What Do We Really Know About Consumer-Driven Health Plans?

What Do We Really Know About Consumer-Driven Health Plans?

Volume 345

Pages 28

This report by EBRI provides a detailed summary of what is known about consumer-driven health plans, a relatively new option for paying for medical expenses that first began to appear nearly a decade ago. Consumer-driven health plans (CDHPs) consist of both health reimbursement arrangements (HRAs) and health savings accounts (HSAs). The EBRI report examines trends in offer rates and enrollment, differences in premiums between CDHPs and other types of insurance, and discusses the drivers of the premium differences.

ABOUT CDHPs: Employers began offering consumer-driven health plans (CDHPs) in 2001 when a handful started offering health reimbursement arrangements (HRAs). They then started offering health savings account (HSA)-eligible plans after the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 included a provision to allow individuals with certain high-deductible health plans to contribute to an HSA. This report summarizes what is known about CDHPs, which include both HRAs and HSAs.

OFFER RATES: Surveys show that employers offering a CDHP increased from less than 5 percent in 2005 to between 12–15 percent by 2009. Growth in offer rates can be seen across all firm sizes. Recently, the percentage of small firms that offered a CDHP declined while larger firms continued to add a CDHP as an option.

ENROLLMENT: Overall, 19.1 million, or 11 percent of individuals with private insurance, were enrolled in a CDHP in 2009. More recent data suggest that by 2010, 10 million people were in an HSA-eligible plan.

PREMIUMS: Generally, premiums for CDHPs were lower than premiums for non-CDHPs. A number of studies have tried to explain the differences in premiums. One found savings ranged from 15.5 percent to a low of –4.7 percent, with average savings of 4.8 percent. However, the study found that most of the savings was due to younger, healthier workers choosing CDHPs and concluded that once typical risk- and benefit-adjustment factors were taken into account, CDHPs saved only 1.5 percent. There is strong evidence that initially CDHP enrollees will be healthier than non-CDHP enrollees, but that over time the CDHP population has a significantly higher illness burden.

IMPACT OF CDHPs ON PREVENTIVE SERVICES: The studies agree that use of preventive services did not change (upward or downward) as a result of the CDHP.

IMPACT OF CDHPs ON MEDICATION ADHERENCE: The studies found that overall use of brand-name prescription drugs fell and, while there was some offset from increased use of generic drugs, some enrollees stopped their use of prescription drugs. CDHP enrollees increased their use of the mail-order pharmacy option. Overall use of prescription drugs among CDHP enrollees with certain chronic conditions fell, or did not increase when enrollees met their deductible. One study found that the financial incentives of the plan are not sufficient in driving behavior, and that educational outreach also matters.

NEED FOR FURTHER RESEARCH: Despite the growing body of evidence on the effect of CDHPs on cost and quality, there are many unanswered questions about these plans. Most of the research to date has focused on HRA-based plans. Little systematic research has been conducted on HSA-eligible enrollees. The differences between these plans are significant enough to warrant separate analyses. Also, most of the research to date has ignored the impact of the account on the use of services and on spending. Individuals may use health care services differently depending on how much money is being contributed to the account, especially relative to the deductible, amounts rolled over, and portability of the account.

