Executive Summary
The EBRI/Greenwald & Consumer Engagement in Health Care Survey (CEHCS) is an online survey that examines issues surrounding consumer-driven health care, including the cost of insurance, the cost of care, satisfaction with health care, satisfaction with health care plans, reasons for choosing a plan, and sources of health information.
The survey was conducted Aug. 10 to Sept. 1, 2017. Over 3,560 adults ages 21?64 who had health insurance through an employer, purchased directly from a carrier, or purchased through a government exchange participated in the survey.
This Issue Brief focuses on whether and how attitudes and behaviors change with the amount of time an individual has been enrolled in their health plan. ?
- Overall satisfaction does not increase when participants are in health plans for long periods of time (e.g., 10+ years), regardless of whether the plan is a traditional health plan, consumer-driven health plan (CDHP), or high deductible health plan (HDHP). ?
- Likewise, consumer engagement does not increase with time enrolled in a health plan. However, there is some evidence that health savings account (HSA)-eligible health plan enrollees are more engaged in some aspects of their HSA the longer they have been enrolled in their HSA-eligible health plan.
Figure 4 Annual Contributions to Health Savings Account (HSA), Figure 1 In The C Ro etnclus fe r po ar tduc te ence rn w ion tion as s found for nearly all of the other various satisfaction questions in the CEHCS. For brevity, those findings Paul Fronstin is director of the Health Educab tion a y Lend ngRe th sea of Time rch Prog Enr ram oll ate td he Employee Benefit Research Institute Overall Satisfaction With Health Plan, have not been shown separately in this paper. As shown in Figure 2, there was one exception: information available on (EBRI). Edna Dretzka is senior director of healthcare at Greenwald & Associates. This Issue Brief was written with Fr Thi The ons s Me Itsin, P su dic e a a B rul. " r eie Pfr H foc esc as E us ripti e ns on ron ollm Dh e re ug, nt a ltin HSA h c Ima prre ov - E eenga ligib ment g le e, m H ae e nd a nt lt Mod h P and la esa ns rniz t is St a fa a tion A lcle tion w d?"c tE i(B tM h va RI MA Is r)iou su of es a 20 Brspe 03 ief, no. icnc ts of lude 44 he d 1 a a (lE tp h m r ov c pa loy is reio e ov e n th B ere a ne ttim c fit e re . aThe ted by Plan Type and Length of Time on Plan < 5 years 5-9 years 10+ years health plan choices. Among CDHP enrollees, satisfaction with information available on health plan choices was highest Re su a he ss ra sea v ilt st eh s y ar nc cfound h I ae v ing ns from ts a t itha ut c tte he c , oun e nga Fe Inb tst s (H r gua ie tut m rS y e eA ’nt s r 20 s) a e 18 and sea nd ). sa rh H cth a SA ttis ps:/ fa -nd ecligib /ww tion fo edle it w or .e he ria b ta l s he rlt i.or h p t a m ff gost la /pd s. ns A f/ p . ny a b Err n tv ie rie d oll fs o w p m not s e de f/nt xpress E cB h in HS RI ange _IeB A d _4 w -in eit 4 ligib h t t 1.p hihe s r le df. e he le pngth of or alt th p arela tt ns hose im , ea s w aof n ind e the ll a iv s ot a idu uthor a he l rs 45% (Percent Extremely or Very Satisfied) among those plan participants who were enrolled the longest. and should not be ascribed to the officers, trustees, or other sponsors of EBRI, Employee Benefit Research Institute- si ha m s b ilae r etn e ypenr s of ollehe d a in t lth p helir a ns he a (c ltolle h pc la tiv n. ely W ha know t ap n a pes arc s t onsu o bm e e dris -d er nga iven h gem ea elnt th p am laong ns or indi CD vH idua Ps)ls ha ws g ith th row en signi longest fic antly 80% May 22, 2018 • No. 450 40% Fronstin, Paul, and Anne Elmlinger. "Consumer Engagement in Health Care: Findings from the 2016 EBRI/Greenwald & 73% si e Enr d nc uc ollm ea 40 tthe ion a % ent y file nd rs ngth t Re besea cm am ary c e h Fun m av ea re illa d yb (r le E e B flect (RI Frons - EtRF) he tin 20 ir, foarm 18 the ili)a . ir r i E tsyn t a r w ff oll it s. h m N e ve a nt it riou he in hig rs op EB hRI t-ions d e nor d uc a v E ta ible Bila RIb -he le ERF l a to lth p ob the b la m ie ns . s or P (la H n sp D taH kP eonso s) s p no osit rts a a ions snd soc on iated 70% 38% Engagement – The CEHCS also asks a number of questions regarding consumer engagement to better understand the Associates Consumer Engagement in Health Care Survey." EBRI Issue Brief, no. 433 (Employee Benefit Research 70% specific policy proposals. EBRI invites comment on this research. e wm ith a ploy sa erv s m ings a ay ne ccount ed to , o