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Evaluating High Deductible Health Plans
Allison Galbraith and Frank Wharam
In recent years, health insurance plans have increased enrollee deductibles in response to escalating health care costs. Health plans with deductibles require that enrollees pay out-of-pocket for health care costs until they have spent up to a certain amount (the deductible), after which the health plan will contribute to the costs of health care services. Typically, high deductible health plans (HDHPs) have deductibles of at least $1,000 per individual and $2,000 per family, and lower monthly premiums than traditional health plans. DACP has several studies that are evaluating the impact of HDHPs on use of health care services.
DACP Investigator Allison Galbraith has received a Hood Foundation grant to investigate how children's health care is affected by the trend toward high deductible health plans (HDHPs). Data largely from adults suggest that when people must pay a larger share of the costs of health care, they use fewer needed health care services. Scant information is available on the effects of HDHPs on children, and whether children with chronic conditions are at increased risk of under-using necessary health care services. The aims of this project are to: 1) examine how children's enrollment in HDHPs affects use of important health care services compared to traditional plans; 2) examine how use of important health care services differs for children with chronic conditions in HDHPs compared to traditional plans; and 3) examine how having other family members with chronic conditions affects children's use of important health care services in HDHPs compared to traditional plans. This project will compare use of important health care services (such as well-child visits and hospitalizations) for children who switched to a HDHP or stayed in a traditional health plan. The results will provide needed data on children's experiences in HDHPs, and help family members, employers, and policy makers make decisions about HDHPs that better promote the health of children, particularly those with chronic conditions.
In addition to this study, DACP fellow Frank Wharam is studying the effect of HDHP's on emergency department utilization. He is specifically examining how appropriate and inappropriate emergency department visits change when members face high deductibles.
DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) Drug Policy Program
Richard Platt
Effect of changes in insurance coverage on quality and outcomes of care:
Steve Soumerai
The Drug Policy Research Group has long-standing interest in investigating how changes in insurance coverage for medication and cost-containment policies affect the quality and outcome of care in the U.S., Europe, Canada, and developing countries. One example of this work is our current National Institutes on Aging-funded study, "Cost-Related Underuse of Medications in the Elderly," described below:
Since Medicare was enacted in 1965 until the enactment of the voluntary Medicare drug benefit this year, the program had excluded coverage for outpatient prescription medications except for injection drugs furnished by a physician. It is now widely recognized that the elderly have experienced an erosion of prescription benefits as insurers respond to mounting fiscal pressures with a variety of cost-cutting and cost-shifting measures. The Medicare Current Beneficiary Survey (MCBS), administered annually to a representative national sample of elderly and disabled adults enrolled in Medicare, represents the gold standard for information on rates and sources of prescription coverage among elderly Americans. However the MCBS provides little information on cost-related non-compliance with medication regimens, and there are few other national data sources.
While preliminary research documents the relationships among out-of-pocket medication costs, rates of non-compliance, and adverse clinical outcomes, no national study to date has addressed whether such cost-related barriers lead to under use of essential drugs for chronic illnesses, substitution of over-the-counter or alternative medicines, or reductions in physician visits. This project has established a permanent, ongoing national data resource that permits policymakers and researchers to measure, monitor, and identify changes in cost-related under use of medications (CRUM) among elderly Medicare beneficiaries. We have developed new, comprehensive measures of CRUM; validated the measures in a survey of approximately 200 elderly enrollees in a large health plan; integrated the measures into the MCBS for annual surveys of approximately 15,000 non-institutionalized elderly Medicare enrollees (the cost of which is borne by the US Department of Health and Human Services, Center for Medicare and Medicaid Services (CMS); and analyzed MCBS data to identify the extent to which CRUM is associated with patient socio-demographics, health status and medical conditions, source of prescription coverage, and out-of-pocket prescription costs.
A natural extension of this work on CRUM is to follow the effects of the Medicare Modernization Act of 2003 (MMA), which allows Medicare beneficiaries to purchase a prescription drug benefit (Part D) via private plans as of January 2006. The implementation of the MMA not only affects elderly beneficiaries in Medicare but also affects disabled dual-eligibles, whose medication coverage automatically shifted from Medicaid coverage to subsidized Medicare Part D plans. The DPRG is working with several large states and CMS to design studies of the effect of the transition from Medicaid to Medicare coverage on the quality and outcomes of care for the elderly and disabled.
Faculty in the DPRG working on these lines of investigation are Stephen Soumerai, Dennis Ross-Degnan, Alyce Adams, Jeanne Madden, Anita Wagner, and Fang Zhang.
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