EBRI Issue Brief

Paul Fronstin

Health

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Ho Puse of Employers with 500 th enroll in d t o the hea ees i h ffer neutr en wev Eff l r i th n o n ates can e al impact on e crease, r, the care servic ct of a ne (b survey - ut not Consu whil be seen across al 999 es. e prevention, we bo PPO inclu m Similar re the er-Driv th) o costs wo ded a f only th le y, Gre despite t n H e qu l fi emp gr uld e e rm s alth e oup to tion ne loyer have h et e Paul Fronstin is director of the Hea Prlojected Medical Costs, th Research and Education Pro Aetna graHealth Fund m at EBRI. Thivs. s Issue Brief was written with Premiums, Offer Rates, Famil byy T Co ype of CDHP and Firm Siz verage, by Plan Type, 2005 e, 2009 –2009 Projected Medical Costs per $100 Spent, CDHP Enrollment by Firm Size, 2005–2009 Projected Medical Costs, Aetna Health Fund vs. Traditional Plans having an inpatient visit, and 27.5 percent overall decline in medical spending. The unanswered questions relate to the Premiums, Employee-Only Coverage, by Plan Type, 2005–2009 Introduction experienc fact that al. plans. increase Employers be sizes. Among regar (20 plan d0 in Th 6d g who these services on M ) in e fou e a a t n u h gan o n increase in e thors conclu small firms, those with 3 e d els dic first year th e al Care at whil was fferin were g cove Ex offer rat a c e self-re de o npen nsumer-drive d co that sw red by covere dntinu itures p es be orte th d 100 itchin ed i e hea d health - and Ut tw 199 work n perce n hea een g to a creasing. lth ilization. 20 p lth status did nt by lan. CDH 08 ers, the perc plans an Ha Acco P all " d does not a in H four employer d mem 200 e rdin not pre al 20 9. th Servic 01, g to t enta For bers r wh d u eac ict ge o tomatically he s e e es Research n pla mained in s a h of u f ferin in rvey, 7. nhan cho the thg e d a iful produc other s ce, e the t 9 mil CDH u st 3 d9 y. arted o n, no. PPO, costs wo rollees in P le more firm siz ion chi increased fro 4 (Au ffe l cost-e dr erin cat H en gg R ust 20 e A-base HRAs. Th were uld g fm foective ries (exce have 04): 4 perc enroll d plans be incre 1 ey t 1 ent in ed in havi 8p 9 h t – wer ased en 1 or. an 2 2005 e 09. assistance from the Institute’ Only one study was found that e s research and xamine Traditional Plans d the im editorial staffs. Any views exp pact of – mo Full Replacement ving to higher de ressed ducti Plans ble in this s on em report erge are those of the aut ncy room use. hor CIGNA Choice Fund vs. Traditional Plans Endnotes Figures 12% 35% comparison group of 4,397 P 6,000 PO enrollees generated from 35 health plans. These enrollees experienced a 21.9 percent $16 $16,000 000 Using premiums from the Kaiser study to track trends in premiums does not control for other factors that might also be Barry, Colleen L., Mark R. Cullen, Deron Galusha, Martin D. Slade, and Susan H. Busch. "Who Chooses a Consumer- $350 Figure 7 33% to 11 5,00 started offeri healthi from $ HRA- or 0 p -2 e e 92 HSA-eligi r th rcent ,6 9 to 9an 9n ) i $32 ,g n PPO e n 2 HSA o3 a b t onl 009. le- plan. fn eli ter rolle y Amo was g five ible es Thus, overa ng mi years th plans a when e ex d-si e pe (a fx ter cted ze amini 43 ll, the Medicare Pres fir percent 19.1 of m ng fs, those wit er rate l prior millio incre claim n, o owe ase), h 5 r s r th 11 data. cription 0whe percent 0 an - 99 th reas u Dru 9 w e ac o o g tual offer n frkers, peopl , der Improvement, the the pe e CDH rate, withrcentag P either but costs initia and Moderni the offer employment-based c e offering a lly fell rate ha zation Act o an CDH d t d decl P h option eno if n verage 2003 ed Wharam, In 2001, a Landon et handful o al. f em (2007) ployers started o examined tfh ferin e hig gh health -deduc rtible hea eimbursem lth ent plan offe arrangements (H red by Harvard P RAs)— ilgri a th m Health en-new type o Care. As f and should not be ascribed to the officers, trustees, or other sponsors of EBRI, EBRI-ERF, or their staffs. Neither EBRI decrease in outpatient visits, 19.9 percent decrease in diagnostic visits, 3.9 percent increase in number of prescriptions, 41 $180 $350 $325 14 Rowe affecti 1 Another study Parente, et a ng pr Ste l. em (2 phen examined one em 008 iums. CDH ) T., Ro exami Ac ger tual Spending ne P premiums may d Fel use dman, a ployer of preve that offered t nd ntive servic Jon B. C be lower hristia than w es, sc o HRA-based pl nson. "The no reeni n-CD nHP g for Im pre ans and a t cancer, a pact of miums simply Healt nraditional d di habetic Status a because monitor plan n the d Pr in C 2004 ice on ing se DHP (Greene Pla rvices a popu n S latio e , m let a en ong ction is l. Figure 1, Offer Rates for HRAs and HSA-Eligible Hi HRA g HSA-Eligible h-Deductible Non-CDH Health Plan P s, 2005–2010 ....................... 