Paul Fronstin, EBRI and Sara R. Collins, The Commonwealth Fund

THE COMMONWEALTH

FUND

Early Experience With High-Deductible and Consumer-Driven

Health Plans:Findings from the

EBRI/Commonwealth Fund Consumerism in Health Care Survey

Paul Fronstin, EBRI and Sara R. Collins, The Commonwealth Fund

EBRI Policy Forum, Washington, D.C.December 8, 2005

THE COMMONWEALTH

FUND

MethodologyThe Consumerism in Health Care Survey was conducted online using Harris Poll Online, Harris Interactive’s online sample of Internet users.

Eligibility: Americans ages 21 to 64 with private health insurance coverage.

Stratification: Gender, age, and region.

Final sample is skewed towards higher income, more educated, and also under represents minorities.

Weighting: The national sample is weighted by gender, age, region, and education to reflect the actual proportions in the population.

The CDHP and HDHP samples are unweighted, since population data does not exist.

Analysis Groups: Comprehensive insurance, HDHP, CDHP

Sample Groups: National sample Oversample

n=1204 (1061 Comprehensive, 126 HDHP, 17 CDHP)

n=505 (337 HDHP, 168 CDHP)

1. Comprehensive n=1,061 (all from national sample)

2. HDHP sample n=463 (126 – national, 337 – oversample)

3. CDHP sample n=185 (17 – national, 168 – oversample)

THE COMMONWEALTH

FUND

Health Plan Definitions

• Comprehensive – plan with no deductible or <$1000 (individual), <$2000 (family)

• HDHP – plan with deductible $1000+ (individual), $2000+ (family), no account

• CDHP – plan with deductible $1000+ (individual), $2000+ (family), with account

THE COMMONWEALTH

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Respondent ProfileComprehensive

(n=1061)HDHP

(n=463)CDHP

(n=185)

Age 21 to 34 29% 17%* 21%*

Education High school graduate or less

32 8* 5*

College graduate or some graduate work

23 38* 46*

Graduate degree 11 17* 21*

Household Income $150,000 or higher 4 3 9*

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.*Difference between HDHP/CDHP and Comprehensive is statistically significant at p ≤ 0.05 or better.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH

FUND

Respondent ProfileComprehensive

(n=1061)HDHP

(n=463)CDHP

(n=185)

Self-Rated Health Status

Excellent/very good 45% 47% 57%*

Obese 36 33 26*

Smokes cigarettes 23 14* 14*

No regular exercise 24 15* 16*

Firm Size Self-employed with no employees

2 9* 8*

2-49 15 31* 38*

50-199 9 9 8

200-499 10 7 5*

500 or more 55 37* 36*



THE COMMONWEALTH

FUND

Distribution of Individuals Covered by Private Health Insurance, by Type of Health Plan

HDHP

9%

CDHP

1%

Comprehensive

89%

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.


THE COMMONWEALTH

FUND

Number of Years Covered by Current Health Plan, by Type of Health Plan

1921

46*

302725

5354

24

0

20

40

60

80

Comprehensive HDHP CDHP

Less than one year 1-2 years 3 or more years



THE COMMONWEALTH

FUND

Familiarity with Consumer Driven Health Plans



4

65*

10*

14

22*

24*

80

13*

50*

0% 20% 40% 60% 80% 100%

CDHP

HDHP

Comprehensive

Extremely or very familiar Somewhat familiar Not familiar

THE COMMONWEALTH

FUND

Deductibles, by Type of Health Plan

Comprehensive (n=1061)

HDHP (n=463)

CDHP (n=185)

Individual Deductible No deductible 47%

$1 - $499 29

$500 - $999 13

$1,000 - $1,999 64 39

$2,000 - $3,499 23 49

$3,500 or higher 8 10

Family Deductible No deductible 48

$1 - $499 17

$500 - $999 14

$1,000 - $1,999 13

$2,000 - $2,999 50 31

$3,000 - $4,999 22 43

$5,000 or higher 20 24

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH

FUND

Satisfaction with Quality of Health Care Received, by Type of Health Plan

4

23

72

14*

34*

52*

28

9*

63*

0

20

40

60

80

Extremely or very

satisfied

Somewhat

satisfied

Not satisfied




THE COMMONWEALTH

FUND

Satisfaction with Out-of-Pocket Costs for Health Care, by Type of Health Plan

21

3642

31

12*

57*

18*28*

54*

0

20

40

60

80

Extremely or very

satisfied

Somewhat

satisfied

Not satisfied




THE COMMONWEALTH

FUND

Satisfaction with Choice of Doctors, by Type of Health Plan

6

21

73

11*

29*

60*

1021

69

0

20

40

60

80

Extremely or very

satisfied

Somewhat

satisfied

Not satisfied




THE COMMONWEALTH

FUND

Overall Satisfaction with Health Plan, by Type of Health Plan

8

28

63

29*39*

33* 3226*

42*

0

20

40

60

80

Extremely or very

satisfied

Somewhat

satisfied

Not satisfied




THE COMMONWEALTH

FUND

Likelihood of Recommending Health Plan to Friend or Co-Worker, by Type of Health Plan