thin r Pk P Os w about it h d diffeed ruc ent tible was of ys to ate le ng aa st g e $ 1,00 plan me 0 for m e bm erps w loyit eh d e-only iffe rc eov nte le ra ngth ge asnd of $2 pla ,000 n te fo nur r e fa . mily r ole that type of health plan plays in cost conscious decision making. The findings from two of those questions are Institu 35t% e, May 2017). https://www.ebri.org/pdf/briefspdf/EBRI_IB_433_CEHCS.25May17.pdf. coverage, has increased at commensurate rates. Employers have moved toward CDHPs and H 60% DHPs as part of a larger 32% 32% 60% shown in Figure 57% 3: whether the plan enrollees checked the quality rating of a doctor or hospital before receiving care, Suggested citation: Paul Fronstin and Edna Dretzka. “The Impact of Length of Time Enrolled in a Health Plan on movement toward increasing consumer engagement and cost sharing through health plan design. Frons30 tin, P % aul, and Anne Elmlinger. "Satisfaction With Health Coverage and Care: Findings from the 2014 C and onsu whe metr he Ernga the gye m tae lknetd a tnd o tH he eir a ltdh P octla or n Sa about tisf a pcrte ion: scrip Fi tio nd n o ings Fr ptions om a nd thec os 20t17 s. L Co on nge surm eenr r ollm Enga eg nt e m lee ngth nt in Hea was not lth C fo ar und e Appendix —About the Consumer Engagement in Health Care Survey 49% The Impact of Length of Time Enrolled in a Health Plan on 50% EBRI/Greenwald & Associates Consumer Engagement in Health Care Survey." EBRI Notes (Employee Benefit Research to increase consumer engagement in either case. 45% Survey.” EBRI Issue Brief, no. 450 (Employee Benefit Research Institute, May 22, 2018). Previous Employee Benefit Research Institute (EBRI) research has found that health engagement is higher among The findings presented in this paper were derived from the 2017 EBRI/Greenwald & Associates Consumer43% Engagement 42% 24% 25% Consumer Engagement and Health Plan Satisfaction: Institute, July 2015) 36 (7): 14-22. https://www.ebri.org/pdf/notespdf/EBRI_Notes_ 40% 07_July15_IRAs-CEHCS.pdf. CDHP and HDHP enrollees than among enrollees in more traditional health plans (Fronstin and Elmlinger 2017). To in Healt 40 h %Care Survey (CEHCS), an online survey that examines issues surrounding consumer-driven health care, 22% Cop ? y rigA hm t In ong form CDH aP ti e onr n:olle Thi es, w s rep e or fou t is nd cop the y rop ight posit ed b ey – t he those Emp enr loy olle ee d B e the ne fit long Reesea st (r10 ch I yns eatris tu or te m (Eor BRI e) )w . e Itr e m ta he y b le ea st Findings From the 2017 Consumer Engagement in Health some degree this has been due to CDHPs/HDHPs attracting a more engaged population. What has not been known is including the cost of insurance, the cost of care, satisfaction with health care, satisfaction with health care plans, 20% Taylor, Humphrey. "Does Internet Research ‘Work’? Comparing Online Survey Results With Telephone Surveys." likely to be engaged in their health care as compared to other CDHP enrollees. used without permission but citation of the source is required. 18% 30% whether engagement increases the longer an individual has been enrolled in their health plan. Ca reason rs for e Su choo rsi v ng eay p lan, and sources of health information. The 2017 CEHCS was conducted within the United International Journal of Market Research 42 (1), 2003. ? Cost-conscious decision-making also did not increase with time for participants in either traditional or high 14% 15% States between Aug. 10 and Sept. 1, 2017, through a 15-minute internet survey. The national or base sample was Report availability: This report is available on the Internet at www.ebri.org 12% 20% deductible health plans. By Paul Fronstin, Ph.D., Employee Benefit 12% Research Institute; and Edna Dretzka, Greenwald & Research has also found 12% that satisfaction among plan enr 12% ollees has been lower in CDHP and HDHP enrollees than d rawn from Ipsos’ online panel of internet users who have agreed to participate in research surveys. Over 2,300 adults 9% 9% Associates among 10 % enrollees in more traditional health plans (Fronstin and Elmlinger 2015). CDHPs/HDHPs are relatively new. They 2017 Consumer Engagement in Health Care Survey Underwriters 10% ages 21-64 who had health insurance through an employer, purchased directly from a carrier, or purchased through a are often confusing. What has not 6% been known is whether satisfaction levels have increased the longer an individual government exchange were drawn randomly from the Ipsos sample for this base sample. This sample was stratified by 4% 5% 3% has been enrolled in their health plan. Figure 3 3% Endno 0%tes This survey was made possible with funding support from the following organizations: Blue Cross Blue Shield gender, age, region, income, and race. The response rate was 10 percent. As a non-probability sample, traditional < 5 years 5-9 years 10+ years < 5 years 5-9 years 10+ years < 5 years 5-9 years 10+ years Cost Conscious Decision Making, A T A G L A N C E Association; Fidelity Investments; HealthEquity, Inc.; National Rural Electric Cooperative Association; Optum, Inc.; and survey margin-of-error estimates do not apply. 