Health Savings Account - Eligible High Deductible Health Plans: Updating the Definition of Prevention

High-deductible health plans (HDHPs) are an important and growing part of the health insurance landscape. By some estimates, as many as 80 percent of large employers may offer an HDHP in 2014. In 2013, more than 15 million Americans received health coverage through an HDHP, a more than a threefold increase since 2007.As outlined by the U.S. Treasury Department, individuals with an HSA-eligible HDHP are required to pay the full cost of most medications and services -- in theory utilizing pre-tax HSA funds -- until deductibles are met. However, the 2003 authorizing legislation and further guidance include a safe harbor allowing plans to cover primary preventive services, those typically deemed to prevent the onset of disease, before the deductible is satisfied.Services or benefits meant to treat "an existing illness, injury or condition," are excluded from first-dollar coverage in HSA-eligible HDHPs, which encompasses most secondary preventive services. For example, plans are prohibited from providing first dollar coverage of disease management services such as insulin, eye and foot exams, and glucose monitoring supplies for patients with diabetes.As chronic disease conditions currently make up 75 percent of total U.S. health spending, appropriate chronic disease management is an important tool to lower long-term health care costs. As the market for HDHPs grow, it is important that they maintain the flexibility to allow for effective health management of all beneficiaries. This report addresses the strict definition of prevention that an HDHP must follow for it to include a pre-tax health savings account (HSA), and how this restriction limits the effectiveness of current plans. A potential solution - allowing HSA-eligible HDHPs to provide first-dollar coverage for targeted, evidence-based, secondary preventive services that prevent chronic disease progression and related complications - can improve patient-centered outcomes, add efficiency to medical spending, and enhance HDHP attractiveness.A multi-disciplinary research team from the University of Michigan's Center for Value-Based Insurance Design, Harvard Medical School, and the University of Minnesota conducted a multi-part project to investigate the impact of updatingthe definition of prevention for HDHPs to include selected secondary preventive services that are frequently used as health plan quality metrics and included as elements of pay-for-performance programs. Specifically, the project aimed to: 1) determine the premium effect, actuarial value, and estimated market uptake of the novel HDHP plan that covers these evidence-based services outside the deductible, and 2) explore through interviews whether insurance industry experts found coverage of secondary preventive services a worthwhile endeavor

Measuring Health Care Costs of Individuals with Employer-Sponsored Health Insurance in the U.S.: A Comparison of Survey and Claims Data

As the core nationally representative health expenditure survey in the United States, the Medical Expenditure Panel Survey (MEPS) is increasingly being used by statistical agencies to track expenditures by disease. However, while MEPS provides a wealth of data, its small sample size precludes examination of spending on all but the most prevalent health conditions. To overcome this issue, statistical agencies have turned to other public data sources, such as Medicare and Medicaid claims data, when available. No comparable publicly available data exist for those with employer-sponsored insurance. While large proprietary claims databases may be an option, the relative accuracy of their spending estimates is not known. This study compared MEPS and MarketScan estimates of annual per person health care spending on individuals with employer-sponsored insurance coverage. Both total spending and the distribution of annual per person spending differed across the two data sources, with MEPS estimates 10 percent lower on average than estimates from MarketScan. These differences appeared to be a function of both underrepresentation of high expenditure cases and underestimation across the remaining distribution of spending.

Informal Caregiving for Diabetes and Diabetic Complications Among Elderly Americans

Objectives: Little is known regarding the amount of time spent by unpaid caregivers providing help to elderly individuals for disabilities associated with diabetes mellitus (DM). We sought to obtain nationally representative estimates of the time, and associated cost, of informal caregiving provided to the elderly with diabetes, and to determine the complications of DM that contribute most significantly to the subsequent need for informal care. Methods: We estimated multivariable regression models using data from the 1993 Asset and Health Dynamics (AHEAD) Study, a nationally representative survey of people aged 70 or older (N=7,443), to determine the weekly hours of informal caregiving and imputed cost of caregiver time for community-dwelling elderly with and without a diagnosis of DM. Results: Those without DM received an average of 6.1 hours per week of informal care, those with DM taking no medications received 10.5 hours, those with DM taking oral medications received 10.1 hours, and those with DM taking insulin received 14.4 hours of care (P

Out-of-Pocket Health-Care Expenditures among Older Americans with Cancer

Objective:  There is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by elderly individuals with cancer. We sought to quantify OOPE for community-dwelling individuals age 70 or older with: 1) no cancer (No CA), 2) a history of cancer, not undergoing current treatment (CA/No Tx), and 3) a history of cancer, undergoing current treatment (CA/Tx). Methods:  We used data from the 1995 Asset and Health Dynamics Study, a nationally representative survey of community-dwelling elderly individuals. Respondents identified their cancer status and reported OOPE for the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. Using a multivariable two-part regression model to control for differences in sociodemographics, living situation, functional limitations, comorbid chronic conditions, and insurance coverage, the additional cancer-related OOPE were estimated. Results:  Of the 6370 respondents, 5382 (84%) reported No CA, 812 (13%) reported CA/No Tx, and 176 (3%) reported CA/Tx. The adjusted mean annual OOPE for the No CA, CA/No Tx, and CA/Tx groups were $1210,$1450, and $1880, respectively ( P  < .01). Prescription medications ($1120 per year) and home care services ($250) accounted for most of the additional OOPE associated with cancer treatment. Low-income individuals undergoing cancer treatment spent about 27% of their yearly income on OOPE compared to only 5% of yearly income for high-income individuals with no cancer history ( P  < .01). Conclusions:  Cancer treatment in older individuals results in significant OOPE, mainly for prescription medications and home care services. Economic evaluations and public policies aimed at cancer prevention and treatment should take note of the significant OOPE made by older Americans with cancer.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73612/1/j.1524-4733.2004.72334.x.pd

