Consumer-driven Health Plan Research Articles

Abstract P366: Enrollment in Medicare Managed Care Plan is Associated With Higher Adherence to Anti-Hypertensive Drugs

Introduction: Adherence to anti-hypertensive drugs, which is sub-optimal despite public health and policy efforts, is essential in controlling high blood pressure. Medicare Advantage plans are gaining popularity, partly due to their managed care designs that held promise to improve chronic disease management. Hypothesis: We assessed the hypothesis that hypertensive patients with a managed care plan have higher adherence to antihypertensive drugs than those with a non-managed care plan. Methods: We analyzed medication adherence – measured using proportion of days covered (PDC) over 12 months for antihypertensive drugs – among 174,172 patients with a hypertension diagnosis from the medical and pharmacy claims and benefits data in the 2017-2019 IBM MarketScan Research Database. We fitted separate generalized linear regression models among monotherapy (use of one class of antihypertensive drugs) and polytherapy (combined use of at least two classes of antihypertensive drugs) users and computed postestimation margins with the best-fitted model to compare medication adherence by plan type: 1) Managed Care exclusive provider organization and health management organization (EPO/HMO) plan, 2) Managed Care point-of-service plan, 3) Managed Care preferred provider organization plan, 4) non-Managed Care comprehensive plan, 5) non-Managed Care consumer driven health plan / high deductible health plan. Other patient characteristics included in the analyses were age, age-squared, sex, comorbidities, census region, and their interaction terms. Results: The average PDC among Medicare patients on monotherapy was 0.53 and among those on polytherapy was 0.74. Patients with a managed-care EPO/HMO plan had the highest PDC (0.53, 95% confidence interval [CI]: 0.52, 0.54 among monotherapy users and 0.73, 95% CI: 0.72, 0.74 among polytherapy users, respectively) and those with a non-managed care comprehensive plan had the lowest PDC (0.42, 95% CI: 0.41, 0.43 among monotherapy users and 0.62, 95% CI: 0.61, 0.63 among polytherapy users, respectively). By census region, patients living in the North Central region with a managed care EPO/HMO plan had the highest average PDC (0.71, 95% CI: 0.70, 0.72 among monotherapy users and 0.85, 95% CI: 0.84, 0.86 among polytherapy users, respectively). Other factors such as age, sex, and number of chronic conditions were significantly associated with PDC. Conclusions: In conclusion, with an increase in the proportion of older adults enrolled in Medicare Advantage insurance, managed care models may play a more important role in influencing adherence to essential drugs such as anti-hypertensive drugs among Medicare beneficiaries. Future research should investigate factors that promote adherence to medications across different managed care plan designs.

IDENTIFYING INADEQUATE RESPONSE AMONG CROHN’S DISEASE PATIENTS ON A BIOLOGIC IN A REAL-WORLD ADMINISTRATIVE CLAIMS DATABASE

