Health Reimbursement Arrangements Research Articles

Choice of high-deductible health plans among enrollees with a substance use disorder

IntroductionHigh-deductible health plans (HDHPs) expose enrollees to increased out-of-pocket costs for their medical care, which can exacerbate the undertreatment of substance use disorders (SUDs). However, the factors that influence whether an enrollee with SUD chooses an HDHP are not well understood. In this study, we examine the factors associated with an individual with an SUD’s decision to enroll in an HDHP. MethodsUsing de-identified administrative commercial claims and enrollment data from OptumLabs (2007–2017), we identified individuals at employers offering at least one HDHP and one non-HDHP plan. We modeled whether an enrollee chose an HDHP using linear regression on plan and enrollee demographic characteristics. Key plan characteristics included whether a plan had a health savings account (HSA) or a health reimbursement arrangement (HRA). Key demographic variables included age, race/ethnicity, census block income range, census block highest educational attainment, and sex. We separately investigate new enrollment decisions (i.e., not previously enrolled in an HDHP) and re-enrollment decisions, as well as decisions among single enrollees and families of differing sizes. The study also adjusted models for additional plan characteristics, employer and year fixed effects, and census division. Robust standard errors were clustered at the employer level. ResultsThe sample comprised 30,832 plans and 318,334 enrollees. Among enrollees with new enrollment decisions, 24.6 % chose an HDHP; 93.8 % of HDHP enrollees chose to re-enroll in an HDHP. The study found the presence of a plan HRA to be associated with a higher probability of new and re-enrollment in an HDHP. We found that older enrollees with SUD were less likely to newly enroll in an HDHP, while enrollees who were non-White, living in lower-income census blocks, and living in lower educational attainment census blocks were more likely to newly enroll in an HDHP. Higher levels of health care utilization in the prior year were associated with a lower probability of newly enrolling in an HDHP but associated with a higher probability of re-enrolling. ConclusionGiven the emerging evidence that HDHPs may discourage SUD treatment, greater HDHP enrollment could exacerbate health disparities.

Affordable Health Insurance Options for Small Business and Low-Wage Workers Remains Elusive: Experience With New Health Reimbursement Arrangements in New Jersey.

Low-wage workers and those employed by small businesses are least likely to be offered health insurance coverage and they are over-represented among the uninsured. Two new forms of health reimbursement arrangements (HRAs) that allow employers to help fund individual market coverage for workers have been touted as breakthrough strategies to help fill this gap. Despite several years of experience and low adoption, little is known about employer understanding of or views about these HRA options. Consistent with other evidence, only 11.8% of New Jersey employers we surveyed offer or plan to offer either of the HRA options. Few respondents (18.5%) report familiarity with either option. Even among businesses that offer or plan to offer this form of HRA, under half (47.6%) say that they are familiar with them. Other reasons cited for not offering these options include broker advice and complexity. While more investigation is needed, these findings suggest that new strategies should be explored to fill the gap in health insurance for low-wage and small business employees.

Texas Ruling Brings More ACA Uncertainty.

Texas ruling and other legal challenges raise questions about the ACA's future even as enrollment holds steady.

Maternal age and risk of low birth weight and premature birth in children conceived through medically assisted reproduction. Evidence from Finnish population registers.