5 Directed Health Plan?" Health Affairs 27, no. 6 (November/December 2008): 1671 -1679. increase slightly from 2 inclu increased or individu health Definity Health and ded a pla d fro n to $297 ally pro kn mv own as 008 purchase 4 ision to allo perc aft to 200 Lume eent a cons r five years d i 9. n in nos were the most well-known thi w surance, 20 individu umer-driven Worker Premium Contri 05 to (a wer 16 als w 31 pe p e h e ienrolle rcent th certai e rcent alth in plan id ncreas 20 n h in a 09 (CDH i C gh e . An D ) (Fi bution, by T -de rd- HP i P) or d amon d party administrators of HRA gucti ur n an 2 e 14 ble 0 acc 0g 9 he ). , the lar y accordin oalth pe of unt-based health plans to gest, or H g to ealth Plan, t c jumbo ho e EBR ntribut s. Early adopters of Definity plan. I/M firms, e to GA These pla 22 a survey. n HSA. perc n ent s were were mentione nor EBRI-ERF d above, Harvard lobbies or takPilgri es positions o m offeredn a h spec HRA igh ific -d poli educ c Hty SA- ible proposals. E Eligible health pla Non-CDHP B n as RI i n pvites co art of amment on much larg this er c research. omplex cost-s haring percent lower chance of having an emergency room visit, 32 percent lower chance of having an inpatient visit, and 14.7 $323 Actual Spending August 2010 • No. 345 $13,591 $14,000 1 $304 10% 200 Fowl healthi more than 8). in a es et er. This st Mutli 30% Th al. 17(200 e p ,000 udy rle e is some -C 4) fou in hoice focue dividual nd d health evi on that self s who d peo enc Be p enef of le had be -r usin e this, it Pro port g en e e g which prescript d rahealth m Inclu nrolle will d coul ion be d in in dr an HRA- d di g H ugs scussed predict RA an forb as a plan d HSA in t sed p thm h choice. e n a O l, choles an e p f xt tions." o sectio r th Tterol, hre e s University of Minnes e ye n. t de udy fo Furth ars. Most pres un e srmor ion, d th $303 of h at employees e, if y th pertens the e en ota Working po rol ion, pul lees a with ation nd Health included Aon, Budget, Charter Communicatio Among Lar Small Employ ns, CompFirst, ge Employers ers Co Laruntrywide, ge Employ , 2009 ers CVS Ph armacy, Dade Behring, Hannaford percent overall decline in medical spending Projected Spending on Traditional . Given that the Plan decline in use and spending in the PPO is not explained in the already offering a CDHP option by 2005, increasing to 43 percent by 2009. $4,902 structure. offered by se Deducti lf-insure bles cou d empl nt oyers and administered by ed toward institutional servi a thir ces, whereas d-party. HRAs were copayments pr were req ovided un uired for office visits der then-existing ta and x la w, $160 10% Figure 2, Offer Rates, 5,000 by Type of CDHP, 2009 .................................................................................. $302 ............. 6 $12,892 $153 $300 Actual Spending $4,769 $289 $297 Projected Spending on Traditional Plan Burke, Jack, and Rob Pipich. "Consumer-driven Impact Study." Milliman Research Report (April 2008). Brothers, Louisiana State University, Medtronic, PWPipe, Raytheon, Ridgeview Medical $283 Center, Scientific Atlanta, Supervalu, ulcers paper at a time Expecte In the (89 percent) h self-re Since leaving non Paper the f p befor ull r orte dICD o intro $300 , May fe d -feC e pl C: t excell r D acement ad a h rates for duction when costs were increasing, it is unclear how HPs for e avai Inside Consumer-Dir 2008. choic entlabi of or ve CDH model, Aetn 2 CD elity 0 of healt 1P 0 ry good he HPs in of the s is hea are slightly h HRA 20 a f plan. lected thier 01, t inds alth an high h that i and They wer Care d th e perce euses less en e r tha (I wer n si th C exami gnif n D e n e tage C), a co th fir ica e actu mpared with n s heal of n e t year CDH no tl d meaningf y more likely than t employe prescri th w-de a care l of funct industry ne fer p th ul both the PPO P tio rs more than rates in costs drop, an the n offeri drug use a ng them po 20 h 128,000 i pulat ose 09, bu wslett and f twith t the but th ie has gro on rema r en CDHP results er pu worse self-reported hea n gro rollment ey divi w w do not come close inin blishe du n. th r als enroll S g ate in iu in non d by nrveys show t are from this paper. the costs in Atla CDHP. -ed in CDH ntic P a to the plans, years h lThe th to at the $12 $12,183 183 $285 $12 $12,223 223 although because of the newness of their plan design and potenti $4,514 al legalities, $4,468 employers were gen $4,517 erally hesitant to outpatient visits, and there was first-dollar coverage for preventive services. Employers could offer an HRA, but only $281 No Contribution Average Monthly Average Contribution $269 $4,365 Textron, University of Minnesota, WelchAllyn, Wise Business Forms, and Woodward. Early adopters of Lumenos included $264 $138 $12,000 $11,571 $11,523 Figure 3, 2009 CDHP Offer Rates, 2009 and 201 Projected Spending on Traditional 0 Predictions, Sel Plan $11,492 $4,254 Figure 1 ected Firm Sizes ................................... $4,274 6 study trie growth tr comparin choose a C two, thre perce Information aditin otage nrates ae, a g d to l PPO. Th D of pre S H n se P control for d fo e m employers rvices thro , an en in 20 iums in t ur is d those ose in highe 06 sel o h ugh mid-2 th e r faf e e nd 20 e Kaiser study e r than ction portin ring HRA- an 07, and eff th g b 0 HRA- a 0 great e e sed p 9 cts proj , f w based o as it fo or HSA e llowe ill not lected gro r util an wd th ization nec e on past und tha r-e eli n e m e w go ssarily provi ib th w t su o l e tvement history e rate ha healt re si plan increas bjecgnif t to c hier, d C they to dicantl e co be D o th H st sh may not materialize. nsumerism an ed from belo tter-e P e e y less likely enro x aper rid ng llees ucate ienc fo re r pr e to d w t d mained in people h e choose a 5 perc growth at an