Abstract Objectives The purpose of this analysis was to assess the frequency of inadequate response (IR) over 1 year from biologic initiation among Crohn’s disease (CD) patients in the United States using a claims-based algorithm. Baseline factors associated with IR to a biologic were also analyzed. Methods This was a retrospective cohort study using claims data from the HealthCore Integrated Research Database. Adult patients with CD who initiated a biologic (TNFi: adalimumab, certolizumab, infliximab; non-TNFi: natalizumab, ustekinumab, and vedolizumab) from 7/1/2016 to 8/31/2018 and had continuous enrollment ≥6 months before and ≥12 months after index date (date of first biologic claim) were included. The index biologic was defined as the first biologic prescribed during the study time period. The claims-based algorithm used in this study to identify IR was originally developed and validated in rheumatoid arthritis and was modified for CD patients. Patients were identified as having IR to their index biologic if during the 12 months after index date they had one or more of the following: low adherence (defined as proportion of days covered (PDC)<80%), switched/added new biologic, added a new conventional therapy, increased dose/frequency of biologic, addition or dose increase of oral glucocorticoids, used a new pain medication, or had surgery for CD. Baseline patient characteristics were compared between responders and IRs using Chi-square tests for categorical variables and t-tests for continuous variables. A multivariable logistic regression model was constructed to identify baseline characteristics associated with IR to the index biologic. Results A total of 2,437 CD patients were included in this analysis. Mean age was 41 years, 53% were female, 81% initiated a TNFi, and 19% initiated a non-TNFi as their index biologic (Table 1). Over the 1-year follow-up period, 62% of CD patients had an IR to their biologic: 41% of patients had low adherence, 14% switched/added a new biologic, 13% added a new conventional therapy, 12% had a dose/frequency increase of their index biologic, 12% had an addition/dose increase of oral glucocorticoids, 8% used a new pain medication, and 5% had surgery. Inadequate responders were more likely to be female (odds ratio (OR)=1.36; p<0.001), have historical use of TNFi (OR=1.94; p<0.001), and be on a consumer-driven health plan (OR=1.28; p<0.001); while patients with baseline use of conventional therapy were more likely to be responders (OR=0.72; p<0.001) (Table 2). Conclusion Over 62% of CD patients had an inadequate response to their index biologic within 1 year after initiation, mostly driven by low adherence. This modified claims-based algorithm for CD appears useful to classify inadequate responders in health plan claims data. Additional research is needed to further validate this algorithm in a clinical setting.

Abstract B131: How do reversal rates vary among patients with colorectal cancer for which intestinal stoma was performed?

Abstract Background: Studies of colorectal cancer (CRC) patients have found patients in whom the intestinal stoma was performed consistently report more impairment and lower quality of life than their non-stoma counterparts. Where possible, the intention is to subsequently reverse the stoma (via stoma closure). The goal of this study is to examine disparities in stoma reversal (SR) rates among colorectal cancer patients who have health care insurance. Methods: This retrospective cohort study was conducted using medical claims and enrollment records from the OptumLabs Data Warehouse®, which includes commercial and Medicare Advantage (MA) enrollees representing a diverse mixture of ages, ethnicities and geographical regions across the United States. Eligible patients were required to have undergone intestinal ostomy (either colostomy or ileostomy) with an intestinal stoma between 2000 – 2017 as part of their CRC treatment and be enrolled for at least one year prior to and one year following the surgery. A Cox proportional hazard model was used to examine the relationship between patient demographics and clinical characteristics and the rate of SR. Patient demographics include age, sex, race, household income, and rurality. Comorbidity was measured using the Charlson Comorbidity Index score (CCI) excluding the two cancer categories. To further control for difference in health plan design and cost sharing, we included the patients’ health plan type (commercial or MA) and if the commercial enrollee was in a consumer driven health plan (i.e., high deductible). Results: We identified 13,633 individuals with colorectal cancer diagnosis between 2000 and 2017 who underwent either a colostomy or ileostomy in which the intestinal stoma was created. The overall SR rate was 16.4% with a median time to reversal of 6 months. The majorities of patients in our study are age 65+ (56%), male (52%), white (77%), and live in a metropolitan area (86%). Excluding cancer, the average CCI was 1.2 (sd=1.4) with 84% having CCI < 2. The cohort had a median follow up enrollment period of 2.5 years. The majority of patient resided in a household with income less than $75K per year (59%). Prior to controlling for other factors, SR rates were found to be higher in males (19.5% vs 13.1%; p<.001) and varying by race (p<.001): non-Hispanic whites (21.48%), Hispanic (18.6%), Asian (16.7%) and non-Hispanic blacks (12.8%). Reversal rates ranged from 14.2% for those in households with annual income under $75K to 22.1% for those above $125K (p<.001). However, after controlling for all factors, SR rates were only lower for females [HR=0.70; 95% CI=0.65, 0.77]) and African-American compared to White [HR=0.79; 95% CI=0.68, 0.90]). Household income, rurality and CCI were not found to be independently associated with varying SR. Conclusions: We find variation in SR rates by race and gender independent of age, health plan design, rurality and household income such that women and African Americans are less likely to receive SR. Citation Format: Lillian Hang, Henry J Henk. How do reversal rates vary among patients with colorectal cancer for which intestinal stoma was performed? [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B131.