STUDY QUESTIONDoes the risk of low birth weight and premature birth increase with age among mothers who conceive through medically assisted reproduction (MAR)?SUMMARY ANSWERAmong MAR mothers, the risk of poorer birth outcomes does not increase with maternal age at birth except at very advanced maternal ages (40+).WHAT IS KNOWN ALREADYThe use of MAR treatments has been increasing over the last few decades and is especially diffused among women who conceive at older ages. Although advanced maternal age is a well-known risk factor for adverse birth outcomes in natural pregnancies, only a few studies have directly analysed the maternal age gradient in birth outcomes for MAR mothers.STUDY DESIGN, SIZE, DURATIONThe base dataset was a 20% random sample of households with at least one child aged 0–14 at the end of 2000, drawn from the Finnish population register and other administrative registers. This study included children who were born in 1995–2000, because the information on whether a child was conceived through MAR or naturally was available only from 1995 onwards.PARTICIPANTS/MATERIALS, SETTING, METHODSThe outcome measures were whether the child had low birth weight (LBW, <2500 g at birth) and whether the child was delivered preterm (<37 weeks of gestation). Conceptions through MAR were identified by examining data on purchases of prescription medication from the National Prescription Register. Linear probability models were used to analyse and compare the maternal age gradients in birth outcomes of mothers who conceived through MAR or naturally before and after adjustment for maternal characteristics (i.e. whether the mother suffered from acute/chronic conditions before the pregnancy, household income and whether the mother smoked during pregnancy).MAIN RESULTS AND THE ROLE OF CHANCEA total of 56 026 children, 2624 of whom were conceived through MAR treatments, were included in the study. Among the mothers who used MAR to conceive, maternal age was not associated with an increased risk of LBW (the overall prevalence was 12.6%) at ages 25–39. For example, compared to the risk of LBW at ages 30–34, the risk was 0.22 percentage points lower (95% CI: −3.2, 2.8) at ages 25–29 and was 1.34 percentage points lower (95% CI: −4.5, 1.0) at ages 35–39. The risk of LBW was increased only at maternal ages ≥40 (six percentage points, 95% CI: 0.2, 12). Adjustment for maternal characteristics only marginally attenuated these associations. In contrast, among the mothers who conceived naturally, the results showed a clear age gradient. For example, compared to the risk of LBW (the overall prevalence was 3.3%) at maternal ages 30–34, the risk was 1.1 percentage points higher (95% CI: 0.6, 1.6) at ages 35–39 and was 1.5 percentage points higher (95% CI: 0.5, 2.6) at ages ≥40. The results were similar for preterm births.LIMITATIONS, REASON FOR CAUTIONA limited number of confounders were included in the study because of the administrative nature of the data used. Our ability to reliably distinguish mothers based on MAR treatment type was also limited.WIDER IMPLICATIONS OF THE FINDINGSThis is the first study to analyse the maternal age gradient in the risk of adverse birth outcomes among children conceived through MAR using data from a nationally representative sample and controlling for important maternal health and socio-economic characteristics. This topic is of considerable importance in light of the widespread and increasing use of MAR treatments.STUDY FUNDING/COMPETING INTEREST(S)Funding for this project was provided by the European Research Council (grant no. 803959 MARTE to Alice Goisis and grant no. 336475 COSTPOST to Mikko Myrskylä). E.S. reports personal fees from Theramex, personal fees from Merck Serono, personal fees from Health Reimbursement Arrangement, non-financial support from Merck Serono and grants from Ferring, grants from Theramex, outside the submitted work. The remaining authors have no competing interests.TRIAL REGISTRTION NUMBERN/A

ACA Heads Back To Supreme Court.

The high court will consider risk corridors payments as developments continue in areas like HRAs and contraceptive coverage.

The Relationship Between Health Plan Type, Use of Specialty Medications, and Worker Productivity

Specialty medications have piqued the attention of employers because spending on specialty medications has been increasing. In 2012, specialty medications accounted for 24 percent of total drug spending in the commercial market, but by 2016 specialty medications accounted for 36 percent. By 2020, specialty medications are expected to account for nearly one-half of total drug spending in the commercial market. Managing specialty medications is considered one of the most effective tactics when it comes to controlling health care costs. In this Issue Brief, the Employee Benefit Research Institute (EBRI) examines the impact of plan type on use of specialty medications. This paper also focuses on the impact that use of specialty medications both among workers and their dependents has on worker productivity. The analysis was conducted on nearly 100,000 unique individuals with rheumatoid arthritis (RA), Crohn's disease, ulcerative colitis, psoriasis, and multiple sclerosis (MS) using data from the Truven Health Analytics MarketScan® Research Commercial Claims and Encounters Database. Use of specialty medications among individuals with multiple sclerosis (MS): Among individuals with MS, there was no difference in the likelihood of filling a prescription for a specialty medication by type of health plan. However, among individuals with MS that had filled a specialty medication prescription, individuals with preferred provider organization/point of service (PPO/POS) and health reimbursement arrangement (HRA) plans used more specialty medications than those with health maintenance organization/exclusive provider organization (HMO/EPO) plans. There was no difference between those with health savings account (HSA)-eligible health plans and those with HMO/PPO coverage. Use of specialty medications among individuals with rheumatoid arthritis (RA), Crohn's disease, ulcerative colitis, and psoriasis: Plan type had no impact on whether any specialty medications were used, with one exception. Among individuals with RA, those with an HRA were less likely than those in HMO/EPO plans to use any specialty medications. Among individuals that had filled specialty medication prescriptions, we found mixed effects on the number of fills. For the most part, there were no differences in the number of fills by plan type. However, among individuals with RA, those in HRA plans filled fewer specialty medications than those in HMO/EPO plans. Among individuals with Crohn’s disease, those in PPO/POS plans used more specialty medications than those in HMO/EPO plans. Use of Specialty Medications and Worker Productivity: Any Use: We found few instances where productivity was affected by use of specialty medications. We did not find any relationship between any use of specialty medication and any use of sick or vacation leave, or number of days absent. We also did not find that any use of specialty medications affected whether a worker took short-term disability. However, we did find that any use of specialty medications reduced the number of days on short-term disability for workers with Crohn’s disease by 37.6 days and for workers with psoriasis by 42.6 days. Number of Medications: Regarding the impact of the number of specialty medications fills on productivity, we did not find an impact on the likelihood of taking any days off or on the likelihood of being on short-term disability. There was evidence that a higher number of specialty medication fills increased the number of absentee days for individuals with Crohn’s disease and psoriasis. However, the magnitude of these effects was quite small, increasing absenteeism by 0.53 days for those with Crohn’s disease and by 0.25 days for those with psoriasis. There was also evidence that a higher number of specialty medication fills increased the length of short-term disability for individuals with MS by 5.6 days. Dependent Use: We also examined the impact of use of specialty medications on worker productivity by examining whether worker productivity was affected by use of specialty medications among dependents. We tested this by examining the impact of spousal use of specialty medications for married workers. We found nearly no evidence that any use of specialty medications reduced worker absenteeism with one exception — among spouses using specialty medications for ulcerative colitis, workers were absent from work 6.5 fewer days. With respect to the number of specialty medications filled among those who had filled at least one prescription, we found mixed results. There was no impact on worker absenteeism among spouses with Crohn’s disease, psoriasis or MS. Higher use of specialty medications reduced absenteeism among workers with spouses treated for ulcerative colitis, but it increased absenteeism among workers with spouses treated for RA.