0% Traditional CDHP HDHP Why would we expect to see health engagement and satisfaction increase the longer an individual has been enrolled in by Plan Type and Length of Time Enrolled Prudential FinanNcoia thl, ingInc. Less than $500 $500-$999 $1,000-$1,999 $2,000 or more Don't know 1 their health plan? When an individual initially enrolls in a new health plan, plan designs – especially those that differ See Appendix for more detail on the methodology. 60% Checked quality rating of a doctor or hospital before I received care Talked to my doctor about prescription options and costs Because the base sample (national sample) included only 354 individuals in a CDHP and 275 individuals with an HDHP, The EBRI/Greenwald & Consumer Engagement in Health Care Survey (CEHCS) is an online survey that examines issues from their prior coverage -- can be confusing. As a result, it may take time for an individual to not only become familiar Source: EBRI/Greenwald & Associates, 2017 Consumer Engagement in Health Care Survey. Source: EBRI/Greenwald & Associates, 2017 Consumer Engagement in Health Care Survey. a 2 n oversample of individuals with a CDHP or HDHP was added. The oversample included 747 individuals with a CDHP surrounding consumer-driven health care, including the cost of insurance, the cost of care, satisfaction with health care, Traditional plans include a broad range of plan types, including health maintenance organizations (HMOs), preferred provider 51% with their health plan, but it may take time for the various different incentives in a new health plan to impact member and 515 individuals with an HDHP, resulting in a total sample (base plus oversample) of 1,101 for the CDHP group and organizations (PPOs), other managed care plans, and plans with a broad variety of cost-sharing arrangements. The shared 50% 48% satisfaction with health care plans, reasons for choosing a plan, and sources of health information. behavior. For example, high-deductibles may at first cause enrollees to cut back on use of health care services to save Table of Contents characteristics of these plans are that they either have either no deductibles or deductibles that are below current thresholds 790 for the HDHP group. After factoring out the base sample—the 259 individuals with a CDHP and the 255 individuals 43% money, but over time, enrollees may become more engaged their health care. They 42% may become more likely to check that would qualify for tax-preferred HSA contribution 42% s. 41% I The ntrod suuc rvteion y w ................................ as conducted Aug. 10................................ to Sept. 1, 2017. Ove................................ r 3,560 adults ages 21- ................................ 64 who had health in .......................... surance through 3 with an HDHP—there were 1,674 individuals in the sample with traditional health coverage. 40% 40% 39% t he price of he 40%alth care services; to engage with their doctor about treatment options; and to seek information about 38% 37% an employer, purchased directly from a carrier, or purch Figu asedr e thr 5ough a government exchange participated in the 3 36% Findings ................................................................................................................................................................ 3 In theory, a random sample of 2,000 yields a statistical precision of plus-or-minus 2.2 percentage points (with 95-percent Figure 2 34% 34% quality and outcomes. In addition to being stratified, the base sample was also weighted by gender, age, education, region, income, and survey. confidence) of wha A t tthe titu re dse ult s sT w ow 32% ould ar d be He if the alth entir Sa evin pop gs ulaAccou tion age n sts 21(H –64 S A), with Amo privatn eg he HS alth A Enr insura oll nce ee cs overage were 3 Satisfaction With Information Available on Health Plan Choices, Conclusion ............................................................................................................................................................ 