1. Department of Planning, Public Policy & Management The University of Oregon Consumer Directed Health Plans and Disparities in Prescription Drug Use Jessica Greene PhD Judith Hibbard DrPH

2. Background CDHPs combine a high deductible health plan with a health care account, and informational resources CDHPs were designed to spark more informed health care decision making Some have voiced concern over CDHPs’ impact on vulnerable populations –“If consumer-directed plans achieve market dominance, disparities in care by class and race will probably grow” (Bloche, Health Affairs 2007) –“Simply put, cost sharing results in de facto discrimination” (Rice, National Academies Press 2003)

3. Cost Sharing & Racial/Ethnic Disparities Little evidence, suggests race/ethnicity may matter, but not always in expected direction –Black women with Medicare had higher mammogram levels under cost sharing than white women (Trivedi et al., NEJM 2008) –Minorities were three times more likely to restrict pharmacy use when they had no prescription coverage than whites (Steinman et al., JGIM 2001)

4. Cost Sharing & Socio-demographic Disparities Little evidence, inconsistent findings, limited by relatively homogenous employed populations and proxy income measures –After enrolling in a CDHP, hourly employees more likely to cut back on office visits than salaried, including high priority acute care visits (Hibbard et al. forthcoming) –Women residing in low income areas were more likely than those in higher income areas to reduce mammogram use when subject to cost-sharing (Trivedi et al. NEJM 2008) –No difference found in some studies (Cherkin et al. Soc Sci Med 1992 & Chandra et al. NBER 2007)

5. Research Question Are people of different backgrounds (race/ethnicity or socio-economic status) differentially impacted by CDHP enrollment? This builds on prior work that has found that CDHP enrollees are more likely to discontinue some chronic illness medications

6. Plan Details Family Coverage 2004 High Deductible CDHP Lower Deductible CDHP 3 Tier Copayment Premium Hourly Salaried $420 $420-$1,128 $1,260 $1,260-$2,600 $1,260 $1,260-$3,600 Deductible Level Personal Care Account Gap (Deductible-PCA) $3,000 $1,500 $2,000 $1,500 $ 500 $600/$1,050 n/a Prescription Drug Costs 10% coinsurance (after deductible) 10% coinsurance (after deductible) Three tiered copay $10, $20, $30 Enrollment13%23%60%

7. Methods Compared discontinuation of 3 classes of chronic disease medication (antidiabetics, antihypertensives and lipid lowering drugs) among whites/minorities and hourly/salaried in two periods: –Baseline period (7/2003-12/2003) n=3,515 –Intervention period (1/2004-12/2004) n=3,785 Discontinuation was defined as not purchasing any of the drug class in observation period, but had purchased in prior 6 months and had 1 day supplied in prior 60 days Propensity weights adjusted for differences in health and socio-demographics of those enrolling in CDHPs

8. Discontinuation Rates by Race/Ethnicity WhiteMinority High Deductible CDHP Baseline 2.92.7 Lower Deductible CDHP Baseline 5.88.0 Three Tier Copayment Baseline 5.97.8 Intervention 12.6 37.3* Intervention 7.2 8.1 Intervention 6.3 7.3

9. Discontinuation Rates by Socioeconomic Status SalariedHourly High Deductible CDHP Baseline 2.62.9 Lower Deductible CDHP Baseline 7.05.7 Three Tier Copayment Baseline5.36.4 Intervention 15.8 15.0 Intervention 7.5 7.3 Intervention 4.5 7.1

10. Summary Enrollment in CDHP resulted in greater discontinuation of chronic illness drugs for minority enrollees than whites –May increase disparities in health outcomes No difference in discontinuation rates in CDHP between hourly and salaried enrollees

11. Limitations Small numbers of minority enrollees in the CDHP Using claims as measure of taking chronic illness medications  Short time frame (1 st year of enrollment)  This is the experience of 1 employer and CDHP market is rapidly changing

12. Implications  Plans should routinely monitor high deductible CDHP enrollees (and others) for discontinuation & send alerts  Plans should monitor racial/ethnic and SES differences in discontinuation  Employers should strongly consider first dollar coverage for preventive medications currently allowed in the HSA regulations  Congress should revisit allowing first dollar coverage in HSAs for chronic illness medications

13. The authors wish to acknowledge both the participating employer and CDHP for their openness and commitment to research. We also would like to thank “The Changes in Health Care Financing and Organization” (HCFO), a program of The Robert Wood Johnson Foundation, for providing support for this research. And we would like to thank Merck for prior support on related work. Acknowledgements