A controlled trial of value-based insurance design – The MHealthy: Focus on Diabetes (FOD) trial

<p>Abstract</p> <p>Background</p> <p>Diabetes affects over 20 million Americans, resulting in substantial morbidity, mortality, and costs. While medications are the cornerstone of secondary prevention, many evidence-based therapies are underutilized, and patients often cite out-of-pocket costs as the reason. Value-based insurance design (VBID) is a 'clinically sensitive' refinement to benefit design which links patient cost-sharing to therapy value; the more clinically beneficial (and valuable) a therapy is for a patient, the lower that patient's cost-sharing should be. We describe the design and implementation of MHealthy: Focus on Diabetes (FOD), a prospective, controlled trial of targeted co-payment reductions for high value, underutilized therapies for individuals with diabetes.</p> <p>Methods</p> <p>The FOD trial includes 2,507 employees and dependents with diabetes insured by one large employer. Approximately 81% are enrolled in a single independent-practice association model health maintenance organization. The control group includes 8,637 patients with diabetes covered by other employers and enrolled in the same managed care organization. Both groups received written materials about the importance of adherence to secondary prevention therapies, while only the intervention group received targeted co-payment reductions for glycemic agents, antihypertensives, lipid-lowering agents, antidepressants, and diabetic eye exams. Primary outcomes include medication uptake and adherence. Secondary outcomes include health care utilization and expenditures. An interrupted time series, control group design will allow rigorous assessment of the intervention's impact, while controlling for unrelated temporal trends. Individual patient-level baseline data are presented.</p> <p>Discussion</p> <p>To our knowledge, this is the first prospective controlled trial of co-payment reductions targeted to high-value services for high-risk patients. It will provide important information on feasibility of implementation and effectiveness of VBID in a real-world setting. This program has the potential for broad dissemination to other employers and insurers wishing to improve the value of their health care spending.</p

The impact of CHIP premium increases on insurance outcomes among CHIP eligible children

Background: Within the United States, public insurance premiums are used both to discourage private health policy holders from dropping coverage and to reduce state budget costs. Prior research suggests that the odds of having private coverage and being uninsured increase with increases in public insurance premiums. The aim of this paper is to test effects of Children's Health Insurance Program (CHIP) premium increases on public insurance, private insurance, and uninsurance rates. Methods: The fact that families just below and above a state-specific income cut-off are likely very similar in terms of observable and unobservable characteristics except the premium contribution provides a natural experiment for estimating the effect of premium increases. Using 2003 Medical Expenditure Panel Survey (MEPS) merged with CHIP premiums, we compare health insurance outcomes for CHIP eligible children as of January 2003 in states with a two-tier premium structure using a cross-sectional regression discontinuity methodology. We use difference-in-differences analysis to compare longitudinal insurance outcomes by December 2003. Results: Higher CHIP premiums are associated with higher likelihood of private insurance. Disenrollment from CHIP in response to premium increases over time does not increase the uninsurance rate. Conclusions: When faced with higher CHIP premiums, private health insurance may be a preferable alternative for CHIP eligible families with higher incomes. Therefore, competition in the insurance exchanges being formed under the Affordable Care Act could enhance choice

Can Broader Diffusion of Value-Based Insurance Design Increase Benefits from US Health Care without Increasing Costs? Evidence from a Computer Simulation Model

Using a computer simulation based on US data, R. Scott Braithwaite and colleagues calculate the benefits of value-based insurance design, in which patients pay less for highly cost-effective services

The cost-effectiveness of early noninvasive ventilation for ALS patients

BACKGROUND: Optimal timing of noninvasive positive pressure ventilation (NIPPV) initiation in patients with amyotrophic lateral sclerosis (ALS) is unknown, but NIPPV appears to benefit ALS patients who are symptomatic from pulmonary insufficiency. This has prompted research proposals of earlier NIPPV initiation in the ALS disease course in an attempt to further improve ALS patient quality of life and perhaps survival. We therefore used a cost-utility analysis to determine a priori what magnitude of health-related quality of life (HRQL) improvement early NIPPV initiation would need to achieve to be cost-effective in a future clinical trial. METHODS: Using a Markov decision analytic model we calculated the benefit in health-state utility that NIPPV initiated at ALS diagnosis must achieve to be cost-effective. The primary outcome was the percent utility gained through NIPPV in relation to two common willingness-to-pay thresholds: $50,000 and$100,000 per quality-adjusted life year (QALY). RESULTS: Our results indicate that if NIPPV begun at the time of diagnosis improves ALS patient HRQL as little as 13.5%, it would be a cost-effective treatment. Tolerance of NIPPV (assuming a 20% improvement in HRQL) would only need to exceed 18% in our model for treatment to remain cost-effective using a conservative willingness-to-pay threshold of $50,000 per QALY. CONCLUSION: If early use of NIPPV in ALS patients is shown to improve HRQL in future studies, it is likely to be a cost-effective treatment. Clinical trials of NIPPV begun at the time of ALS diagnosis are therefore warranted from a cost-effectiveness standpoint