The use of high health plan deductibles is an increasingly common strategy to enhance health care consumerism and lower health care spending. Proponents speculate that high levels of cost sharing enhance consumers’ tendency to discriminate between high- and low-value care. In other words, cost sharing is a tool for teaching members to “choose wisely” throughout the plan year when it comes to the services they use. But does this work?
In this study, we examine the extent to which members who satisfy their plan deductible continue to discriminate when it comes to services used. To quantify whether deductibles help patients learn to “choose wisely” and avoid low-value care once deductibles have been met, we compared the use of six commonly overutilized imaging, screening, and pre-surgery testing services among 1.5 million individuals enrolled in commercial health plans with a deductible who had, and had not, satisfied the deductible.
We found that the likelihood of receiving low-value health care services increased by as much as 83 percent, depending on the service, for those who had satisfied their plan’s deductible relative to those who had not. We also examine cancer screenings and find that use of these screenings is higher among those who do not meet the age recommendations once deductibles are met. Strategies in addition to high plan deductibles may be needed to reduce the use of low-value care.
Figure 2 Measures of Low-Value Services Use be would only W Miss Ref Moy Endn hil caus er, V e we ere ed e ot the ir e n es gi O b xa ces ni yia pportunities mined our a could be s our A. 2 012. key relia f findi "Sc indbl ing reening ng y st s sand se if th udied paratel for “Blunt” T e thr te Pr ndency os ough y for tate ad ind to Cancer: mi ivi oo inaccu nistr duls als in U.S. Pr ative rately i Hclaims DHPs eventi denti a d fy nd ve Servic ata low indivi — -val re du es Ta prese ue als serv not in HDH s nted k Force Reco ices vari a vares iPs ety ,by the mm of having d re end ifferent were atio satis no n tyfied th pes ofe Paul Fronstin is Director of the Health Research and Education Program at the Employee Benefit Research Institute Do People Choose Wisely After Satisfying Health Plan de di low fd fere -uctib valnce ue le. Stat sc are in t ement. (e.g., he findings " A ima nnals of gi b ny d g, In secree du tecti rnin nal ble g, Me le and vel dici . lab ne As orat 1 a 57 resu (2): ory w lt, our 120 ork) - and 1mo 34. de we doi:10.7 l is re relev neutral 326/0 ant to on 003 the a ran -48 level 1ge 9-157 o of f po t- he 2-pu d 201 elations du 207170 ctibl . e.- 0I0459. n other (EBRI). M. Christopher Roebuck is Pr esident and CEO of RxEconomics, LLC. Jason Buxbaum is a Ph.D. candidate in Benarroch Promoted as a -Gampel, tool to Jaime, better Kris eng tin age M. S consu heffie mers ld, Cas aney d re Bduc . Dunc e use an, K of im low be -value rly M. B car ro e, wn, dedu Yime ctibl i Han, es have Courtney been increas M. ing. Deductibles? Evidence From the Use of Low-Value Health The following dichotomous dependent variables were created and analyzed. 1 words, Inapprowhe priat re we e delivery find th ofat u thes f e ollo of wing serv low-value ices was services exam increas ined ed: after reaching the health plan deductible, the result was Am H Fro ealth ong nstin a Paolicy Townse lar nd R ge at n oebuck Har nd ationa Jr., var an ( l popu d2019) Uni d T vers lation aylor do find that 5 ity S. . A. Mar with Riall em . 201 0 k Fendrick pl –60 percen oy2. ment "Preope - i bas s t o the ed f rativ high D insuranc irector e use Laborato rs of of e, we foun the hry ealth care Testing in Pat Center d th f serv at or V thos ices not o alie ue e nts -who Bas Und nly rea ed sa er I tis nsurance goin fie chded g hE ea their lective, Lo D lth plan esign, a w - Service Description Source Care Service National Committee for Qu sa lity Assurance. 