ven I ti em ve or ent in 2 n enroll in fact the CD ploy C sc D e , predicting HP (Fow PPO. d HPs. r er may se 005 e in en th in to betw Specific Variou e hi g se les gh e i rgr ,v et ee s reports e f ic owth at i ally, in re al. t-n s. $140 Copyright Information: This report is copyrighted by the Employee Benefit Research Institute (EBRI). It may be Required HRA Dollar Amount HSA as a % of Premium 23 1.4 offer perc HRAs un ent oftil the the sample release inof IRS this study Rev of enu fe e Ru red on ling 2 $254 e and 0$261 02 the stud -41 and Not y focused ice 200 mostly on 2-45, whic small b h proviudsinesses. ed guidance clarifying the 25% Abbott Laboratories, CIBA Vision, Federated Department Stores, Gerber, Macy’s, Novartis, Pharmacia, Pitney Bowes, Radnor Chen, See www.ahipresearch.org/p Song, Regina A. Levin, and James A dfs/HSA_Preventive_S . Gartn $10,759 er. urvey_F "Medication inal.pdf Adh (last accessed erence and Enro July 20 llmetn 10). in a Consumer-Driven a $3,983 b 8% Parente, Stephen T., Roger Feldman, a $245 nd Song Chen. "Effects of a Consumer-Driv $10,623 en Health Plan on Pharmaceutical $10,482 $3,894 deductible C this poi 2004). When year two, moves 12 provide -15 from a examin S perc n dt is co ideta CDH $250 milar en Di iHP. It t n led non-C mplicate P ly, Barry g t by 20 costs incre enrol Offe h $3,872 e m also fo D 09. Gr HP to d r lment e et al Rate an by t a a und that t owth .either s data h (2008) fo n ed 9. s e timi d stan for i for an H n 4 HRAs ng of o dard deviations in perc s ffer hund e p RA eci e h h $3,865 rn igher -a e bas a ft w that, at o tes can ic i alth r nd HS hile e ns -d d urers ed e plan PPO form be seen across al uctib A n or e . us - c . T E employer, C o le CDH HSA- lig e Some em he mos sts would ha of services, t ible Hig e $124 P e ligi t rb nroll ploy ele D cen h l fi plan. H -ve incr D ers may not P ees w rm sizes. th en e data e aut du ro Th c ere e llees come tased 6 h ib e e ors fo mor le However, were more likely x m Healt pe fr e .u a 7 percent rience like om a com n ke any d simil h ly tha Plan recentl that changes and may take a ar l (Fi n b an s, 2005 t ina eg h y ve ure ose wit , the than P tion of employer ls of use 1–2010 5 perc ). P the hO In tra of ent may enro Au y d age o itional eg. 8, ar llees see f 4,000 CDHP $244 $10,380 $245 8% used without permission but citation $236 of the source is required. general ta $250 x treatment of HRAs; the benefits offered under an HRA; the interaction between HRAs and cafeteria plans, Figure 4, Enrollment in HRAs and HSA Holdings, StyroChem, and WinCup. Definity -Eligible Health was acquir High-Deductibl ed by United e Health Healthcare in 2004, and Lume Plans, 2005–2010 ......................... nos was acquired by 8 $3,666 Health Plan." American Journal of Managed Care 16, no. 2 (February 2010): e43 -e50. $227 $227 Spending and Utilization." Health Services $9,654 Research 43, no. 5 (October 2008): 1542–1556. $120 $9,580 c $227 d $10,000 $226 $226 $3,534 $114 Employee-only 16% $64 20% to be w coverage wait-a What Do We Really Know About Consumer-Driven Health three, C prevent small firms t 200 ill also de 8, r youn nd e ive a D port -s an HP ee ger pend d h c n approac fat off d s o ,o the lo higher r 24 sts increased 7.8 on cree e of wer w re nin h befo h - the d a wa e-g s tde he C ge, la ductibl e r the e D re rvices rgest insur and w HP makin percent decli e bet m CDH hite. ploye g nw ed c ers e ha P t T w er while n the nges and t o hey also offers t hile disconti lar . HRA- PPO he A Others g her costs woul e C foun nue ubas fir g. D m HP optio d that 22, ed may ado two of s continue en 20roll pr d 08, r fihave n ior h v ees a ps alo e t ch edru d port for e in to add a anges soon n n alth car g creased 7.6 d t gside classes. he Blue no PPO e CDH spen n-C Cr er 7% Specifica en oss BlueSh percent. P D than th ding an as an rollees over HP op optio lly, use tions, ey d t An iel wou he d i d th nor if pla . Overal presence of n lof pr e thre d h year n it moves t ave. s. Accor escriptio four, e-ye l, 1 For ar 9a c C .d 1 n o p ing to D dru a f h eHP riod. ronic ull gs - Emergency room visits were subject to KFF/HRET the high $111 deductible, and there was a $100 co-payment required aft Mercer er the Wellpoint in 2005. 20% flexible spending accounts (FSAs), and coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act of $9,00 $9,001 1 $107 $3,280 Family $208 20% 8 239 28 Recommended C Figure 5, CDHP Enrollm itation ent : Paul by Firm Si Fronstin, ze, 2005–2009 “What Do We ............................................................................. Really Know About Consumer-Driven Health Benef ....... 10 its?” EBRI condition to treat replac ins The authors costs increase million, or the Unitance, i vdata ers ement ehypert for th af 1 f tfe 1 h di model, ey ex cted c perce d d not ese two ension a 16.2 pect n h use r percent wh t of oice issues n to ere peo T d cholesterol of hre egr bthe C e e or m health p whi ession analysi , 10. af le with fecte D le ore w 7 mil HP is pla PPO eit dfell, n ork lion by t th co .h er ers e only wher sts would hav he e s persons w employm . Th 2 x eas ther cis option e aut e tax e e h nt re or e was offer -based coverage or i e on hi s (a enrolle $101 incr ll egh conn d. e no cha ased 7. d -cost h in HR ecte ng 7 percent. e e A- or H d to A alth cov for as ne div SA-e tna thma, e It irage that dua ) 5 co 00 or m ligi is ldepr lnclud not unt b y purc le pla ore w es takes e ed that t s hased in n ion, or il yea s. orkers Wh ffect i r ulcer h five ile ma surance, e findings n that me 201 ny insur CD dicati 8, t were su HP hpport ons ey ers . deductible was met. $100 The $100 co-payment is waived when individuals were admitted to the hospital. The study found that Plans? 