Preventive Care in Consumer Directed
Health Plans:
Do Consumers Avoid Deductible
Exempt Care?
Mary
y Reed,, DrPH1
Vicki Fung, PhD1
Ilana Graetz1
John Hsu, MD MBA MSCE2
1Kaiser
Permanente Division of Research
2Mongan Institute for Health Policy, Massachusetts General Hospital
& Department of Health Care Policy, Harvard Medical School
AcademyHealth Annual Research Meeting June 2010
Introduction
 Consumer directed health plans (including HSA-eligible
plans) could encourage patient participation as consumers
 Exemption
p
of p
preventive care from deductible should
remove cost barrier
 Limited
Li it d iinformation
f
ti
on patient
ti t k
knowledge
l d
off preventive
ti care
exemptions or subsequent effects on patient care-seeking
choices
Research Questions
 Do members with a consumer directed health plan
understand which preventive services are exempt from the
deductible?
 How does knowledge of exemptions affect patient care-
seeking for:


Preventive Office Visits: 1 Annual Routine Physical
Preventive Medical Tests




Cholesterol Lab Test
Diabetes Lab Test
Colon Cancer Screening
Mammogram
Background: HSA
HSA-eligible
eligible Plans
 Deductibles in this setting
g $1,400-2,700 (($2,800- $5,450 for
families)
 Paid full cost of care (until deductible) for deductibleapplicable

No out of pocket cost for exempt services
 Contributions from employee and/or employer
 Account can be used to pay for any qualified expenses
 Account balance is owned by employee until spent
Methods
 Setting: Integrated Delivery System (KPNC)
 Design: Cross-sectional telephone interviews collected in
2008


488 respondents
78% response rate
 Population: Randomly selected sample
 Adults
 Employer-sponsored HSA-eligible high deductible insurance plan
 Benefit structure: deductible applicable/exempt services
 English-speaking
Questionnaire Measures
 Knowledge
D
Does
your h
health
lth insurance
i
plan
l
iinclude
l d ad
deductible?
d tibl ?
Did the following services apply to your deductible?
 Annual routine preventive physical exams (PCP)
 Preventive health screening and lab tests
 Care-seeking Behavior
Because of the amount you had to pay, did you delay or avoid:
 Annual routine physical (with your PCP)?
 Cholesterol lab test?
 Diabetes lab test (fasting blood glucose test)?
 Screening test for colon cancer?
 Mammogram?
Analysis: Multivariate Logistic Regression
 Dependent Variable