2014. HEDIS 2014 Volume 2: Techical Specifications. Washington, DC: the same regardless of whether the plan member was in an HDHP. Profess deductible but also reached or of Internal Medici th ne eir o in ut th-e ofSc -poc hoket ma ol of Mxi ed mum. Hi icine, an gh u d a Profes sers were def sor of ined as Health t M he 10 p anageercent of ment an the p d Policy in opulati th on e who de ductibles Riskw Ambu ere mo lato re ry Surg likely to ery." rec eiv Annals of e low-valu Sue rge servic ry 256 (3): es com pare 518-d 528 with . doi: thos 10e wh .109o had not. 7/SLA.0b013 Th e31 es8 e 265bc finding db. s s uggest October 22, 2020 • No. 516 Whether patients diagnosed with low-back pain Evidenc • I Nmagin ational Com e of g for lo Increa mitt w-back ee for Qu sed pai Odds of Low n.a lity Assurance.- Value Services Usage accounted for 70 percent of health care spending. School o that deduct f Pub iblles may ic Health not at b th e the e Univers most effe ity ofctiv Michigan e tool to . This teach mem Issue Bri be ef rs was writt to “choos en e w wis ith ass ely” tist hroug ance ho from ut the the p In lan sy tit eute’s ar. By Paul Fronstin, Ph.D., Employee Benefit Research Institute; M. Christopher Roebuck, Ph.D., received imaging (i.e., X-ray, computed tomography Our findings related to screening for breast cancer, cervical cancer, and colorectal cancer are shown in Figure 4. We Buxbaum, Jason D., Michael E. Chernew, and A. Mark Fendrick. 2017. "Tackling the Epidemic of Low-Value Spending The use of the specified low-value health care services was demonstrably higher among patie Na nts tio satis nal Cfying their ommittee fo pl r an res earch and editorial staffs. Any views expressed in this report are those of the authors, and should not be ascribed to RxEc 2 onomics, LLC; Jason Buxbaum, Harvard University; and A. Mark Fendrick, M.D., University (CT), magnetic resonance imaging (MRI)) within 6 Quan, H., Amo • ng individua Imagin P. Halfon Sun g for ls with a ded uncom darapl raj uctibl icat an, A. ed e, the av head Fong, acerage B he. B . urnan deducti d, J. ble i C. ncrea Luthi, sed f L. rom D. Saund $446 to ers $1,846 from , C. A. Beck 2002 , T. E. to 2018 among Feasby, and W. A. those find that Ima u gisne g o fo f rthes low-e b scree ack pani inngs is higher among those who do not meet the clinical recommen Quadat lity A ions once ssurance deductible wh and M en edcom ical O pare verus d with e:." htt pati pents s://vbi who had dhealth. n com ot met the /docs/TF ir -de LVC ductibl -%20 e. Wh O itur e% spe 20Pa cific pefindin r%20g -s can be seen in Figure These findings are consistent with the literature on the relationship between HDHP enrollment and low-value care the officers, trustees, or other sponsors of EBRI, EBRI-ERF, or their staffs. Neither EBRI nor EBRI-ERF lobbies or takes of Michigan weeks following diagnosis, as well as 120 days post- with employee-only coverage. And it increased from $958 to $3,392 among those with family coverage. See Figure 4 in Ghali. 2005. "Coding Algorithms for Defining Comorbidities in ICD-9-CM and ICD-10 Administrative Data." (2014) deductibles are met. The largest effect is seen for colorectal cancer screenings. We found a 126 percent increase in %20October%20Draft.pdf 3 . Overall, we find that the increased odds of receiving low-value health care services after having met the health plan service receipt. Reid, Rabideau, and Sood dia ( g20 no1 si7) st s. Inud diviie dd ua com ls wmerc ith coial enrolle mplicatinges s conwit ditio ching from ns a traditional plan to an positions on specific policy proposals. EBRI invites comment on this research. • Pre-operative testing before outpatient hernia repair. Fronstin and Roebuck (2019). Medical Care 42 (11): 1130-9. Do People Choose Wisely After Satisfying Health Plan use of colorectal cancer screenings once individuals reached their deductible among individuals under age 50 (e.g., cancer, injury, substance abuse) were excluded. deductible ranged as high as 83 percent, depending on the service. HDHP. Examining overall use of 26 commonly overused services, the authors found no significant reduction in 3 Buxbaum, Jason D., John N. Mafi, and A. Mark Fendrick. 