1985); and other matters under current law. Fairman, Kathl $200 een, Heather Sundar, and Emily Cox. "What Happens to Prescription-Drug Use After Consumer-Directed 2 $96 6% 6% Parente, Ste $200 $100 phen PPO T., Roger Feldman, and Yi Xu. Impact of Full Replacement with Consumer Driven Health Plans on e Issue Brie f, no. 345 (August 201 a 0). b 9 a b The Ruling 3,000 and Notice were published in Internal Revenue Bulletin (2002–28), dated July 15, 2002, and can be found at $7,538 Type of CDHP $8,000 6% HRA or HSA -eligible plan HRA or HSA -eligible plan The the case for costs increase enrolle were may start moving to study not d in a inclu fou c C o n slower ded in D st sharing th d t HP i hat 1 n war the than 27 0d ICD 0 per C 9 e . D at varies c x C HPs today as More rec ent of pect estimates, A ed PPO th wi e e hi th nt c gher-de the e data suggest th a way o ests. CDHP tna, th ffe to avoid the tax ct of ducti e B t lue ble c ho e use s, Cigna, CDHP at by sts increased 4.3 of 20 enrol the in t 10, Hum 10 h service on le e futur e ana, an million s taking me percent e.d Un peopl fut w uit di re costs an ed hile e cine to wer wer PPO ee i treat i n costs woul n a d clu n health. H h ded. y SA-eli pertension Colle T d ghave his ible ctivel would pla in late y, n. emergency room visits among high-deductible health plan enrollees fell after a move to the higher deductible, whereas Figure 6, Percentage of Eligible Workers Enrolled in CDHP, by Type of CDHP, Among Large Employers Health Plan Enrollment?" Express Scripts Pub. 07-05235 (April 2007). Employee-only 12 110 24 Total Health Care Cost and Use of Preventive Services. Final Technical Report for DHHS Contract http://benefitslink.com/IRS/revrul2002-41.pdf and www.irs.gov/pub/irs-drop/n-02-45.pdf (last accessed July 2010). Parente, Various stu Feldman, an dies by insur d C ers r hristianson (200 eportedly stan 8) exam dardize results ined a large em . Cigna, ploy for er of example, fering has r eight di eleased a fferent num options, inclu ber of studin dies g an 200– 1,000 500– 1,000– 5,000– 10,000– 20,000 or By Paul Fronstin, Employee Benefit Research Institute 200 increased 6. imply s There are no they accou 3 were upport no nt 8 fcomparabl percent. I o for valu longer r about takin e- 1 bas en 4 0 data yet g fa e t million ct, PPO d he me benefor HR lives, a dicatio fits cost in des A enrollm n nicreases are pr in gn a d 9.3 20 nd million 04. a ent. Am pre fof the ong i erence ojected to ndivi 1 for 0.7 dua HR be mil lA-bas s who co lion more stable than th persons c ed plans ntinued to over HSA overed by C take m e actu -bas D al eHPs. dications a eCD d plans HP Whil cost increases . e th fterere ar e Ultimately, HRAs paved the they were unc 15% hanged among tra way for ditional heal pl than en savings acco rollees. uOverall, nts (HSAs). there Twas no he Me 14% dicar change in the num e Prescription Dr ber of first visit ug, Improvems ent, to the Family EBRI Em $80 ployee Benefit Research Institute Issue Brief (IS5 342 SN 0887 ?137X) is published monthl 200- y by499 the Employee32 Benefit Research Institute, Offering a Choice of Health Plan, 2009 .............................................................................................. 10 Report availability: HHSP2332005430 This r 1ER, 20 eport is 08. available on the Internet at www.ebri.org 13% 999 4,999 9,999 19,999 Year Total 3–199 999 or more Total 10–49 50–199 more HSA and comparin two g th e HRA-bas experience ed pl of ans its . T HRA- he s bas tudey foun d and HSA d that -elw ig hen ible both plans an H (collectively RA and an know HSA wer n as th e of e CI fer GNA Choice ed in additio Fund) n to other with 1100 13 $150 $150 $150 $150 $6 $6 th S ,000 000 t. NW, Suite 878, Washington, DC, 20005-4051, at $300 per year or is included as part of a membership subscription. Periodi- 3 HMO moving to and Mo that were no compar der a C experienc abl niza e D t data ion Act o HP, th e for d. ere Proj 2009 from f wa 2003 ected PPO s no observ inclu ICDC, ded a cost increases ed reduction t provision to he 2008 data in ra all a nged are inc o dw in her e from 6. divi nce. luded f duals 7o perc with r comparison ent to certa 8. in 2 p h pur igh-de ep rcent oses only ducti over ble the . healt five h -year plans t perio o d, Fel emerg dman, ency ro Roger, Ste om, but p ther hen T. e Pare was a nte, a big dro nd pJon B. C in repeat hristia visits nson. "Consu . In contrasmer-Dir t, the number ected Health of repeat Plans: visits among tr New Evidence adit on ional 4% See www.forrester.com/ER/Research/Brief/Excerpt/0,1317,15958,00.html (last accessed July 2010). CDHP Enrollment 2005 2,000 4% 4% 4% 10% 15 2% 2% 1% 5% 4% 4% 10% 19% 22% cals postage rate paid in Washington, DC, and additional mailing offices. POSTMASTER: Send address changes to: EBRI Issue Brief, 1100 Figure 7, Worker P 4% remium Contribution, by Type of Health Plan, Among Large Employers, 2009 ............... 