CDHPs may lead to less preventive care

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Patients with a consumer-driven health plan receive fewer preventive services than patients in traditional health plans, a study by the Employee Benefit Research Institute found.

For five years, the EBRI study tracked a full-replacement CDHP with 18,000 participants from one large employer in the Midwest. The comparison group was from a second employer that provided traditional health plans.

Benefit brokers and advisers can work with clients to proactively address any differences in quality between CDHPs and traditional plans. For example, the introduction of the CDHP in the study resulted in a drop in several quality metrics:

  • Slightly fewer office visits for annual physicals, well-child visits and preventive visits, relative to the comparison group.
  • Lower rates of medication monitoring for adults on maintenance drugs.
  • More use of antibiotics for adults with acute bronchitis (often considered unnecessary).
  • More use of imaging services for adults with low back pain (often considered unnecessary).
  • Lower rates of LDL cholesterol testing for adults with cardiovascular disease in the first year.
  • Lower rates of colorectal cancer screenings.

CDHPs are high-deductible plans with a health savings account or a health reimbursement arrangement. A growing number of companies are using them to contain health benefit costs. At least 30% of employers offered a CDHP to their workers this year, according to the Society for Human Resource Management.
Higher out-of-pocket costs typically reduce utilization of health care services, whether they are necessary or not.

“Proponents of CDHPs contend that providing participants with a pre-funded account and subjecting claims to high deductibles before insurance benefits are triggered will induce enrollees to make more cost- and quality-conscious health care decisions,” the EBRI study report explains. “Skeptics, on the other hand, caution that patients lack comprehensible, timely and trustworthy information that is critical for them to make informed decisions. Skeptics are also concerned that higher cost-sharing might lead to less use of preventive care, primary care and other necessary health care services, especially among individuals of lower socioeconomic status. Another concern is that the reduced utilization might save costs in the short-term, but might well result in larger long-term costs.”

Likewise, a recent policy paper by the American Academy of Pediatrics noted, “Because high-deductible health plans require out-of-pocket payment in the initial stages of care, primary care and other outpatient services, as well as elective procedures, are the services most affected, whereas higher-cost services in the health care system, incurred after the deductible is met, are unaffected … High-deductible health plans discourage use of non-preventive primary care and thus are at odds with most recommendations for improving the organization of health care, which focus on strengthening primary care.”


Conflicting evidence

However, an annual study by Cigna, analyzing the claims of more than 3.6 million Cigna customers, found that patients in a CDHP had the same or higher compliance with about 500 evidence-based medical best practices 96% of the time in the first year, compared to patients in traditional plans, and compliance increased in the second year.

It also found that CDHP customers were almost 50% more likely to complete a health risk assessment, and CDHP customers with a chronic illness were up to 41% more likely to participate in a disease management program, compared to customers in traditional plans.

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