2017. "Tackling Low-Value Care: A New “Top Five” for ( evidence-based guidelines recommended screening of average-risk individuals beginning at age 50 in 2015), whereas Deducti While subsequent reco blesmmenda ? Evtio idence ns have changed Fro , the U. m the Use of Low S. Preventive Services Task Force applied a Grade -Value Health "D" • Laboratory testing for vitamin D deficiency. s Int pend roduction ing on these l ow-value services relative to changes in a control group. Hong et al. (2017) examined use of low- Suggested citation: Paul Fronstin, M. C Wh hrist ethopher Roe er patients bu diack gn , Jaso osed n w B ithuxb hea ad um, an ache re d A. ceiv Mark Fen ed drick, “Do People Reid, Rachel O., Brendan Rabideau, and Neeraj Sood. 2017. "Impact of Consumer-Directed Health Plans on Low-Value Purchaser Action." Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20171117.664355/full/ s reco creenin mmenda gs inc tioreas n to PS ed 60 p A testing during ercent amon thg in e time perio dividuals d of o agesur s 50 and ol tudy. See der. Moyer It is p (2012) ossibl e for mo that tre inform he largeatio effect n. among value imaging for back pain prior to and a imfa ter the ging (i releas .e., CT,e M of R r I) elevant within 6 w Ce hoos eks ing follo Wisel wing y recommendations among the Ch Care oose Wisely Se Af rvices ter Satisfyin g Health Plan Deductibles?Figure Evidenc3 e From the Use of Low-Value Health Care Services,” Between 2007 and 2018, the percentage of individuals with private insurance who were enrolled in a high-deductible Healthcare." The American Journal of Managed Care 23 (12): 741-748. Imaging for uncomplicated 3 indivi •du als Screeni ages 50 an ng for5 d pros oldtat er, where e cancer (men colorectal ca of any age ncer screeni ). ngs are clinically indicated, has to do either with a lack of diagnosis, as well as 120 days post-diagnosis. Schwartz et al. (2015) 4 commercially insured. Increase HDHP e innrollm Oddent s of d id Receiv not leain d g to Lo greater w-V avoid alue a Healt nce oh f this Care Serv low-value ices servA ice ft er than enrollment in EBRI Issue Brief, no. 516 (October 22, 2020). health The Ch pla arlso n (H n Como DHP) rbidity increas Ind ed ex ( from CCI) 17.4 , whic percent h is wi to near dely used in the ly one-hal extan f (Frt li ons terature tin and as Roaeb gau uck ge of ge 2019). ne Em ral hea ploylth statu ers have s, was heahttps: dache//cdn.sanity.io/files/0vv8moc6/ajmc/0a0b693bfa7966b34b9bf5bc1b1d227ae0eb3531.pdf Capretta, James C., and Kevin D. Dayaratna. 2013. "Compelling Evidence Makes the Case for a Market-Driven Health By Paul Fronstin, Ph.D., Employee Benefit Research Institute; M. Christopher Roebuck, Ph.D., Individuals with complicating conditions (e.g., cancer, understanding that these services are not subject to cost sharing or confusion regarding when they might be subject to traditional plans. Importantly, these stHav udies ing compare Met Health HDHP with non Plan Dedu -HDHctib P enrolle le es. To our knowledge, ours is the adop derived f ted rom HDH medical c Ps as a way to laims fo manage t r every individu he cos al in o t of provi ur sample. More i ding health bnf ene orm fits atio to w n aork bout the CCI can b ers and their fami e fo lies. und in Mor Ch earlso n et Care System." Backgrounder (The Heritage Foundation). We also examined how screenings for breast cancer, cervical cancer, and colorectal cancer were affected when injury, substance abuse) were excluded. RxEconomics, LLC; Jason Buxbaum, Harvard University; and A. Mark Fendrick, M.D., University cost sharing 90% . Thus, people may wait until reaching deductibles to receive the service to minimize any potential cost Copyright Information: This report is copyrighted by the Employee Benefit Research Institute (EBRI). You may copy, Schwartz, Aaron L., Michael E. Chernew, Bruce E. Landon, and J. Michael McWilliams. 2015. "Changes in Low-Value first study to explicitly compare the behavior of enrollees who do and do not satisfy the deductible, irrespective of al. (1987), Deyo, Cherkin, and Ciol (1992), and Quan et al. 2005). specifically, they adopted HDHPs to reduce use of low-value health care services — services that offer little to no net Whether indiv83 id%** ual*s for outpatient inguinal hernia repair http://thf_media.s3.amazonaws.com/2013/pdf/BG2867.pdf individuals reached deductibles by the recommended age for the screening. Screenings before or after specific ages of Michigan sharing. print, or download this report solely for personal and noncommercial