Our friends at the Employee Benefits Research Institute (EBRI) have come out with a new study on consumer-directed health that raises far more questions than it answers. The study was published in Health Affairs, but EBRI also offers an extensive appendix with additional information.
The abstract sums up the lessons thusly –
We explored effects of consumer-directed health plans on health care and preventive care use, using data from two large employers — one that adopted a CDHP in 2007 and another with no CDHP. Our study had mixed results relative to expectations. After four years under the CDHP, there were 0.26 fewer physician office visits per enrollee per year and 0.85 fewer prescriptions filled, but there were 0.018 more emergency department visits. Also, the likelihood of receiving recommended cancer screenings was lower under the CDHP after one year and, even after recovering somewhat, still lower than baseline at the study’s conclusion.
The authors seem to be saying that CDHPs aren’t working all that well and are discouraging the use of preventive services. They also suggest that, by discouraging physician office visits, CDHPs may increase the use of emergency departments. They recommend exempting physician office visits from the deductible.
Maybe, but this research is an awfully thin reed to hang such a recommendation on.
It completely fails to consider what, if any, employee education this employer offered. Did the company just suddenly change benefits or did it work with employees so they would understand the new program? Did it offer patient information support once the program was in effect, or did it leave people in the dark? The authors have nothing to say about any of this.
The authors note that one of the motivating factors in changing to CD Health is financial — employers are trying to save money. But there is not a word in here about the financial effects on the company, or on the workers.
The authors seem to believe that preventive services are unquestionably a good thing, but they acknowledge in a footnote that during the time of this study the recommendations for breast cancer and cervical screening were changed substantially, so even the experts were confused about what to do.
Finally, the authors look solely at the numbers of visits without any consideration of the value of the visits. For instance, they measure the number of prescription drug fills without any consideration of generic substitution, or of replacing some physician office visits with more efficient retail clinic visits for routine services.
The Health Affairs article presents the information on the use of services in a table of raw data –
This is curious because Health Affairs is usually far more graphical in presenting data. And it turns out that such a graphical presentation is readily available, but not unless you go to page 13 of the online appendix
Now that we can see the data in chart form, we have a better idea of what is going on here.
There was a substantial first-year dip in discretionary services among the people who were switched to a CDHP. This should not be at all surprising. It always takes a while for people in a new plan to figure out how to use it — what’s covered, how to file claims, what providers are in the network, and so on. Plus, when a change is imposed on employees by the company, there is a great deal of first-year skepticism and even hostility. After that first year, things seemed to settle down quite a bit.
The study authors seemed concerned about the use of preventive screening, but these charts show that the CDHP enrollees had a higher use of screening services than the PPO enrollees in the last three years of the study period. Perhaps the authors should be more concerned about why PPO enrollees had such a dramatic reduction in their use of screening services over the years of the study.
The authors might also wonder about the spike in inpatient hospital days among the PPO enrollees in the first year of the study. Was there an epidemic that hit only PPO people that year? And why are PPO enrollees’ use of emergency departments steadily dropping? Was there a change in available emergency services for this population?
It is also curious that, after the first-year dip, the rate of Rx fills for the two populations is rising almost identically. This makes our earlier question about generic substitution all the more important.
Like I say, this research raises many more questions than it answers. It’s a pity the authors chose to address only a few of them.