The Impact of Length of Time Enrolled in a Health Plan on Consumer Engagement and Health Plan Satisfaction: Findings from the 2017 Consumer Engagement in Healthcare Survey

The EBRI/Greenwald & Consumer Engagement in Health Care Survey (CEHCS) is an online survey that examines issues surrounding consumer-driven health care, including the cost of insurance, the cost of care, satisfaction with health care, satisfaction with health care plans, reasons for choosing a plan, and sources of health information. The survey was conducted Aug. 10 to Sept. 1, 2017. Over 3,560 adults ages 21-64 who had health insurance through an employer, purchased directly from a carrier, or purchased through a government exchange participated in the survey. This Issue Brief focuses on whether and how attitudes and behaviors change with the amount of time an individual has been enrolled in their health plan. Overall satisfaction does not increase when participants are in health plans for long periods of time (e.g., 10 years), regardless of whether the plan is a traditional health plan, consumer-driven health plan (CDHP), or high deductible health plan (HDHP). Likewise, consumer engagement does not increase with time enrolled in a health plan. However, there is some evidence that health savings account (HSA)-eligible health plan enrollees are more engaged in some aspects of their HSA the longer they have been enrolled in their HSA-eligible health plan.

A Government Sponsored High-Deductible Consumer-Driven (HDCD) National Health Plan Could Provide Universal Health Coverage and Simultaneously Reduce the National Health Expenditures (NHE) in the United States of America

Rather than a tweaking of an inefficient system, why not rethink entirely how the United States (US) Government allocated the $1.155 trillion ($1,815 - $660) spent on non-Medicare healthcare funding in 2016. The US Government could allocate $325 billion to provide every family in the country with a high-deductible consumer-driven (HDCD) health plan limiting each family to an annual out-of-pocket maximum of $14,300. The US Government could then use the remaining $830 billion to provide each family with a $12,205 contribution to a Health Savings Account (HSA). This would leave each family with an annual total out-of-pocket maximum of $2,095 which is about a twelfth of the combined amount that employers and employees are currently paying for health insurance. The portable HSA managed by the employee would incentivize employees to control costs since unused HSA funds, in any given year, could be rolled and available for use in future years. This would reduce administrative costs, likely reduce overall demand for healthcare, and subsequently reduce the cost of care.

Employee Health Benefit Redesign at the Academic Health Center

The rapidly escalating cost of health care, including the cost of providing health care benefits, is a significant concern for many employers. In this article, the authors examine a case study of an academic health center that undertook a complete redesign of its health benefit structure to control rising costs, encourage use of its own provider network, and support employee wellness. With the implementation in 2006 of a high-deductible health plan combined with health reimbursement arrangements and wellness incentives, the Penn State Hershey Medical Center (PSHMC) was able to realize significant cost savings and increase use of its own network while maintaining a high level of employee satisfaction. By contracting with a single third-party administrator for its self-insured plan, PSHMC reduced its administrative costs and simplified benefit choices for employees. In addition, indexing employee costs to salary ensured that this change was equitable for all employees, and the shift to a consumer-driven health plan led to greater employee awareness of health care costs. The new health benefit plan's strong focus on employee wellness and preventive health has led to significant increases in the use of preventive health services, including health risk assessments, cancer screenings, and flu shots. PSHMC's experience demonstrates the importance of clear and ongoing communication with employees throughout--before, during, and even after--the process of health benefit redesign.