use, provided that all hard copies retain any and deductible lev Services el. in Year 1 of the Medicare Pioneer Accountable Care Organization Program." JAMA Internal Medicine benefit in specific clinical scenarios. HDHrPs ece are ex ived ape ny cte of td to he fo reduce llowing te use sts of witlo hin w 3 -valu 0 dae h ys p ealth rior cB are ser enarrovices ch-Ga b m y penha el et ncing 5 80% are often considered low-value health care services. Precise sample sizes for each health care service examined are The Choosing Wisely campaign promotes conversations between clinicians and patients to help patients choose care that is Pre-operative testing all copyright and other applicable notices contained therein, and you may cite or 73 qu %***ote small portions of the report 175 (11): 1815-1825. doi:10.1001/jamainternmed.2015.4525. to surgery: complete blood count, metabolic panel, or al. (2012) Charlson, M. E., P. Pompei, K. L. Ales, and C. R. MacKenzie. 1987. "A New Method of Classifying Prognostic Comorbidity consumerism and promoting shopping for medical care (Capretta and Dayaratna 2013). These health care services Smaller provide supported by d efin Fi fect egu svidence a w re ere 1 f alon ound f nd tr g with uly n or btre ecessa he perc ast canc ry. entage T er and he ca of mp the cervical aign relevant incl cancer udes sampl reco scree e mm n rec ing enda eivin . W tio g hile th ns fro the se m va ervice wom rio e by us me n whether und dical er 2 soc 1 or not wieti erees thre the . Oe ne 68%*** 70% A lack of provided nuan that yo ce i u ndo plan desi so verbatim a gn regar nd wit ding ch h c eov pro st erage Xpe -ra ry ci . of tat lo ion. Any u w-value s servic e beyo es may nd the contri scope bu o te f to th the for e e ogoin bserved patt g requires EBRI’s erns for likely cosin t priv Longit ate an udinal d pu Studies: blic healt Dev h car elopment e purchas and ers V hun alidation. dreds" of Jo bi urnal llions of dollars of Chronic Di every seas year e 40 ((5): 373 Lyu et a -83. l. 2 017) (Sisko et A T A G L A N C E de example co ductible ha mes f d been reac rom the North American S hed. Further info pirmat ne Soc ion iety whic on the h recommends a construction of gainst th each meas e uure se of imaging of the s of low-value servic pine wi es usthin the e is times as likely as women 21 and older to receive cervical cancer screenings once deductibles had been met, the Whether the member received testing for vitamin D Schwartz, Aaron L., Bruce E. Landon, Adam G. Elsbaug, Michael E. Chernew, and J. Michael McWilliams. 2014. prior express permission. For permissions, please contact EBRI at permissions@ebri.org. those enrollees who satisfy their deductibles (or expect to). Plan sponsors likely miss opportunities to encourage Vitamin D testing Holick et al. (2011) al. 2019). 60% first six weeks of an acute episode of low-back pain in the absence of red flags. More information can be found at availabl estimate for e in Fi wo gumen unde re 2. r 21 is not statis de tically sig ficiency w nif ithic ina e nt. This may ach calendar m be o ndu th.e to the fact that there are so few women "Measuring Low-Value Care in Medicare." JAMA Internal Medicine 174 (7): 1067-1076. doi:1067-1076. Deyo, R. smarter shop A., D. ping C. wh Cherkin, en com amo nd M. nly A. overuse Ciol. 19 d s 9ervices 2. "Ada are pting treat a Cl ed inical no C diff om erently t orbidity han Index unam forbiguous Use wily th ICD high- -valu 9-CM e services https://www.choosingwisely.org/ National Committee for Figure 1 in this age group. Report availability: This report is available on the internet at www.ebri.org The use of high health plan deductibles is an increasingly common strategy to enhance health care consumerism and doi:10.1001/jamainternmed.201W 4.1 he54 the 1. r males received prostate-specific antigen P for purpos ropone 50%nts Administra es o of f HDH cost tive Ps s argue hari Data ng.bases that hi In short, ." gh cos Journal the t s de o haring can f velo Clinic pment al Epi e nhance and demiolo impl consu gy emen 45 mers tat (6): ion ’ 613 ten of p de -9. lan des nc y to d igisc ns that rimina cte betwe onsistently en h an igh d - Prostate cancer screening Quality Assurance Sample Sizes, by Receipt of Various Health Care Services 6 testing within each calendar month. lower health care spending. Proponents s 41%** pe *culate that high levels of cost sharing enhance consumers’ tendency to See continuously discourage the use of specific low-value services may be called for to more precisely address this issue and low-value health care services (Madison and Jacobson 2007). However, a proportion of enrollees will satisfy health (2014) 40% Sisko, Andrea M., Sean P. Keehan, John A. Poisal, Gigi A. Cuckler, Sheila D. Smirth, Andrew J. Madison, Kathryn E. Fronstin, Paul, and M. Christopher Roebuck. 