Ten-Year Trends in Consumer-Directed Health Plan Enrollment and Out-of-Pocket Costs among Commercially Insured Members with Diabetes

Background: Diabetes is a major cause of morbidity and mortality and a driver of escalating health care costs in the U.S. In attempts to reduce costs, U.S. employers are increasingly offering consumer-directed health plans (CDHPs) that include Health Savings Accounts (HSA) or Health Reimbursement Arrangements (HRA) and high annual deductibles. Recent research has found that CDHPs are associated with concerning impacts on diabetes patients, but growth in CDHP enrollment and their out-of-pocket (OOP) cost trends in this vulnerable population are unknown. Methods: We used a time series design to assess 2005-2014 annual trends among ∼70 million unique members of all ages insured by a large national commercial insurer from 2005-2014. We analyzed mutually exclusive populations of interest, identified by ACG, comprising: (1) diabetes mellitus with no cardiovascular disease (DM), (2) diabetes with co-morbid cardiovascular disease (DM+CVD), and (3) “healthy” (i.e., ACG score &amp;lt;=1). We used linear models, t-tests and chi-square tests to assess (a) CDHP and non-CDHP prevalence and (b) total annual OOP costs in 2014 dollars. Results: CDHP prevalence among DM members increased by 2.5% per year (p&amp;lt;0.001), from 1.3% in 20to 23.2% in 2014. DM+CVD members had a similar increase. In 2014, 19.5% of DM+CVD members and 28.7% of healthier members were in CDHPs (p&amp;lt;0.001 for both compared to DM). Annual OOP costs for non-CDHP members were significantly lower than for CDHP members throughout the study period. For example, in 2014, CDHP DM members had average OOP costs of $2103.62 compared to $1379.87 for non-CDHP DM members (p&amp;lt;0.001). Conclusions: CDHP enrollment has increased markedly over the last 10 years among members with and without diabetes. However, diabetes members were less likely than healthier members to be in CDHPs, particularly if they had co-morbid CVD. Among diabetes patients, OOP costs were significantly higher for CDHP than non-CDHP members. Disclosure L.F. Garabedian: Other Relationship; Self; Harvard Pilgrim Health Care. D. Ross-Degnan: None. F. Zhang: None. M.X. Callahan: None. R. LeCates: None. J. Wallace: None. S.B. Soumerai: None. J.F. Wharam: None.

FUZZY MULTIATTRIBUTE CONSUMER CHOICE AMONG HEALTH INSURANCE OPTIONS

People buy insurance to protect themselves against possible financial loss in the future. Health insurance provides protection against the possibility of financial loss due to health care use. A selection among health insurance options is a multiattribute decision making problem including many conflicting criteria. This problem can be better solved using the fuzzy set theory since human decision making is generally based on vague and linguistic data. We propose an integrated methodology composed of fuzzy AHP and fuzzy TOPSIS to select the best health insurance option. The considered option types, Health Savings Account (HSA), Flexible Spending Accounts (FSA), and Health Reimbursement Arrangement (HRA) are evaluated using eight different criteria under fuzziness. A sensitivity analysis is also realized.

