i ?
Activation?
More activated more likely
y to enroll in
CDH
 Activation did not increase in any of
the plan designs
 Those who were more activated more
likely to seek information and to
engage in healthy behaviors
regardless of plan design

Discussion
Cost sensitivity
y is increased
 Findings do not support assumptions
about cost effective choices

◦ Prescription drug use
◦ High priority care
◦ Findings do not support assumptions
about increasing consumer activation