2019. "Persistency in High-Cost Health Care Claims: “It’s Where the discriminate between high- and low-value care. In other words, cost sharing is a tool for teaching members to “choose https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/mm_0526_coveragepositioncriteria_vitamin_D_test Met Deductible Did Not Meet pl rather an detdu han cti o ble ft-s s,atis no matte fied “blu r how hig nt” dedu h. cti bl Pat esients w . Exam ho hav ples oe f this met the are t irhe St dedu ate of ctible Ore may gopay l n’s publ ittle N ic em or ati n on op a thing for loyees l Comm plan i subs ttee, fo w eq rhich uent Whether females under the age of 40 received a Rennie, and James C. Hardesty. 2019. "National Health Expenditure Projections, 2018–27: Economic And Table of Contents Spending Is, Stupid”." EBRI Issue Brief, no. 493 (Employee Benefit Res Prio earch I r to Rec nst eivitute ing D ). eductible Prior to wisely” ing.pdf B throu ran ead sthttp:// ca ghout th ncewww.aetna.co r scre plan eenin 28 g %** year w *m/cpb/medi hen it com cal/es to the data/900_999/0945 services th .html ey u 28%** s e. But does this workQ ? u ality Assurance impose s consumer surcharges for certain commonly overused services (Kapowich 2010). This policy led to a 13 care, w 30%hereas members still under their deductible generally face 100 percent cost sharing. It is possible that when a mammogram within each calendar month. Figure 4 Total Service Receiving Service Demographic Trends Drive Spending And Enrollment Growth." Health Affairs 38 (3): 491-501. (2014) https://www.ebri.org/docs/default-source/ebri-issue-brief/ebri_ib_493_highcostclaims- Introduction .......................................................................................................................................................... 3 21%*** pl pean rce dnt re educti duble is met, ction in the rel uat sei vely low of specified levels of overused cost service sharing s th (G ereaft ruber et er r al. elease 2020 pe ). nt Othe -up deman r examd for ca ples are re, i Aetna nclud ’s ian ng l d ow- Low-Back Pain Without Red Flags Diagnosis 203,744 8,664 195,080 Increase in Odds of Receiving Cancer Screening After Having Met In this s 20%tudy, we examine the extent to which members who satisfy their plan deductible contin Natiue ona to dis l Comcriminat mittee foe r when doi:10.1377/hlthaff.2018.05499. 6 24oct19.pdf?sfvrsn=ced83c2f_6 Whether females under the age of 21 received a pap Cigna’s changes in their policies to no longer cover population-based vitamin D screening. value medical services. Alternatively, meeting a health plan deductible may be associated with less patient scrutiny Data and Met %hods rece i................................ ving imaging within 6 week ................................ s ................................ 29% ................................ 31% 29% ................. 3 Cervical cancer scr Health eening Plan Deductible, by Recommended Age of Screening Quality Assurance it comes to services used. To quantify whether deductibles help patients learn to “choose wisely” and avoid low-value smear within each calendar month. 8%** over the value of health care services being prescribed by health care providers. Research to date has not examined 10% 140% (2014) G ruber, Jonathan, Johanna Catherine Maclean, Bill J. Wright, Eric S. Wilkinson, and Kevin Volpp. 2020. "The Effect of care Evidence once de of Inc ductibl reases have ed Odds be of en Lo met w-Val , w ue Serv e compare ices Us d th ag e us e ................................ e of six commonly ov................................ erutilized imaging, screenin ........................ g, and pre- 6 In addition to more nuanced plan designs that effectively discourage low-value car 1 e, these findings underscore the Uncomplicated Headache Diagnosis 48,861 2,699 46,162 how satisfying plan deductibles impacts patterns of low-value health care receipt. National Committee for 126%*** Whether members under the age of 50 received a Increased Cost-sharing on Low-Value Service Use." Health Economics 29 (10): 1180-1201. surgery testing services among 1.5 million individuals enrolled in commercial health plans with a deductible who had, 0% % receiving imaging within 6 weeks 11% 14% 10% need to implement provider-facing initiatives to reduce low-value care — and ensure that policies are aligned with Missed C Opport olorectauni l caties a ncer scr nd “ ee Bl nunt” ing Tools ................................................................................................ Quality Assura................... nce 8 120% First 6 Weeks First 120 Days First 6 Weeks First 120 Days Baseline Labs Chest X-Rays Vitamin D Testing Prostate-Specific colonoscopy within each calendar month. and had not, satisfied the deductible. (2014) cons In this umer cos paper, twe exami sharing to ne ac how hieve low use of- valu low-e value -care h avoi ealth c dance. are servic The use es i sof afmeas fected ur whe es of n lo a w pl -an valu mem e-cabe re delivery r reaches in th new e Antigen (PSA) Conclusion Holick, Micha ................................ el F., Neil C. Binkley, Heik ................................ e A. Bischoff-Ferr ................................ ari, Catherine M. Gordon, Da ................................ vid A. Hanley, ............................ Robert P. Heaney, 8 Inguinal Hernia Repair 5,157 370 4,787 Testing payment models, learning collaboratives for providers, and performance feedback are among the tools that may help deductible. Examining the relationship between health plan deductibles and use of low-value health care services is % receiving blood testing within 30 days pre-op 42% 50% 41% M. Hassan Murad, and Connie M. Weaver. 2011. "Evaluation, Treatment, and Prevention of Vitamin D We found that Imaging the for Lo likeli w-Bahood ck Pain of W r itheceivi out ng l Imagow ing -for Un valuc e omp heal licate th dcare Un s ne ervice eded Tes s increas ting Before ed by Low-R as much isk Scree as 83 perc ning Contrary to ent, Curr dep ent ending 100% References ............................................................................................................................................................ 9 The key important reduce th inde e del give pend ivery of n the ent varia incr low eas -ble vialue ng — preval c having are ence (B m ux of et the bau H m, Ma DHPs dedu as fi,cti aa w nd ble Fendrick ay — to man was con 2017 age us struct ) (B e ed uxbau o f by hesalth m, Chern umm car ing e t ew she pai ervi , and ces d an Fe amo nd d overal u rick nts i 20 n l t 1he 7). % receiRe vin d Fl g ca h gs est x-ray within 30 daysHe pre ad-o ac p he S 10% urgery 17% Evidence 10% Deficiency: an Endocrine Society Clinical Practice Guideline." The Journal of Clinical Endocrinology & on the service, for those who had satisfied their plan’s deductible relative to those who had not. We also examine de ductible field on all medical claims, and comparing this total to the individual deductible level of the plan in which the spending more generally. It is important to examine deductibles not only due to the growth in the adoption of HDHPs Metabolism 96 (7): 1911-1930. doi:10.1210/jc.2011-0385. cancer screenings and find that use of these screenings is higher among those who do not meet the age 80% 2 Eligible for Vitamin D Testing 1,228,552 67,680 1,160,872 bu member t also w beas cau enrolle se dedu d. An i ctiblend levels icator thems was c eoded lves have , which be r en efl iect ncreas ed w ing hetacr her os th s e de all pla dun ctibl type e h s.a d bee Using n satis claims fie data d prior from to a 2015 Source: Authors’ analysis of 2015 Truven MarketScan. recommendations once deductibles are met. Strategies in addition to high plan deductibles may be needed to reduce Figures % receiving vitamin D testing 1.0% 1.8% 0.9% Conclusion selected time *p< 0.0 poin 5, **t. p<0.0 For 1, l **o *p< w0.0 -value 01. services 1–3, this single anchor event was the diagnosis (low-back pain or on 1.5 million full-time employees with employment-based health benefits, we found that meeting the deductible was Hong, Arthur S., Dennis Ross-Degnan, Fang Zhang, and J. Frank Wharam. 