Overvaluing Employer-Sponsored Health Insurance

Although positive and negative assessments of tying health insurance to employment abound, most scholars and policymakers have acknowledged that our long history in this area predicts our future. What they have largely ignored, however, is the extent to which individual attachment to employment-based insurance is at the root of our inability to make broader health reforms. The attachment (1) harms exchange-based insurance and (2) denies employers the ability to use Health Reimbursement Arrangements (“HRAs”) to subsidize the purchase of insurance by their employees on the exchanges. This Article advocates reducing or eliminating workers’ overvaluation of their health insurance and increasing their exposure to health insurance offered outside of employment. First, the Article details how our attachment to employer-sponsored health insurance developed and why the attachment persists. I explain that law and behavioral science scholars have missed an opportunity to apply their theories to prevent the overvaluation of employee benefits. Next, I discuss how the attachment to ESI has raised fears that the ACA will result in employers “dumping” employees on the exchanges and how this is motivating the administration to take further steps to preserve the current system while implementing health reform. Finally, the Article provides background on the growth of defined contribution plans in health financing backed by the notion of increasing consumer choice and how recent IRS guidance halts innovation in this area. I argue that employers should be allowed to use HRAs to subsidize employees’ purchase of health insurance on the exchanges because it would reduce the attachment to employer-sponsored insurance and create larger, more diverse exchanges.

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.

The Effects of Consumer-Directed Health Plans on Episodes of Health Care

Abstract Past research has shown that high deductible and consumer-directed health plans (HD/CDHPs) can significantly reduce health care costs. In this paper we investigate how these cost savings are realized. We use panel data from many large employers and difference in difference models to examine how HD/CDHPs affect the number of health care episodes and the cost per episode. Our results show that about two-thirds of the cost savings from HD/CDHP enrollment are from reductions in number of episodes and the remaining one-third of the savings are from reductions in costs per episode. The presence of a Health Reimbursement Arrangement (HRA) or Health Savings Account (HSA) does not temper the effects of high deductibles on number of episodes. However, enrollees in plans with generous employer contributions to HSAs have more episodes of care than enrollees in plans where employers make smaller account contributions. The reductions in costs per episode and in visits to specialists, inpatient care, and use of non-generic pharmaceuticals suggest that higher deductibles are effective at making patients more cost conscious even after care is initiated.

Participation of patients in the development of advanced therapy medicinal products

An increasing number of advanced therapy medicinal products (ATMPs) are under development and in clinical trials. Patients are central to this progress. In research, patients have funded, catalysed, coordinated and led projects. In regulation, patient groups have contributed to the creation of the political momentum for regulation of ATMPs, contributed to the debate and now participate in the regulatory process. Once licensed, patients will have a role in the pharmacovigilance, health technology assessment and reimbursement arrangements for these products. Patient groups contribute valuably as equal stakeholders at every step of the development of an ATMP.

How Do Consumer-Directed Health Plans Affect Vulnerable Populations?

Abstract We use health care claims data from 59 large employers to estimate how consumer-directed health plans (CDHPs)—plans that combine a high deductible with personal accounts—affect health care costs and the use of preventive services by vulnerable populations. The vulnerable populations studied are those that will have increased access to health insurance under health care reform: families with high health care needs and low income families. A difference-in-difference framework is used with costs and use available for a full year before and after enrolling in a CDHP and for controls. Our key finding is that in almost all cases, CDHP benefit designs affect lower income populations and the chronically ill to the same extent as non-vulnerable populations. These effects include significant reductions in overall spending that increase with the level of the deductible and greater reductions for high deductible plans when paired with health savings accounts (HSAs) in comparison to health reimbursement arrangements (HRAs). However, enrollment in CDHPs also leads to reductions in care that is considered beneficial for all groups, and this may have greater health consequences for lower income and chronically ill people than for others.

The Effects of Consumer-Directed Health Plans on Health Care Spending

We use unique data from an insurer that exclusively offers high-deductible, “consumer-directed” health plans to identify the effect of plan features, notably employer contributions to the spending account, on health care spending. Our results show that the marginal dollar contributed by the employer to the spending account is entirely spent on outpatient and pharmacy services. In contrast, out-of-pocket spending was not responsive to the amount the employer contributes to the spending account. Our results represent the first plausibly causal estimates of the components of consumer-driven health plans on health spending. The magnitudes of the effects suggest important health care spending consequences to higher employer contributions to spending accounts. Our findings are most directly relevant to health reimbursement arrangement plan designs, though our results are still of value to health savings account plan designs.

