Cost effective choices within different plan designs Judith H. Hibbard Jessica Greene Anna Dixon Martin Tusler University of Oregon Funding provided by The Changes in Health Care Financing and Organization (HCFO) initiative, a program of The Robert Wood Johnson FoundationThe Robert Wood Johnson Foundation

Will CDHPs increase cost effective choices? Use of health information tools will help consumers make more cost effective choices. They can help them determine:  When care is actually needed  What kind of care is needed  When self-management strategies are appropriate, and which ones to use  When no action is necessary

Operationalizing “Cost-Effective Choices”: Measuring “unproductive utilization” Using a schema based on the Oregon Health Plan priority list, ICD-9 codes are used to classify office visits into productive (evidence for efficacy) vs unproductive care (little or no evidence of efficacy) Acute and chronic visits are examined Ratios of acute “unproductive” visits are calculated by dividing the number of “unproductive” acute visits by the number of all acute visits (for those with at least 3 visits in 2003) - the ratios indicate a “pattern of use”

Examples of the most common “unproductive” acute and chronic visits Acute  Acute non-specific upper respiratory infection  Cough  Acute pharyngitis  Impacted cerumen (earwax) Chronic  Allergic Rhinitis  Rotator cuff syndrome non-specific

Claims data for employees was included in the analysis Examined whether there was a change in “unproductive care” chronic or acute care from 2003 to 2004 (year employees entered CDHP) Examined differences across the three plans looking at differences in ratios of “unproductive acute and chronic care Analysis controls for 2003 ratio, employee level, gender, age and a co-morbidity index

Ratios of “unproductive” acute visits For those with a minimum 3 visits in 2003 High Deductible CDHP Lower Deductible CDHP PPO *** Key: *p<.05, *** p<.001

Ratios of “unproductive” chronic care visits For those with a minimum 3 visits in 2003 High Deductible CDHP Lower Deductible CDHP PPO None of the results were significant

Use of “unproductive” acute care visits in 2004 Beta weights from regression PPO compared to lower deductible CDHP PPO compared to high deductible CDHP High deductible CDHP compared to lower deductible CDHP.108***N.S..044* Controlling for unproductive acute care in 2003, age, gender, employment type, and Charlson Co-morbidity Index Key: *p<.05, *** p<.001 NS not significant

Use of “unproductive” chronic care visits in 2004 Beta weights from regression PPO compared to lower deductible CDHP PPO compared to high deductible CDHP High deductible CDHP compared to lower deductible CDHP.034***N.S..044* Controlling for unproductive acute care in 2003, age, gender, employment type, and Charlson Co-morbidity Index Key: *p<.05, *** p<.001 NS not significant

Evidence for cost-effective choices in the claims data This is only true for the lower deductible CDHP enrollees Lower deductible enrollees changed patterns of use - to use fewer unproductive visits High deductible enrollees did not differ from the PPO in their unproductive utilization patterns. Their patterns were largely unchanged from pre- enrollment period.

Conclusions Evidence supports both the hopes and the fears about CDHPs Study design allows us to:  hold constant cost exposure and look at the impact of the CDHP plan elements (comparing PPO enrollees to lower deductible CDHP enrollees)  Hold constant CDHP plan elements and examine the impact of greater cost exposure (comparing high and lower deductible CDHP enrollees) The basic theory underlying the CDHP approach seems to be correct, but greater cost sharing appears to be counter productive

Conclusions continued Limitations and future studies  Cannot rule out outcomes a result of selection  Need to replicate findings beyond one employer Future studies should examine different levels of cost exposure and calibrate effects Who are the people that do well in a CDHP? What are their characteristics? How well do people with less education and income manage in a CDHP?