Mixed results for consumer-directed health plans

Washington -- Consumer-directed health care users decline both needed and unneeded health care and might be modestly healthier than the average population.

That's according to a Health Affairs article by RAND, the Santa Monica, Calif.-based think tank, published online Oct. 24. The article analyzed previous reports and studies on consumer-directed care.

The researchers also concluded that there isn't enough reliable information to reach a verdict on the value of health savings accounts, high-deductible health plans, health reimbursement accounts and other types of consumer-directed care.

But a consensus seems to be building around the need for more quality and price information on health care services, according to one of the article's co-authors, RAND health economist Melinda Beeuwkes Buntin, PhD.

Consumers will need this information if health savings accounts and related plans are going to be effective. Part of this would be achieved through the use of comprehensive electronic health records.

"There's tremendous potential for information technology right now. But in these early studies, I don't think it was realized," Dr. Buntin said.

The millions of people using health savings accounts still represented only 3% of the commercial insurance market earlier this year, but that's up from the 1% reported in early 2005.

American Medical Association policy supports health savings accounts and liberalizing the rules for HSAs and flexible spending accounts.

Making wise choices

The study found that consumers responded to the greater cost sharing consumer-driven plans require by cutting some ineffective care but also some efficacious care. Emergency department use for less-urgent problems dropped among people in these plans more than ED use for urgent problems.

Meanwhile, several of the studies that RAND analyzed found that patients in consumer-directed plans "are significantly more likely to adopt cost-saving behavior that might have adverse consequences."

Some trends might encourage patients to make more appropriate care choices, the study noted. Many consumer-directed plans offer financial incentives to patients participating in disease-management and wellness programs. Also, a 2005 survey of employers found that one-third of people using health savings accounts had some preventive services paid for before the deductible was met.

The RAND article shouldn't have focused on the possibility of consumers making poor health care decisions, said John Goodman, PhD, president of the National Center for Policy Analysis, a nonprofit research institute that promotes private sector alternatives to government regulation.

"What it should have asked is: 'Is there any other rationing scheme which is likely to lead to better decisions?' " said Dr. Goodman, a health savings account advocate.

Would it be better, he said, for insurance companies, employers or the government to choose for consumers?

One study cited in the article found some grounds for worries that consumer-directed plans might attract healthier-than-average people. However, Dr. Buntin said, "If there's some selection going on so far, it's modest."

The question of whether these plans curb long-term health system costs needs more study, the researchers wrote.

The studies they analyzed suggested that moving everyone from traditional plans to high-deductible, consumer-driven plans might generate a one-time reduction in health care use of 4% to 15%. But coupling these plans with tax-free health savings accounts would cut those percentages in half.

"What we don't know is how these plans would affect growth and costs," Dr. Buntin said.

The focus on saving money through different insurance plans leaves out one key population -- the uninsured, said Kathleen Stoll, director of health policy at the consumer group Families USA.

People without health coverage often delay preventive care until they have an emergency, which drives up costs, she said.