Department of Planning, Public Policy & Management

The University of Oregon

Consumer Directed Health Plans and

Disparities in Prescription Drug Use

Jessica Greene PhDJudith Hibbard DrPH

Background• CDHPs combine a high deductible health

plan with a health care account, and informational resources

• CDHPs were designed to spark more informed health care decision making

• Some have voiced concern over CDHPs’ impact on vulnerable populations– “If consumer-directed plans achieve market

dominance, disparities in care by class and race will probably grow” (Bloche, Health Affairs 2007)

– “Simply put, cost sharing results in de facto discrimination” (Rice, National Academies Press 2003)

Cost Sharing & Racial/Ethnic Disparities

Little evidence, suggests race/ethnicity may matter, but not always in expected direction

– Black women with Medicare had higher mammogram levels under cost sharing than white women (Trivedi et al., NEJM 2008)

– Minorities were three times more likely to restrict pharmacy use when they had no prescription coverage than whites (Steinman et al., JGIM 2001)

Cost Sharing & Socio-demographic Disparities

Little evidence, inconsistent findings, limited by relatively homogenous employed populations and proxy income measures– After enrolling in a CDHP, hourly employees more

likely to cut back on office visits than salaried, including high priority acute care visits (Hibbard et al. forthcoming)

– Women residing in low income areas were more likely than those in higher income areas to reduce mammogram use when subject to cost-sharing (Trivedi et al. NEJM 2008)

– No difference found in some studies (Cherkin et al. Soc Sci Med 1992 & Chandra et al. NBER 2007)

Research Question

Are people of different backgrounds (race/ethnicity or socio-economic status) differentially impacted by CDHP enrollment?

• This builds on prior work that has found that CDHP enrollees are more likely to discontinue some chronic illness medications

Plan Details

Family Coverage 2004

High Deductible

CDHP

Lower Deductible

CDHP3 Tier

Copayment

Premium Hourly Salaried

$420$420-$1,128

$1,260$1,260-$2,600

$1,260$1,260-$3,600

Deductible LevelPersonal Care AccountGap (Deductible-PCA)

$3,000$1,500$1,500

$2,000$1,500

$ 500

$600/$1,050n/an/a

Prescription Drug Costs

10% coinsuranc

e (after deductible)

10% coinsurance

(after deductible)

Three tiered copay

$10, $20, $30

Enrollment 13% 23% 60%

Methods• Compared discontinuation of 3 classes of chronic

disease medication (antidiabetics, antihypertensives and lipid lowering drugs) among whites/minorities and hourly/salaried in two periods:– Baseline period (7/2003-12/2003) n=3,515– Intervention period (1/2004-12/2004) n=3,785

• Discontinuation was defined as not purchasing any of the drug class in observation period, but had purchased in prior 6 months and had 1 day supplied in prior 60 days

• Propensity weights adjusted for differences in health and socio-demographics of those enrolling in CDHPs

Discontinuation Rates by Race/Ethnicity

White Minority

High Deductible CDHP Baseline

2.9 2.7

Lower Deductible CDHP Baseline

5.8 8.0

Three Tier Copayment Baseline

5.9 7.8

Intervention 12.6 37.3*

Intervention 7.2 8.1

Intervention 6.3 7.3

Discontinuation Rates by Socioeconomic Status

Salaried Hourly

High Deductible CDHP Baseline

2.6 2.9

Lower Deductible CDHP Baseline

7.0 5.7

Three Tier Copayment Baseline 5.3 6.4

Intervention 15.8 15.0

Intervention 7.5 7.3

Intervention 4.5 7.1

Summary

• Enrollment in CDHP resulted in greater discontinuation of chronic illness drugs for minority enrollees than whites– May increase disparities in health outcomes

• No difference in discontinuation rates in CDHP between hourly and salaried enrollees

Limitations

• Small numbers of minority enrollees in the CDHP

• Using claims as measure of taking chronic illness medications

Short time frame (1st year of enrollment)

This is the experience of 1 employer and CDHP market is rapidly changing

Implications Plans should routinely monitor high

deductible CDHP enrollees (and others) for discontinuation & send alerts Plans should monitor racial/ethnic and SES

differences in discontinuation

Employers should strongly consider first dollar coverage for preventive medications currently allowed in the HSA regulations

Congress should revisit allowing first dollar coverage in HSAs for chronic illness medications

The authors wish to acknowledge both the participating employer and CDHP for their openness and commitment to research.

We also would like to thank “The Changes in Health Care Financing and Organization” (HCFO), a program of The Robert Wood Johnson Foundation, for providing support for this research. And we would like to thank Merck for prior support on related work.

Acknowledgements