11 choices such the experien Wharam Generally, etpre al. c a e m (2008) exami s of tradit an HMO, iums for ional CD PPHPs wer PPO O, and POS ned data and HM e fr loom w pl e O grou an, the HSA Harvard Pil r thanps. premi It gu attracte ri r ms for m Health eports in d no a n-C Care in M its la popu DHPs. lation o test release th aGrowt ssachusetts. This stu f relati h in vely hea at results premiums lthy wer varies w de o y examined t standar rkers, whil both dby type o ize ed for h a more e f Employee-only 11 95 23 $60 whereas actual CDHP cost increases were 10% negative the first year but then ranged from 4.3 percent to 16.2 percent. contribut plan enrol Spene din l to ees gan HSA. a increased. nd Utilization. Thes Th e plans ar e authors " Inquirye kn 44 det (Spri own as ermined that ng 20 HSA-e 07): lo ligible plans 2 w-seve 6 -40. rity be visi cause not ts accounte alld persons eli for most of t gible he to contri drop in em bute er gency to an 200 13t 6h St. NW, Suite 8 778, Washingto 7 n, DC, 205 005-405117 . Copyright 6 2010 by E5 mployee B7 enefit Res7 earch Instit6 ute. All right 12s reserv18 ed. No. 345. 21 37 Reed, Mary, Richard Brand, Joseph P. Newhouse, EXEC UTIV Joe V. Selb E SUMMAR y, and John Hsu. "CopY ing with Prescription Drug Cost There are a number of different sources for enrollment rates and for the number of people with access to and enrolled 10% Statement of Ownership 4 Family 3% 3% 6 325 30 gene Parente, impact o dif plan fere and over rous HRA nces i Feldman an KFF/HRET: f a hi n gh- health attracte time. I ded status d C ucti I nd re n 2 200 h ble en 009, la 9 mix in (200 health tively un , HSA-e the 8) e order t K pla a ligi healt x iser Fam n on ami ble o h n prev compare premiums y workers. ed a la ily entive Frge oundatio th se incr s ee ex lf-i rvices eas ns n/He peri ed sli ured wit ence alth em g h f htly of R irs p e its Choic loyer that search t- do faster tha llar cov and E e ad n Fu no e d nd d red a ucatio an-CDHP ge grou n HRA and n ps wit a pr premi l Tr in eve ust (K h 200 traditional ntive s ums, increasin 1 i FFn or /e Hrvic RET) ann der pl es an to s g ee ual $4,000 See 200 www.acce 7 ssmylibrary.com/coms2/sum 10 10 13 mary_0286-20 18 7 873836_ITM 6 (last reviewed 8% 9 6 July 20910). 16 22 36 41 HSA do, in fact, have one. Advocates of HRAs and HSA-eligible plans claimed that they simultaneously provided room visits among $100 high-deductible health plan enrolless, but there was also a slight (though not statistically significant) Figure 8, Pre $100 miums, Employee-Only Coverage, by Plan Type, 2005–2009 ................................................... 12 United Sta Sharin tesg Po : Kno stal Serv wledge, A ice State dher ment o ence, an f Owner d sh Fi ip, Manageme nancial Burden. nt, and Circula " Healtht Servic ion es Research 43, no. 2 (April 2008): 785 -797. in a CDHP. Selected available estimates, as shown in Figure 4, are discussed in this section. Source: Mercer. $40 2008 13 13 15 22 10 8 14 11 14 22 28 40 45 if th subject to t survey of g As mentione 3.5 roup perc ere s. wer ent a The near h ed e n 2009 stud dif above, Aet ly 2,000 employers of all deductible. d 2. fere 8 nces perc y shows trend i ent, nn H a salso prese arvard P p res endi pect ngively. an ilgr sn in ted cost tren s d im izmed us e offer Premiums se of foun ical costs e pr d d t es a h ds fo hat cription iin H gh fo 8 p -de r wh r fo RA-bas ed rcent dru ur years uc en ti g e emplo ble health s w d bplan e er tween after t ey enro ers offe s decre plan the h lle e d i intro a red HR as part of sn e ed t A enroll duction 4. ither a he C 3 p DeHP as o n HRA a muc ees rcent. of the an Ho h d in or HSA- ne of CDHP. larger wever, divi aduals compl num bas After CDHP e d be with eplan. x cost- r of a Fowles, Jinnet Briggs, Elizabeth A. Kind, Barbara L. Braun, and John Berkto. "Early Experience With Employee Choice of Publication Title: 1,000 EBRI Employe 2% e Benefit Research Institute Issue Brief – Publication Number: 0887-137x consumers wit decline in high- hseverity visits broader choi. Ad ces than mission wes ref curre rom emer ntly avai genclable, y room visits droppe while their aggrd sli egate ghtl decisions y among hi woul gh-deductible d cap costs m hea ore lth ABOUT CDHP s: Employers began offering consumer-driven health plans (CDHPs) in 2001 when a handful started 5 Table of Contents  2009 2% 12 11 18 28 151518 16 162042 39 43 Fronstin (2009) found that while adults in CDHPs exhibited more cost-conscious behavior than individuals in traditional Figure 9, Premium Changes, Empl See www.treas.gov/offices/public-affairs/hs oyee-Only Coverage, a/pdf/fact-sheet-dramatic-gr by Type of Health owth.pdf (last Plan, 2006–2009 accessed July 2 ..................... 010). 