Consumer-Driven Health Care: The Changing Nature of Health Insurance

Consumer-driven health care (CDHC) plans are a new health insurance paradigm that lets consumers control some of their own health care dollars. It also provides financial incentives to manage medical spending wisely while affording consumers greater choice and control over the types of medical services received. The premise of CDHC is coupling a tax-preferred, personal health account, used to fund day-to-day medical expenses, with a high-deductible health plan to fund care of a catastrophic nature. When individuals enter the medical marketplace, they will spend first from their health savings accounts, health reimbursement arrangements, or flexible spending accounts. Once they reach their deductible, insurance pays all remaining costs. CDHC plans are relatively new to the market, and the market share is still quite small compared to traditional forms of health insurance. CDHC is not for everyone—and not everyone wants to take greater control of health care spending. However, early evidence is encouraging. Virtually all the studies have found that people treat their own money with more care than funds belonging to someone else. Many individuals will appreciate the flexibility in benefits and the added convenience that controlling health care dollars allows.

Consumer Directed Health Care

Consumer driven health care (CDHC) is a potential solution to two perplexing problems: (1) How to choose between health care and other uses of money, and (2) how to allocate resources in an industry where normal market forces have been systemically suppressed. In the consumer-driven model, consumers occupy the primary decision-making role regarding the health care that they receive. From an employee benefits perspective, consumer driven health care in the broadest sense may refer to limited employer contribution or dual option plans featuring high deductible health coverage with tax advantaged savings vehicles such as Health Savings Accounts (HSAs), Flexible Spending Accounts (FSAs) and Health Reimbursement Arrangements (HRAs) (Daly, 2005). However, before we consider the solution, we must first investigate why a solution is needed in the first place.

Occupational and Environmental Health Nursing in the Era of Consumer-Directed Health Care

Consumer-directed health care plans (CDHPs) present an opportunity to control health care costs. Health savings accounts (HSAs) and health reimbursement arrangements (HRAs) are two different approaches to providing pre-tax funding for CDHP enrollees. Each has a significant impact on the nature and business aspects of worksite health care. Worksite clinics can provide support via on-site education, expanded acute care services, and referral to other health-related benefits and resources for all CDHP enrollees. With attention to the type of employee health benefits funding support (HSA or HRA), occupational health nurses can maximize the effectiveness and value of worksite clinic services for CDHP enrollees.

Do Chronically Ill Patients Benefit From Consumer-Driven Care?

Do Chronically Ill Patients Benefit From Consumer-Driven Care?

Employer-Sponsored, Personal, And Portable Health Insurance

Personal and portable health insurance is an idea whose time has come. Despite its stated intent, however, the Health Insurance Portability and Accountability Act (HIPAA) strongly discourages individually owned, portable insurance. Federal tax laws do the same. Some examples of portable benefits exist, such as the TIAA-CREF system. This paper considers three reform models for moving toward personal, portable coverage: the National Center for Policy Analysis-Texas Blue Cross Blue Shield proposal, the Massachusetts health care plan, and a health reimbursement arrangement (HRA) approach. Congress could make the transition smoother by clarifying when and if individually owned insurance can be purchased with pretax dollars.

The Employer's Role in Reforming the U.S. Health Care System

In 2005 large U.S. employers spent an average of almost $7,400 per head on health care benefits, a 73% increase in the last five years. If the current trend continues, American companies may find it difficult to compete in a global marketplace where international competitors provide labor with heath care at a fraction of U.S. costs.This article argues that effective reform of the U.S. health care system will require major efforts from all major “stakeholders,” starting with the federal government and state and local governments and including insurance companies and the “consumers” of health care services. By far the important role, however, is reserved for private‐sector employers, which have been the incubator for recent innovations in American health care and are in the best position to coordinate and drive health care reform.But incremental steps in cost‐sharing, small‐scale pilot projects of consumer‐based designs, and employee awareness campaigns will not be enough. Employers need to take radical steps to break through the inertia that has built up among all stakeholders over the past 50 years. Chief among the author's proposals for employers are the following: In choosing a health care plan for employees, use value‐based purchasing criteria that consider more than just the price and access to services. Help consumers by demanding information from providers and insurers about the cost and efficacy of health care services, and of alternative treatments, before the choices are made. Encourage “consumerism” by setting up benefit plans that have a Health Reimbursement Arrangement (HRA) or a Health Savings Account (HSA) component. As the author states in closing, “Let these reforms begin with employers as the organizing force to drive needed change across the system. That may very well be the only way to save our employment‐based model.”