7 race/ethnicity to reflect the actual proport29% ions in the population ages 21–64 with private, health-insurance coverage. surveyed with 30c %omplete accuracy. There are also other possible sources of error in all surveys that may be more serious than 27% (Percent That Strongly or Somewhat Agree) To shed light on these unknowns, this paper presents findings from the 2017 EBRI/Greenwald & Associates Consumer by Plan Type and Length of Time Enrolled the The Thio s re C Is D tical su HP e cB aand rlc ieula fH foc D tions H us P e ov o s on f esrasm a w m phe lip ng le the s w er rro a end r. re Th w how e es ight e a inc te tit d lud ude be y s r gee a fu n nd sda e ls b r, eto a ha g b e ve , ior inc inte s c om rv ha ie enge w ae nd d w arit n ah th d c eo/e th ete hni a r m fo coun it rms y, t us oof fing no tim nre te he s a p n ind doe ns me og iv , the idu rap ahl ic ha s Appendix—About the Consumer Engagement in Health Care Survey.......................................................................... 7 Engagement in Health Care Survey (CEHCS) – a study designed to provide nationally representative data regarding effects of question wording and question order, and screening. While attempts are made to minimize these factors, it is been enrolled in their health plan. (Percent Extremely or Very Satisfied) profile of the CDHP and HDHP respondents to the omnibus survey described below. 20% g Re row ferte h o nce f C s ................................ D 20H %Ps and HDHPs, and ................................ the impact of these p ................................ lans on behavior and ................................ attitudes of adults wit............................ h private health 8 impossible to quantify the errors that may result from them. 70% th 64% I need help determining how much money I 34% insurance coverage. Now in its 12 year, this study was based on an online survey of 3,560 privately insured adults Whil ? e paOv nel eirnt all s erne atis t fsa ur ctvion d eys a oe res not nonr inc ando rea m se , sw tudie hen p s ha artvie cipa den m ts a onst rer a in he ted tahltah p t su lacn h su s for rv long eys, w pe he riod n ca s of reful tim lye d(e esi .gg., ne 10 d, + 62% Endnotes .............................................................................................................................................................. 8 should put into my HSA versus other 33% ages 21-64. The sample was randomly drawn from the Ipsos’ online panel of more than 775,000 internet users who investments or expenses 39% 60% years), regardless of whether the plan is a traditional health plan, consumer-driven health plan (CDHP), or high obtain results comparable with random-digit-dial telephone surveys. Taylor (2003), for example 57% , provided the results 10% 56% had agreed to participate in research surveys. The survey used a base sample of over 2,300 to draw incidence rates for from a num dedbuc ert ible of su he rvaelt yh p s th la an ( t wH eD re H P cond ). ucted at the same time using the same questionnaires both via telephone and 50% 51% 71% 50% Having an HSA has empowered me to make people with CDHPs and HDHPs, and the base sample was complemented with a 62% n additional random oversample of 50% ? Likewise, consumer engagement does not increase with time enrolled in a health plan. However, there is some online. He found that the use of demographic weighting alone was sufficient to bring almost all of the results from the better healthcare and financial decisions 45% 65% 0% these two groups. More specifically, the oversamples were: 1) those with either an 42% HSA-eligible health plan or health online sue rv ve ide y nc close e tha to t th he ea rlteh plie sas fr vings oma tche count par a (H lle SA l te )-le eligib phone le he sua rlt ve hy p . la Hn e e anr lso found ollees a rte h a m t o in so re enga me g ca eses d in som prope ens aspe ity cts of < 5 years 5-9 years 10+ years < 5 years 5-9 years 10+ years < 5 years 5-9 years 10+ years Figur es reimbur 40seme % nt arrangement (HRA), and 2) those in a plan with an individual de 62% ductible of at least $1,300 and a family their HSA the longer T ratdhe itiony al have been enrolled in theCD ir HH P SA-eligible health plan. HDHP weighting I am in (m ter ea esnin ted in g a t the ype o pfr aop utoe mns aticity for a certain type of person to be online) reduced the remaining gaps, but in other Figure 1, Overall Satisfaction With Health Plan, by Plan Type and Length of Time on Plan (Percentag 92% e Extremely or Very 1 investment feature for my unused HSA funds deductible of at least $2,600, but who reported that they were not eligible to open an HSA. The final sample included 87% c ases it d id not reduce the remaining gaps. Perhaps the most striking difference in demographics between telephone Source: EBRI/Greenwald & Associates, 2017 Consumer Engagement in Health Care Survey. Satisfied) .................................................................................................................................................. 