12 three-t sharing struct Unlike oth standardi premiums m other hie er alth zcost-sharin e in 5% r st g c aure. y be o costs to $100, udies, t verage low De gducti optio h e struct e sur r thb an les count n Cigna sho v ure. s. Unlike non ey di Th -d not CDHP e stu ed toward institutio th w fi premium sim s e n d that in fin d y was a growth dings from year b in le to o p en ly n n the f e a control for beca rollment al fservices, te ull use th r t replac he bet con introduction of t e whereas cop wement sce CDHP een tinuous e 20 popu 08 an n nlati roll ari ayments were d h o, Aetna on is h ment in e C 200D 9. HP e Th th althi , costs fell to die K e va d n re erF o q ,rious pla F/HRE and ther t fin uired f d a T o $96 decli surve r o ne is s. It fo ffin cr those some y e i e does vi nsi ts Consumer-Dir $2,000 ected Health Plans and Satisfaction With Enrollment." Health Services Research 39, no. 4 (August e Rowe, John W., Tina Brown-Stevenson, The Em Ro plo berta L. yee Benefi Dow t Research Institut ney, and Joseph P. e (EB Ne RI) was founded in 1978. Its whouse. "The Effect Of Consume mission is to r- effectively than top-down, conventionally managed care plans had done. But some analysts warned that consumers plan enrol AHIP: lees, whi Since le t 2 hey 005, inc America reased ’among traditio s Health Insura nal nce P plaln ans enro (AH llees. IP) It has con is import ducted a ant tn o a note nnua that th l census o ese fi f ndi health ngs s plans hould offeri 201ng hea 0 lth reimbursement arrangements (HRAs). They then 17 started o 19 ffering h 20 ealth savin 19 gs a 24 ccount 43 (HSA)-eligi 43ble 47 3% $50 $20 1% Introduction ................................................................................................................................................................ 4 plans, were more engaged in wellness programs, and were more affected by financial incentives, they were also $50 2% found that and o not incl icosts in the fir evide 1n ) the Filing n u CD ce o Date: tpati ude no HP CD fe th , nt 0a 8/13/2010. HP enrol is. One nworkin s visits, and th nt year of the d they study g in lees ac 2 d rul ea )c I ere o program, ts or chil found that ssue F se ntinue dwas first-dollar covera to rcontribute to eq d to $dren uen 1 but 1 w 1 us c for y: i hactual C e bra n iMonthly. le actu its estimat th , to encourag ose nd name al sa D in 3) Number of Issue HP c PPOs a ge for vin es. osts s and fe g It a e, an s ran n preve did d HMOs d to enhanc lso do ged fro wer increa ntive generic ses P(s m u services. F not incl e more s blis ig a hi e the developmen u hed Annua r dr egh 12 u ugs i of 15.5 percent de f lo ) Pre .w In n ll le y y: the v deral than th enti 12 e se secon . 4) Annual t of sound empl ve servic employe proj cond ect d to year of ye e es with a low of e Subscr d a s or wo PPO cos r, th the o ipt fi y e CD ee ben ion - rst-dollar rkers pr 4. tPri sHP ogram, 7 per- fcoe e: in fit r the 2004): 1141 -1158. 6Sources: Kaiser Family Foundation, Mercer. Directed Health Plans On The Use Of Preventive And Chronic Illness Services." Health Affairs 27, no. 1 lacked the not be Figure 10, Premium to determine gene dis ral tciplin h ized to t e nu e a mbe sn , Fam h d sophistication e r of ex perie ily Cove people nce enroll th rage, by Plan Ty to at e successfully might d in HSA be fou -eli n pe, gnia b dvigate le amon 2005–2009 ............................................................... 1 plan an g C s. D inc Th He estimates reasingly P enrollees com . include plex h bot ealth h ca people re system an with an H d SA an 3 d plans a See Inside Co fter thensumer-Directed Care Medicare Prescription (Nov. 4, 2005). Drug, Improvement, and Modernization Act of 2003 included a provision to allow a Who we are $300 per year or is included as part of a membership subscription. 5) Complete Mailing Address of Known Office of Publication: (Not printer): signific CDHP Offe antly r Rates less likely to .............................................................................................................. have a health programs and so problem, und public policy less likely to smoke, through objective more likely to resear exerci ch and se, less likely to educati ....................................... 4 on. EBRI is the only be obese, Health reimburs - ement arrangements. coverage but th firms wit experienc Premiums same po cent, an e gen d pulati h incl e aver few d a eri un on (Fi c dru e d age savi incr r tha ed pa g e g n ase i ure use r p s thr ngs m 1 e ne e e 6 c were a ductions did no ). Aft employees. o rssts. Cost inc , mammogra 4.8 er fperc ive ye en Th reases contin ars, actual s t persist. t, most of th p e lack hy, an of d gro CDH feca pe u w ele n P occult savings w th d din enro for may g iboth t llees n be due to bloo thee C wit re d t he CDHP due D e hsting. HP i chron large ma to f ncrease an In act th ic con d t con rgins o he no d 34 at younger, dtitions rast, colonoscopy, fl percent, n-C f error did not DHP h for data w e groups althier use mor hile projecte t work relat hrou exi e bdru le e e gd to rs h the d gs $0 th (January/February 2008): 113 -120. understand $0 what care is truly necessary. They saw the initiative as an opportunity for employers to transfer a growing the n b umber w 0% ho are in a plan that makes them eligible to contribute to an HSA. The latter group may or may not have Employee Be individuals 0% wit nefit Research Ins h certain high-deductible titute (EBRI), 1100 13 health plans to Str co eet ntribut NW, Sui e to te an 878, Washington, DC 20005. HSA. This report summarizes what 6) Complete Ma is kno ilingw n private, nonprofit, nonpartisan, Washington, DC-based organization committed exclusively to 2005 2006 2007 2008 2009 Health savings account. more like Figure 11, Premium Changes, Employee-Only Cove ly to have high2005 2005 household income2006 2006 , and more lik rage, by Type of Health Plan, 2006–2009 ely to 2007 2007 be highly educated. 