HSA enrollees spend less on care than those in traditional plans

They also receive less preventive care, a fact experts find troubling, a study says.

By Emily Berry — Posted March 31, 2011

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In the first year consumers are enrolled in high-deductible health plans paired with health savings accounts, they save money on what they spend on health care -- in part because they are not getting as much preventive care, according to a study released March 25 by the RAND Corp.

The study, which appeared in the March issue of The American Journal of Managed Care, raises questions about whether the cost savings of HSAs comes at the price of enrollees' health.

RAND researchers examined enrollment and claims data from 2005 for more than 800,000 households from 523 large employers, both with and without high-deductible plans and HSAs, often referred to as consumer-directed plans.

The review showed that during the first year enrolled in a consumer-directed plan, families spent 14% less on average than their counterparts in traditional health plans. The savings was realized only with deductibles of at least $1,000.

However, the review showed a "moderate" drop in the use of preventive health services by those patients.

Roger Feldman, PhD, professor of health insurance at the University of Minnesota School of Public Health, has done similar work examining consumer-directed health plans. He said the RAND findings were consistent with what he and other researchers have found. For example, a study of Californians with high-deductible health plans found that those with deductibles of more than $1,000 were more likely than consumers with lower deductibles to put off preventive visits.

Dr. Feldman called the drop in preventive care among high-deductible plan enrollees "very puzzling and a little bit troubling."

He said it might be useful if future research looks beyond a single year's claims data to see whether enrollees' understanding of their plan improves so that they use preventive care that won't cost them anything out of pocket.

Other experts said patient confusion might be behind the drop. In some cases, the plans will cover preventive visits completely, without forcing patients to pay toward their deductible. Under health system reform, insurers will be required to cover 100% of costs for an increasing variety of preventive visits. But researchers said patients might believe they have to pay for all preventive visits.

With enrollment in high-deductible plans growing, experts say it will be important for both health plans and physicians to help patients understand when preventive care is covered without cost-sharing.

"Somehow there must be a way to signal, 'Here's a patient who has a high-deductible health plan,' and then for their physician to have a conversation with them and say, 'You need to get your mammography done, and it's free for you,' but that's such a complex chain of events," said Alison Galbraith, MD, MPH, a pediatrician and assistant professor in the Dept. of Population Medicine at Harvard Medical School in Boston.

Dr. Galbraith, a researcher at the Harvard Pilgrim Health Care Institute's Center for Child Health Care Studies, is studying the effect that high-deductible plans have on care for children, particularly the chronically ill.

Meanwhile, the Commonwealth Fund's Bienneal Health Insurance Survey, released March 15, found that 18% of people who were insured all year in 2010 had a deductible of $1,000 or higher, up from 10% in 2005, the year the RAND study examined.

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