M d l1
Model
1: D
Delay
l or avoid
id yearly
l routine
ti
physical
h i l

Model 2: Delay or avoid any preventive test or screening
 Independent Variable
 Knowledge of preventive service exemption
 Covariates
 Socio-demographic:
Socio demographic: Age,
Age Gender,
Gender Race/ethnicity,
Race/ethnicity Marital status,
status
Household income, Educational level
 Clinical: Self-reported health status, Chronic disease
Table 1. Participant Characteristics
Characteristic
N
%
Gender: Female
241
49.4
Have a PCP
428
87.7
Health Status: Very Good/Excellent
197
40.4
Marital Status: Married
277
56.8
Race/Ethnicity: Non-White
175
35.9
Educational Level: Less than College
Household Income: <$40,000
77
93
15.8
19.1
$40,000-59,000
86
17.6
$60,000-99,000
149
30.5
$100,000+
122
25.0
<35
136
27.9
35-45
113
23.2
45-55
146
29.9
55+
93
19.1
263
55.0
Age:
Had a deductible in the prior year
Table 2. Limited Knowledge of Services that Apply to
Deductible
C
Correct
P ti t
Patient-reported
t d Cost-sharing
C t h i
Offi
Office
Visits
Vi it
Non Preventive
Preventive
%
Deductible
Deductible
49.7%
Deductible
Exempt
18.1%
Exempt
Deductible
4.3%
Exempt
Exempt
10.5%
No Deductible
17 4%
17.4%
Total
100.0%
9
Table 2. Limited Knowledge of Services that Apply to
Deductible
C
Correct
P ti t
Patient-reported
t d Cost-sharing
C t h i
Offi
Office
Visits
Vi it
M di l Tests
Medical
T t
Non Preventive
Preventive
%
%
Deductible
Deductible
49.7%
48.7%
Deductible
Exempt
18.1%
13.8%
Exempt
Deductible
4.3%
10.3%
Exempt
Exempt
10.5%
9.7%
No Deductible
17 4%
17.4%
17 4%
17.4%
Total
100.0%
100.0%
10
Figure 1.
1 Cost-related
Cost related changes in Preventive Care Behavior
18.6%
Delayed or Avoided an Annual Routine Physical
Delayed or Avoided at Least One Preventive Test
19.2%
14.8%
Cholesterol Lab Test
Diabetes Lab Test
11.0%
Colon Cancer Screening Test
13.2%
Mammogram
11.6%
Other Preventive Care Screening or Lab Tests
0 0%
0.0%
8.3%
5 0%
5.0%
10 0%
10.0%
15 0%
15.0%
20 0%
20.0%
25 0%
25.0%
Table 3. Delaying or Avoiding Preventive care associated
with being unaware of exemptions
Delay or Avoid a Routine Physical due to Costs:
Odds
Ratio
Mistakenly reported that all office visits applied to
deductible
2.30
95%
Confidence Interval
1.36, 3.88
12
Table 3. Delaying or Avoiding Preventive care associated
with being unaware of exemptions
Delay or Avoid a Routine Physical due to Costs:
Odds
Ratio
Mistakenly reported that all office visits applied to
deductible
95%
Confidence Interval
2.30
1.36, 3.88
Delay or Avoid a Preventive Test due to Costs:
Odds
Odd
Ratio
Mistakenly reported that all medical test applied to
deductible
1.69
95%
Confidence Interval
1.01,2.84
13
Limitations
 Single IDS with set delivery options and non-experimental
allocation of plans
 Modest levels of deductibles and applicable services
 English-speakers
E li h
k
only
l
 No measure of clinical impact
 No
N measure off non-CDHP
CDHP plans
l
Conclusions
 Less than one in five consumers understood each of the
office
ffi
visit
i it and
d preventive
ti ttestt exemptions
ti
 Despite preventive exemptions from the deductible, one
in five consumers reported:


Delaying
y g or avoiding
g a preventive
p
physical
p y
due to cost
Delaying or avoiding a preventive test or screening due to cost
 Those who did not know of the exemptions were more
likely to avoid preventive care because of cost concerns
Implications
 The complexity of plan preventive exemption details may not
be clearly understood by patients

Confusion could create barriers to seeking preventive care, even
when it is exempt from the deductible
 Reports of avoiding preventive care raise concerns about
the
e clinical
c ca appropriateness
app op a e ess o
of ca
care-seeking
e see g choices
c o ces
 Education efforts important to increase awareness of
iinsurance b
benefit
fit d
design
i
ffeatures
t
d
designed
i
d tto promote
t
preventive care
General
Ge
e a Knowledge
o edge of
o Deductible
educ b e Plan
a
%
Knew plan included a deductible
83.6%
Knew plan was HSA-eligible
81.5%
C
Correctly
tl reported
t d deductible
d d tibl amountt (±20%),
(±20%) %
67 6%
67.6%
18
Background: HSA
HSA-eligible
eligible health plans
 High
g deductible health plan
p
 $1,400-2,700 for individuals
 Contributions from employee and/or employer
 Account can be used to pay for any qualified expenses
 Account balance is owned by employee
Questionnaire Measures: Knowledge
 Did the following services apply to your deductible?
 Annual
A
l routine
ti
preventive
ti physical
h i l exams with
ith a primary
i
care
provider
 Preventive health screening and lab tests (e.g., cholesterol tests,
mammograms diabetes tests)
mammograms,
 Non-preventive doctor’s office visits, visits with a specialist,
Prescription drugs, Emergency room care, Hospital stays, Nonpreventive lab tests or x-rays
Questionnaire Measures: Care-seeking
g
Behavior

Because of the amount you had to pay,
pay did you:





Delay or avoid going to a yearly routine physical with your primary
care provider?
Delay or avoid a cholesterol lab test?
Delay or avoid a diabetes lab test (fasting blood glucose test)?
Delay or avoid a screening test for colon cancer?
Delay or avoid a mammogram?