High Deductible Health Plans, EBRI Ruins A Good Note

Paul Fronstin, writing the June Note for the Employee Benefit Research Institute (EBRI), presents some interesting survey data about about medication adherence and delays/avoidance of health care distributed by type of health plan and income level.

He breaks down the various plans levels into:

  • traditional – meaning a plan that has a deductible of less than $1,000
  • high deductible (HDHP) – deductible $1,000 or higher without a funded HSA/HRA
  • consumer directed (CDHP) – deductible $1,000 or higher with a funded HSA/HRA

Not surprisingly, there is a statistically significant difference in medication adherence by plan.

Members who had a HDHP plan had a higher incidence of not filling prescriptions or avoiding some medical care than those in a traditional plan, with the CDHP members in between the two groups. These relationships held when the survey data was sorted by those who had a self reported health problem versus those without a health problem. And, again, when the sorting was done by household income of below $50,000 versus $50,000 and above.

Where There High Deductible Options?

One item that the note does not address is whether the individuals and families in each high deductible plan had other options when selecting their plan. I am assuming here that we are talking about employer offered plans in the note since there is discussion about employer contribution to HSA accounts. If someone has the ability to choose between plans, I would be curious how this effects the results reported. A person picking a high deductible plan over a traditional plan because of cost would seem more likely to skimp on prescriptions and other care.

Is There A High Deductible Learning Curve?

A very interesting result reported was the performance of individuals and families in the CDHP plans, those plans with funded HRA/HSA accounts. There is a increase in prescription adherence with members that had their accounts for over three years. This change was not seen in the high deductible only group. Does this indicate that over time as members start to fund their accounts and learn that they can purchase health care items with tax free money? Does it mean that high deductible plans need a savings account to be usefull?

What Constitutes Access?

The one issue that I have with this note is Fronstin’s use of the word ‘access’ to characterize health system usage around prescription adherence.

Prescription adherence is a very common problem, for example see this recent talk on the issue. Cost is only one factor and there is no indication of whether the respondents were given multiple reasons to select for non-adherence.

In addition, access is a politically charged word for what are economic decisions by individuals. I may have only $100 in my pocket for gasoline, but I decide to pay my cable bill instead of buying gas to take a short trip. Do I have an access problem with gasoline?