2426

5143*

34*

22*31 35*34*

0

20

40

60

80

Extremely or very

likely

Somewhat likely Not likely




THE COMMONWEALTH

FUND

Likelihood of Staying With Current Health Plan If Had the Opportunity to Change, by Type of Health

Plan

11

28

61

33*37*30*

2133*

46*

0

20

40

60

80

Extremely or very

likely to stay

Somewhat likely

to stay

Not likely to stay




THE COMMONWEALTH

FUND

Agreement With Statements About Health Plan: Percent Reporting That They Strongly or Somewhat

Agree, by Type of Health Plan

5346

7769

39*40

67*50* 46

75

41*54*

020406080

Health plan is easy

to understand

Health plan will

protect me in the

event of an

expensive illness

Health plan

encourages me to

adopt a healthier

lifestyle

Health plan provides

information to help

me choose among

physic ians,

pharmac ies, labs,

and hospitals




THE COMMONWEALTH

FUND

Attitudes About Consumerism and Quality

71

64

50

9

70

68

46

10

74

67

9

41*

In general, the choices made by thepeople who use health care services

have a significant impact on the total costof health care

In general, the choices made by thepeople who use health care services

have a significant impact on the quality ofhealth care they receive

It is possible to find information you cantrust about the quality of health care you

receive

In general, doctors who charge higherprices provide higher quality health care




THE COMMONWEALTH

FUND

Percentage of Individuals Covered by Employment-Based Health Benefits With No Choice of Health

Plan, by Type of Health Plan

34

52*51*

0

20

40

60

80




THE COMMONWEALTH

FUND

Among Individuals with a Choice of Plan, Reasons for Choice

• Comprehensive– Low out of pocket costs, good benefits (54%)

• CDHP (n=63)– Opportunity to save money in the account,

and rollover funds for future years (62%)

• HDHP– Cost of the premium (64%)

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account


THE COMMONWEALTH

FUND

Health Plan Choice and Premium Cost

12

29

27

21

11

32

31

14

24

10*

50*

5*More expensive than all the other plans

More expensive than some, but less expensivethan others

Less expensive than all the other plans

About the same cost as the other plans

Comprehensive HDHP (n=279) CDHP (n=114)



THE COMMONWEALTH

FUND

Percentage of Individuals With Comprehensive Employment-Based Health Benefits

Offered CDHP or HDHP

Offered a CDHP or HDHP

33%

Don't know if CDHP or HDHP was offered

26%

Not Offered a CDHP or HDHP

41%

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH

FUND

Reasons HDHP Members Give for Not Selecting a CDHP Plan That Was Available

18

19

30

10

15*I did not like the high out-of-pocketcosts

I am more familiar with the plan Iselected

It is too much trouble to open and/ormanage the savings account

I did not have the money to put into asavings account

It's too complicated, I did notunderstand it

HDHP (n=136)

Note: HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account.

*Difference between HDHP/CDHP and Comprehensive is statistically significant at p ≤ 0.05

or better.


THE COMMONWEALTH

FUND

Issues Not Addressable

• Employer contributions• Individual contributions• Rollover amounts• Choice:

– Reasons why those in CDHP chose plan– Reasons why those in comprehensive did not

choose CHDP

THE COMMONWEALTH

FUND

Implications of Consumerism For:

• Out-of-pocket costs • Access to health care services• Information on cost and quality

of providers• Health care decision making

THE COMMONWEALTH

FUND

Percent of Income Spent Annually on Out-of-Pocket Medical Expenses

8 1216

30*

21*14*

11640

20

40

60

ComprehensiveHDHP

CDHP

ComprehensiveHDHP

CDHP

ComprehensiveHDHP

CDHP

10%+ of income 5-9% of income

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.*Difference between HDHP/CDHP and Comprehensive is statistically significant at p ≤ 0.05 or better.**Health problem defined as fair or poor health or one of eight chronic health conditions.Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

Percent of adults 21-64 spending ≥ 5% of income

TotalHealth Problem**

<$50,000 Annual Income

5

20*

118

29*16

14

45*

23

6* 8*15*

731 1 3 3

(n = 61)

(n = 90)