Quality of Care in a Low-Income Consumer-Driven Health Plan: Assessment of Healthcare Effectiveness Data Information Set (HEDIS) Scores for Secondary Prevention

The passage of the Patient Protection and Affordable Care Act of 2010 (PPACA) may create an estimated 16 million new Medicaid enrollees. This underscores the need to develop innovative strategies to provide efficient care to this population without compromising quality. To address concerns that consumer-driven health plans (CDHPs) and cost sharing discourage individuals from seeking needed care, we examined the Healthcare Effectiveness Data Information Set (HEDIS) measures of secondary prevention for a CDHP offered to uninsured, non-Medicaid eligible adults with incomes under 200% of the federal poverty level and compared them to the National Committee for Quality Assurance (NCQA) benchmarks achieved by national Medicaid and commercially insured health plans. Results suggest that the cost-sharing component in the CDHP plan did not deter these low-income enrollees from pursuing or receiving appropriate care when compared to either Medicaid or commercially insured populations. As these results are only descriptive and not statistical measures, further research is needed with comparable populations and more detailed data for hypothesis testing.

Health Literacy and Health Care Spending and Utilization in a Consumer-Driven Health Plan

We examined health literacy and health care spending and utilization by linking responses of three health literacy questions to 2006 claims data of enrollees new to consumer-driven health plans (n = 4,130). Better health literacy on all four health literacy measures (three item responses and their sum) was associated with lower total health care spending, specifically, lower emergency department and inpatient admission spending (p < .05). Similarly, fewer inpatient admissions and emergency department visits were associated with higher adequate health literacy scores and better self-reports of the ability to read and learn about medical conditions (p-value <.05). Members with lower health literacy scores appear to use services more appropriate for advanced health conditions, although office visit rates were similar across the range of health literacy scores.

Effects of a Consumer Driven Health Plan on Pharmaceutical Spending and Utilization

To compare pharmaceutical spending and utilization in a consumer driven health plan (CDHP) with a three-tier pharmacy benefit design, and to examine whether the CDHP creates incentives to reduce pharmaceutical spending and utilization for chronically ill patients, generic or brand name drugs, and mail-order drugs. Retrospective insurance claims analysis from a large employer that introduced a CDHP in 2001 in addition to a point of service (POS) plan and a preferred provider organization (PPO), both of which used a three-tier pharmacy benefit. Difference-in-differences regression models were estimated for drug spending and utilization. Control variables included the employee's income, age, and gender, number of covered lives per contract, election of flexible spending account, health status, concurrent health shock, cohort, and time trend. Results. CDHP pharmaceutical expenditures were lower than those in the POS cohort in 1 year without differences in the use of brand name drugs. We find limited evidence of less drug consumption by CDHP enrollees with chronic illnesses, and some evidence of less generic drug use and more mail-order drug use among CDHP members. The CDHP is cost-neutral or cost-saving to both the employer and the employee compared with three-tier benefits with no differences in brand name drug use.

Evolution and early evidence of the impact of consumer-driven health plans: from e-commerce venture to health savings accounts

Using results from peer-reviewed empirical analyses we describe the development and impact of the consumer-driven health plan market over the last 5 years. The results of these analyses show that consumers are responding to the financial incentives of these new health insurance benefits. Although the results may not always be what the consumer-driven health plan developers intended, there is clear evidence of ‘consumerism’, where individuals act in a way that generally increases their access to healthcare or investments, if the opportunity is present. Just as Medicare Part D enrollment demonstrated consumers could identify differences in prescription drug plans and make rational choices, so too are prospective patients able to function as consumers in the medical marketplace when give the opportunity.

High-Deductible Health Plans and the New Risks of Consumer-Driven Health Insurance Products

Consumer-driven health care is the most noteworthy development in health insurance since the widespread adoption of health maintenance organizations and preferred provider organizations in the 1980s. The most common consumer-driven health plan is the high-deductible health plan, which is essentially a catastrophic health insurance plan, often linked with tax-advantaged spending accounts, with very high deductibles, fewer benefits, and higher cost-sharing than conventional health maintenance organization or preferred provider organization plans. The financial risks are significant under high-deductible health plans, especially for low- to moderate-income families and for families whose children have special health care needs. Of concern for pediatricians are the potential quality risks that are predictable in high-deductible health plans, in which families are likely to delay or avoid seeking care, especially preventive care (if it is not exempted from the deductible), when they are faced with paying for care before the deductible is met. This policy statement provides background information on the most common consumer-driven health plan model, discusses the implications for pediatricians and families, and offers recommendations pertaining to health plan product design, education, practice administration, and research.