2017. "Small Decline In Low-Value Back 60%*** the use of low-value care. 60% For beneficiaries meeting their plan deductibles, current benefit designs do not consistently address low-value care. head associated ache) or wit the h aning incr uinal eas hernia r e in use of epa com ir damo te. For nly ov4 eruse –8, nd o such low-val de ue cish io ealth n poic nt are was o services bvious of — as h i.e., igh ind asivi 83 perc duals co ent uld . We Figure 1, Sample Sizes, by Receipt of Various Health Care Services ........................................................................... 4 Imaging Associated With The ‘Choosing Wisely’ Campaign, 2012–14." Health Affairs 36 (4): 671-679. Eligible for prostate-specific antigen (PSA) Testing, Men 259,930 28,818 231,112 Use of imaging for low-back pain within six weeks of diagnosis was 8 percent higher among plan members who Additional strategies, such as targeted benefit designs and provider-facing policies, are more promising routes for low- decide to consume these low-value services at any time. Therefore, for each person, we constructed 12 monthly also examine cancer screenings and find that use of these screenings is higher among those who do not meet the % receiving PSA testing 1.8% 2.5% 1.7% doi:10.1377/hlthaff.2016.1263. reached their deductible as compared with those who did not. When we look at use of imaging for low-back pain Figure 2, Measures of Low-Value Services Use ......................................................................................................... 5 value- 40 car % e elimination. observ clinical i ations ndicati oons f havi once ng met t deduc he deduct tibles are m ible eprior t. The to se the findin begi gs have nning of imp eac lich ations month. for deductible-level setting specifically 33% within 120 days of onset, those who reached their deductible were 28 percent more likely to use the service than those Women, Ages 40+ 487,551 30,607 456,944 Kapowich, Joan M. 2010. "Oregon’s Test Of Value-Based Insurance Design In Coverage For State Workers." Health and Figure 3, future be Increas nefit e d inesi Odds gns mo of Re re genera ceiving ll Ly as they ow-Value Heal relate th to Care effort Se srvic to redu es After ce use Havin of g low Met -val Healt ue heal h Plan th care Dedu service ctible s ........ . 6 This study was conducted through the EBRI Center for Research on Health Benefits Innovation (EBRI CRHBI), with the who did not. Similarly, individuals reaching their deductible were 41 percent more likely than those not reaching their % receiving breast cancer screening 5.0% 5.9% 4.9% A logistic model was estimated for use of each low-value service as a function of having met the deductible. In order Affairs 29 (11): 2028-2032. doi:10.1377/hlthaff.2010.0809. 16%*** 20% funding support of the following organizations: Aon Hewitt, Blue Cross Blue Shield Association, ICUBA, JP Morgan deductible to have received imaging for an uncomplicated headache within six weeks of being diagnosed and 83 Figure 4, Increas 11 e %** in Odds * of Receiving Cancer Scree 11%** ning * After Having Met Health Plan Deductible, by Recommended to red uce the risk of biased results, we also included the following measures in the logistic model: age, age-squared, Chase, Pfizer, and PhRMA. Women, Under Age 40 328,767 20,488 308,279 percent more likely within the first 4 120 days of diagnosis. Age of Screening ..................................................................................................................................... 7 Ly sex, u, Char Heatlso her, n Co Tim mo Xu, rbid Dity an I iel nd B erot x, man, geogra Bra pnd hic an re Mayer gion, and -Black health well, Micho plan type. l Coop Odds rat er, Michios ael , a D anie meas l, ur Eliez that abeth r C. epresen Wick, ts the Da ta and Methods % receiving breast cancer screening 0.4% 0.6% 0.4% 0% Vikas Saini, Shannon Brownlee, and Martin A. Makary. 