THE COMMONWEALTH

FUND

Percent of Income Spent Annually on Out-of-Pocket Medical Expenses, Including Premiums

9 13

2529*

35*

58*

23* 26*

44*

0

20

40

60

80

100

ComprehensiveHDHP

CDHP

ComprehensiveHDHP

CDHP

ComprehensiveHDHP

CDHP

10%+ of income 5-9% of income


**Health problem defined as fair or poor health or one of eight chronic health conditions.Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

Percent of adults 21-64 spending ≥ 5% of income

Total Health Problem**<$50,000

Annual Income

12

42*31*

17

38*34

92*

66

53*

13* 9*18* 12* 10

33* 213 4

(n = 61)

(n = 90)

THE COMMONWEALTH

FUND

Percent of Adults Who Have Delayed or Avoided Getting Health Care Due to Cost

2621

17

42*

31*31*35*

48*40*

0

20

40

60

Total Health Problem** <$50,000 Annual

Income



**Health problem defined as fair or poor health or one of eight chronic health conditions.


Percent of adults 21-64

(n = 61)

(n = 90)

THE COMMONWEALTH

FUND

Percent of Adults Who Have Not Filled a Prescription Due to Cost

2027

2116

3233*26* 2526

0

20

40

60


Income






(n = 61)(n = 90)

THE COMMONWEALTH

FUND

Percent of Adults Who Have Skipped Doses to Make a Medication Last Longer

32

20 212015

35*

26* 2829

0

20

40

60


Income





Percent of adults 21-64 with prescriptions in last twelve months

(n = 50)(n = 85)

THE COMMONWEALTH

FUND

Availability and Use of Quality and Cost Information Provided by Health Plan

Comprehensive HDHP/CDHPHealth plan provides information on quality of care provided by:

Doctors 14% 16%

Hospitals 14 15

Health plan provides information on cost of care provided by:

Doctors 16 12

Hospitals 15 12

Of those whose plans provide info on quality, how many tried to use it for:

Doctors 42 54

Hospitals 25 45*

Of those whose plans provide info on cost, how many tried to use it for:

Doctors 15 36* (n = 76)

Hospitals 14 32* (n = 76)Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.*Difference between HDHP/CDHP and Comprehensive is statistically significant at p ≤ 0.05 or better.


THE COMMONWEALTH

FUND

Most Trusted Sources for Information on Health Care Providers, by Insurance Source

10

15

20

4342

25

16

8

4

2

6

2

0 20 40 60

Government or other

agency

Own health plan

Medical assoc iation

Family member or friend

Consumer group

Your doctor

Comprehensive

HDHP/CDHP




THE COMMONWEALTH

FUND

Percentage of Adults who Agree that Terms of Coverage Make Them Consider Cost When Deciding

to Seek Health Care Services

71*

60*

38

0

20

40

60

80

Comprehensive HDHP CDHPNote: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.*Difference between HDHP/CDHP and Comprehensive is statistically significant at p ≤ 0.05 or better.


Percent of adults 21-64 who strongly or somewhat agree

THE COMMONWEALTH

FUND

Cost Conscious Decision-Making, by Insurance Source

27

43

49

19

32*

44*

55*

60*

14

23

0 20 40 60 80

Checked quality rating ofdoctor or hospital

Checked price of service

Asked doctor torecommend less costly

prescription drugs

Talked to doctor abouttreatment options & costs

Checked whether planwould cover care

Comprehensive

HDHP/CDHP



Percent of adults 21-64 who received health care in last twelve months

THE COMMONWEALTH

FUND

Conclusion• Low diffusion of consumer-driven plans• Among adults with plans, lower satisfaction with

quality of care, out-of-pocket costs, plan overall; few would recommend plan to friends/co-workers

• High out of pocket costs + premiums amount to substantial share of income, especially among those with lower income and health problems

• No differences in service use, but higher reported rates of cost-related delays, avoidance, or skipping care or Rx, esp. lower income and health problems

• More cost-conscious decision making behavior• Little quality/cost information provided by plans• Consumerism gives disproportionate responsibility

for cost control to those with health problems and low incomes

THE COMMONWEALTH

FUND

Acknowledgements

• Dallas Salisbury, President & CEO, EBRI and EBRI-ERF

• Karen Davis, President, The Commonwealth Fund

• Cathy Schoen, Senior Vice-President, The Commonwealth Fund

• Michelle Doty, Senior Analyst, The Commonwealth Fund

• Jennifer Kriss, Program Assistant, The Commonwealth Fund

Visit EBRI and the Fund at: ebri.org cmwf.org

Paul Fronstin, EBRI and Sara R. Collins, The Commonwealth Fund

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