Wellness, consumers, and case managers: Where is the fit?

No matter the location or the practice arena you find yourself in these days, it has become apparent that the consumer and the employer are beginning to drive the health care bus. The purchasers of health care have raised their voices and are seeking professionals who can help them control escalating costs. The purchaser of health care may soon be the individual with a consumer-driven health plan, as well as the employer with specific benefit packages for their employees. These groups see the importance and the positive impact that a wellness campaign could have on both the quality of care and the cost of delivering health care.

Employee choice of consumer-driven health insurance in a multiplan, multiproduct setting.

To determine who chooses a Consumer-Driven Health Plan (CDHP) in a multiplan, multiproduct setting, and, specifically, whether the CDHP attracts the sicker employees in a company's risk pool. We estimated a health plan choice equation for employees of the University of Minnesota, who had a choice in 2002 of a CDHP and three other health plans--a traditional health maintenance organization (HMO), a preferred provider organization (PPO), and a tiered network product based on care systems. Data from an employee survey were matched to information from the university's payroll system. Chronic illness of the employee or family members had no effect on choice of the CDHP, but such employees tended to choose the PPO. The employee's age was not related to CDHP choice. Higher-income employees chose the CDHP, as well as those who preferred health plans with a national provider panel that includes their physician in the panel. Employees tended to choose plans with lower out-of-pocket premiums, and surprisingly, employees with a chronic health condition themselves or in their family were more price-sensitive. This study provides the first evidence on who chooses a CDHP in a multiplan, multiproduct setting. The CDHP was not chosen disproportionately by the young and healthy, but it did attract the wealthy and those who found the availability of providers more appealing. Low out-of-pocket premiums are important features of health plans and in this setting, low premiums appeal to those who are less healthy.

Consumer experiences in a consumer-driven health plan.

To assess the experience of enrollees in a consumer-driven health plan (CDHP). Survey of University of Minnesota employees regarding their 2002 health benefits. Comparison of regression-adjusted mean values for CDHP and other plan enrollees: customer service, plan paperwork, overall satisfaction, and plan switching. For CDHP enrollees only, use of plan features, willingness to recommend the plan to others, and reports of particularly negative or positive experiences. There were significant differences in experiences of CDHP enrollees versus enrollees in other plans with customer service and paperwork, but similar levels of satisfaction (on a 10-point scale) with health plans. Eight percent of CDHP enrollees left their plan after one year, compared to 5 percent of enrollees leaving other plans. A minority of CDHP enrollees used online plan features, but enrollees generally were satisfied with the amount and quality of the information provided by the CDHP. Almost half reported a particularly positive experience, compared to a quarter reporting a particularly negative experience. Thirty percent said they would recommend the plan to others, while an additional 57 percent said they would recommend it depending on the situation. Much more work is needed to determine how consumer experience varies with the number and type of plan options available, the design of the CDHP, and the length of time in the CDHP. Research also is needed on the factors that affect consumer decisions to leave CDHPs.

Medical Savings Accounts: Theory, Politics, Pros, and Cons

The Internal Revenue Service recently ruled all employers, regardless of size, can adopt a medical savings account–type program as part of an employee benefit package. This frees all employers to adopt a version of a consumer-driven health plan as part of their benefit package. This could continue a trend toward consumer-driven health insurance that began with the Health Insurance Portability and Accountability Act of 1996. The authors review current health insurance problems, including a discussion of competitive market and insurance theory. The medical savings account experiment is summarized, including pros, cons, politics, and theory. Finally, the authors briefly review the theory of agency and conclude with a call for nursing to fill this niche quickly for the good of our patients.