1. The Impact of Cost Sharing on Middle-Income Children AcademyHealth Annual Research Meeting June 2008 Amy M Lischko

2. 2 Today’s agenda  Background and policy relevance  Research questions  Methodology  Results  Conclusions and policy implications  Limitations and future research  Questions

3. 3 Background and policy relevance  Consumer-driven health plans require engagement of consumers in their health care decision-making.  Increased and differential cost sharing is being used by health plans to direct patients to more “efficient” use of health care services.  RAND HIE remains the gold standard, however results may be outdated. Medicine, the delivery of health care, insurance plans, and peoples’ beliefs about health care have changed dramatically since the late 1970’s.  Little published literature on whether and how privately insured employees change their utilization of health services when increases are made to cost sharing.

4. 4 Today’s agenda  Background and policy relevance  Research questions  Methodology  Results  Conclusions and policy implications  Limitations and future research  Questions

5. 5 Research questions  What is the impact of increased cost sharing on utilization of health care services?  Are there differences in response by age, income or health status?  Are there differences in the responses to increases in cost sharing by type of service?  Do any offsets occur due to responses to increases in cost sharing?

6. 6 Today’s agenda  Background and policy relevance  Research questions  Methodology  Results  Conclusions and policy implications  Limitations and future research  Questions

7. 7 Study design State employees <65 with 5+ continuous years in any GIC health plan (n = 73,476) Claims drawn for employees and dependents (n = 124,045) Claims for 3 yrs used (2002-04). Eliminated 13,950 members (employees and dependents) who changed plans (final n = 110,095). Claims were collapsed by plan for each month (8 * 36) = 288 observations. Difference-in-difference and trend models are used depending on service

8. 8 Summary* of changes to cost sharing Office visits ED visitsOutpatient surgery Inpatient stays MH/SA visits Indemnity (pre) $5$25$0$1501-4 $0/5-25 $20/25+ $40 Indemnity (post) $10$50$0$1501-4 $0/5+ $15 HMO (pre) $10$25-$35$0 $10 HMO (post) $15$50$75$200$15 PPO (pre) $5$25$0 1-4 $0/5-25 $20/25+ $40 PPO (post) $15$50$75$200-$3001-4 $0/5+ $15 *Changes are more complex in some cases but difficult to display on single chart

9. 9 Today’s agenda  Background and policy relevance  Research questions  Methodology  Results  Conclusions and policy implications  Limitations and future research  Questions

10. 10 Characteristics of sample Education < College14.0 College48.8 >College37.2 Age 18-240 25-346.0 35-4424.4 45-5441.1 55-6428.5 Household Income < $45,00012.8 45-$75,00032.5 75 - $105,00030.5 >$105,00024.2 Married63.8 Race White84.0 Black6.6 Other9.4 Any Chronic Disease No53.2 Yes46.8 * Respondents who changed plans are not included % Respondents * Children Any 51.3% Average number 1.9 Work status Full-time 94.3% Avg. years with state 18 Union position 71%

11. 11 Results (1 of 2)  What is the impact of increased cost sharing on utilization of health care services? Type of Service Coef. se p-value Mental Health visits 02-03 -.0035.0016 0.02* Mental Health visits 03-04 0.001.0015 0.49 Outpatient Surgery -.0108.0073 0.14 Inpatient LOS.0009.0013 0.46 Coefficients are from difference-in-difference models Type of Service Coef. se p-value Office visits -.0018.0009 0.047* Emergency Dept. visits -.0000085.0022 0.6 Research question Coefficients are from linear trend models

12. 12 Results (2 of 2)  Are there differences in the responses to increases in cost sharing by type of service, age, income or health status? Age0-1819-3435-64 Type of Service Mental Health visits 02-03.0055***.0017-.007*** Mental Health visits 03-04.0200***-.007**.002 Outpatient Surgery-.005-.0143-.0129 Inpatient LOS.0006.0064-.0013 Coefficients are from difference-in-difference models Type of Service Office visits -.004*.0003-.0027 Emergency Dept. visits-.00005*.00006*.000014 Research question Coefficients are from linear trend models

13. 13 Today’s agenda  Background and policy relevance  Research questions  Methodology  Results  Conclusions and policy implications  Limitations and future research  Questions

14. 14 Conclusions and policy implications  Increases made to cost sharing did not deter most utilization  Similar results across income and health status  Reduction in office visits for children  No significant offsets in utilization were found More work needs to be done to study whether observed decreased utilization among children affected health outcomes. More targeted cost-sharing arrangements may be advisable.

15. 15 Today’s agenda  Background and policy relevance  Research questions  Methodology  Results  Conclusions and policy implications  Limitations and future research  Questions

16. 16 Limitations and future research Limitations –Underlying trends in utilization may confound –Adverse selection or retention in plans –Omitted variables –GIC population may have some problems with external validity –Massachusetts’ unique health care environment Future research –What services are being reduced for children? –Is there an impact on outcomes? –How do parents make decisions about children’s healthcare utilization? How do they balance physician orders with convenience and economic incentives?

17. 17 Today’s agenda  Background and policy relevance  Research questions  Methodology  Results  Conclusions and policy implications  Limitations and future research  Questions