4 2 30% 1,101 in a CDHP, 790 in a HDHP, and 1,674 in a more traditional health plan. 10+ years and online surveys was the under-representation of minorities in online samples. 51% I am interested in investing some of my HSA 58% 5-9 years Figure 2, moSa neyt in isf sto ac cks tion Wit , bonds or h muItu nafor l fun m dsation Available on Health Plan Choices, by Plan Type and Length of Time Enrolled 47% 20% < 5 years (Percentage Extremely or Very Satisfied) .................................................................................................... 4 Findings Similar patterns were found for the other consumer engagement questions not shown here. 94% I appreciate the unique tax advantages of my 92% 10% HSA Satisfaction – The CEHCS asks a number of questions regarding satisfaction with health care and coverage. Figure 3, Cost Conscious Decision Making, by Plan Type and Length of Time Enrolled ................................ 93% ................ 5 HSA-Eligible Health Plan Enrollees – There was some evidence that HSA-eligible health plan enrollees were more 50% 0% enga ?g I e vd ieA win som m myong HSA a e indiv s aa lo spe ng- idu tc erm ta s of ls sav w intg it he sh veir a h icl H C eS DA H P the , ov long erall s er a the tisf ya h ca tion w d beeitn h t enr heolle ir he d a in t lth p hela ir n d HSA id -e not ligib inc ler e he ase alth p witla h n the . A c le cngth of ording to Figure 4, Annual Contributions to Health Savings Account (HSA), by Length of Time Enrolled ..................................... 6 64% that I < can 5 y u ear ses for my re 5- ti9 y rem ear en st 10+ years < 5 years 5-9 years 10+ years < 5 years 5-9 years 10+ years 49% the data tin imF eigur a pe e r4, th son w e a long s enr erolle a p de in t rson ha heir d he baelt eh p n ela nr nolle , ac dc o in a rdin n HSA g to t-he eligib finle dings in health p Fig la ur n, e t1 he : m Sa or tis efa lic kteion w ly the ays highe were tst o Traditional CDHP HDHP Figure 5, Attitudes Toward Health Savings Accounts (HSA), Among HSA Enrollees (Percent That Strongly or Somewhat contributp er ior $2 ,00 to 0 o yearr m fiv oe re . to their HSA. However, when it came to how they viewed their HSA, there were no major 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Agree) ...................................................................................................................................................... 6 diffe ? re ncI en con s by le trngth of ast, among time t reanr diolle tionda l p in t la he n e H nr SA olle -eligib es, sle a the isfa ac ltth p ionla pn, eatkhoug ed in y h p ea arrts 5 icipa -9. nt s enrolled for 10 years or more were ? slight Sim lyila mro lyr, ea lik me ong ly t h HaD nH tP hose enrolle enre olle s, sa d le tisss fa c tim tion e twa o rs highe eport th r a atm the ong H tSA ho se had e nr em olle pow d 5 e-r9 ye ed the ars ma s c to m om ak pe a rb ee dt tte o r Source: EBRI/Greenwald & Associates, 2017 Consumer Engagement in Health Care Survey. Source: EBRI/Greenwald & Associates, 2017 Consumer Engagement in Health Care Survey. health catrhose e and enr fin olle anc dia for l d e le css isions tha, n afi s vsee e yn in ears Fi or g ur for e 10 5. years or more. EBRI Issue Brief is registered in the U.S. Patent and Trademark Office. ISSN: 0887 ?137X/90 0887 ?137X/90 $ .50+.50 © 2018, Employee Benefit Research Institute ?Education and Research Fund. All rights reserved. e e e e e e eb b b b b b br r r r r r ri. i. i. i. i. i. i.o o o o o o or r r r r r rg g g g g g g IIIIIIIs s s s s s ss s s s s s su u u u u u ue e e e e e e B B B B B B Br r r r r r rief ief ief ief ief ief ief • • • • • • • M M M M M M Ma a a a a a ay y y y y y y 2 2 2 2 2 2 22 2 2 2 2 2 2,,,,,,, 2 2 2 2 2 2 20 0 0 0 0 0 01 1 1 1 1 1 18 8 8 8 8 8 8 • • • • • • • N N N N N N No o o o o o o....... 4 4 4 4 4 4 45 5 5 5 5 5 50 0 0 0 0 0 0 5 6 4 8 2 3 7 A research report from the EBRI Education and Research Fund © 2018 Employee Benefit Research Institute