2017. "Overtreatment in the United States." PLoS ONE odds that an individual will use a low-value health care service given that they reached their deductible, were calculated Ages 40+ Ages <40 Ages 21+ Ages <21 Ages 50+ Ages <50 To study the impact of having satisfied the deductible on use of low-value health care services, we made use of the Among patients having outpatient hernia repair — a common low-risk surgery — individuals who had reached their for each 12 oW f (9). th om e elow n doi: , A B- g rvalu do e eas s it Ca 2 .org/10.1 e 1+nc he er Sc alth ree 371/j car nine g ®ournal.po services and ne.0 canc 18 Ce 1r970. e vir scr cal Ca eenings ncer Scree 8e ni 1xamine n 4g,086 d in this p 5 Co ap 0,l9 orec er 64. ta F l Ca ornc the er Sc lo r7 ee w 63 ni -,val ng 122ue health Truven Health Analytics MarketScan Commercial Claims and Encounters Databases (CCAE) and the Benefit Plan deductible were 28 percent more likely than those who did not reach it to have had baseline blood tests within 30 days % receiving cervical cancer screening 3.4% 3.7% 3.4% care services related to a screening, p-values were based on standard errors clustered by individual to account for the Design (BPD) Database (copyright © Truven Health Analytics, all rights reserved) for 2015. The BPD Database was be fore the surgery. These individuals were also 73 percent more likely to have had chest X-rays preoperatively. Madison, Kristin, and Peter D. Jacobson. 2007. "Consumer-Directed Health Care." University of Pennsylvania Law 12 monthly observations for each person. created by Truven Health via a statistical analysis of the CCAE data to infer values for plan-level design elements such Women, Under Age 21 2,232 131 2,101 Review 156: 107-125. scholarship.law.upenn.edu/penn_law_review_online/vol156/iss1/19 Source: Authors’ analysis of 2015 Truven MarketScan. Receipt of screenings that were not clinically indicated was also higher among patients who had reached their as deductibles % , coinsuranc receiving cerve r icaates l can, and cop cer screeniaym ng ent amounts. Our analytical 2.4%dataset consist 3.5 ed % of 1.5 million full 2.3%-time *p< 0.05, **p<0.01, ***p<0.001. This methodological approach has limitations. First, the Truven Benefit Plan Design Database, and specifically the de employees ductible. T withos h em e w plho h oyeea-d o reach nly cov ed era the geir b de etwee ductib n a le wer ges 1e 8 6 an 8 perce d 64 w nt homo were re l contin ikely to uo have h usly ea nroll d a vit ed in em amin D tes ployment t and- 21 Mafi, John N., Kyle Russell, Beth A. Bortz, Marcos Dachary, William A. Hazel, and A. Mark Fendrick. 2017. "Low-Cost, prevailing health plan deductible, is inferred from claims data, which may be subject to inaccuracies. Because of the Men and Women, Ages 50+ 501,877 30,602 471,275 percent more likely to have had a prostate-specific antigen (PSA) test relative to individuals who had not reached their based health insurance during 2015. Members in capitated health plans were excluded. High-Volum EBRI Issu e H e Brief ealth is r Seg ervice istereds in th Contrib e U.S.ut Pa e T tent and he Mos Tradt em To ark Un Ofnecess fice. ISSary N: 08 Hea 87 –1lth 37X/9 Spe 0 0887 ndin –g." 137X/9 Health 0 $ .50 Af +.50 fairs 36 (10): % receiving colorectal cancer screening 1.9% 3.0% 1.8% way deductibles are determined, there are no $0 deductible plans in the database. Second, measures of low-value deductible. © 2020, Employee Benefit Research Institute –Education and Research Fund. All rights reserved. 1701-1704. doi:10.1377/hlthaff.2017.0385. health care service delivery based on claims are inherently limited given the lack of nuance available in administrative Informed by previous related research (Mafi et al. 2017), diagnosis codes, procedure codes, and individuals’ age and Men and Women, Under Age 50 874,371 49,311 825,060 claims data. Nevertheless, this approach is common in the literature on low-value care (Schwartz et al. 2014) and gender were used to construct measures of six low-value health care services. 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