2008 2008 The company e................... 2009 2009 healthinsuranc 13 e.com Fronstin, 7 Paul. "Findings from the 2009 EBRI/MGA Consumer Engagement in Health Care Survey." EBRI Issue Brief, no. $0 th CDHP Enro llment ...................................................................................................................................................... 7 s than those CDHPs in fourth y spendi choose CDHPs igmoidos ng for ear. this c in opy t By the other his po survey. T ;, the and Befor study co do plan pulatio fourth y e Choic ubl des he e en F -c lack of und had they e ncluded that o igns, ontras ar, the $100 despit growt t bari rem e 1s h ut being abov m ained in may also be ycost for CDH n ear enema ce typical the w e th er P risk- P du e P e de s groups O e to 2nd y ubj an incr du d the ect ear e ctibl ben ased 44 perc increas to th fact e efit . CDHP e hi -that, w adjustment ed to gh de $ ent. e 3r hile n 114 d y ducti rolle ear the f U (a actors wer e nlike b survey shows sle. cumulative used t he full mor e ta e 4th y 1 r mail-order dru e ken into 4 plac gro ear perc ement wth i ent accou nincre o mfo fg n e del, ase), s r t, than c See http://ehbs.kff.org/ Overall (KFF/HRET) (last accessed July 201 10–0 499 ). (Mercer) 500+ (Mercer) Jumbo (Mercer) Addres This sectio s of Head n co quart mpares ers o2005 rprem General iums by Business pla Of nfi 2006 tce o ype. f P Premi ublisher (N umo st are pri 2007 ntus er): ed E to mp des loyece rib Be e 2008 ne em fitpl Re oyer co search sts, recog Inst2009 itutenizing that (EBRI), 1100 13 self- $0 p opene ortion of rising d an HSA. AHIP’s costs to cen employees (Jaf sus does not public poli fe i 200 nclude a cy r 2). es earch ny HRand A enroll educat ees. ion on economic security and employee benefit issues. Kaiser Family Foundation and the Health Research and Educational Trust (HRET). about CDHPs, which include both HRAs and HSAs. Pre-AHF 1st year 2nd year 3rd year 4th year 5th year found that the average age of individuals who purchased HSA-eligible plans was 40, whereas the average age for non- Impact on Quality Street d 337 NW (Em , Suite 878, Was ployee Benefhington, DC 20005. it Research Institut 7) F e, Dec ull Names ember and Co 2009a mpl ).e te Mailing Addresses of Publisher, Editor, and Managing Editor PPO Sedjo, R rates in wher actual spending CDHPs saved plan eas the large e enro becc $fonly 1.5 a L., an 100 llees i irms, it shows increases in cost for Pr ne- al d Emil AHF pl thr ercent on th e y R. Cox. the C e years. e no a dec n-C p D line 1s rHP em D t "The Th y in HP ear wer ium costs. of er groups Infl e was e fer rat at or uenc no increas es amo b 2nd y e o edif low f ear fTarget e ed to n projected rence g small $ ed Educ bet 153 firms spe w 3r d y (a ee ear ation on n n (contr cumulative din the g CDHP in ary to t crease Me 5 a dic 4th y 3 nh perc s in th ation P d ear e Mer POS ent e P c e enroll er rsistence a incre Pfin O. ees in 5th y dase). ings). In year ear mail n B d Gener one, e-or caus d C er ie ther c DHP use. e Enrollment by Firm Size ....................................................................................................... EBRI’s membership includes a cross-section of pension funds; businesses; trade associations ................................. 9 ; ins 2010 ured dat em a fplo romy M ers erc do er re not pres pa ent y premi the perc ums enta a ge of nd a em lso p incl loyers ud ve er the y lik po ely to rt o ion fferof total an HRAcosts paid for or HSA-eligible by plan i wo n 2010, rkers. Further as reported i mn ore, 2009. Figure 12, Projected Medical Costs per $100 Spent, CIGNA Choice Fund vs. Traditional Plans .................. 15 Source: Kaiser Family Foundation. th 8 20 Source: Kaiser Family Foundation. (e Do not leave blan Sour k):c P e:u http://news blisher, Employee Be room.cigna.com/imnef agesi/5 t Res 6/1209 e_CIG arch Institute NA%20ChoiceF– Education and Re und_Study.pdf search Fund, 1100 13 Street NW, Suite Employers HSA-eli See www.mer gible cou purchasers w ld o cer.com ffer an /ushealthplansurvey HR as 35. A, but only When 1. (last accessed it 4 p comes to pr ercent of the s J ior ul use o y 20 ample 10 f i ).in t n form his study o ation, neffe w CD red o HP enrol ne. Thlees e study fo were fou cused 10nd to mostly be labor unions; health care providers and insurers; government organizations; and service firms. Consumer-direc Note: ted heal 2005 and th 2006 plan. data for Non-CDHP represents weighted average of premiums published by Kaiser Family Foundation. Substitution a Sources: m Kaiser Family Foundation, ong Consumer-Dir Mercer. ected Health Care Enrollees." Health Services Research 44, no. 6 (December CDHP enrollees also sp Initially, are many Only one costs increase proje study was fo mor Note: ctions for d e 4 small 2005 and 2006 data percent firms t un ent less than PO gro d t ww h hile t h th i at attem an lar for nh Non-CDHP HRAs ey ge firm wer pted to determi Sa e e represents n ex s, th d HSA nrollees o pecte e overa weighted -eldigi to n nb e pr ll i l aver e n the im offer escription plan crease age of rate s pact t premiums published by (ref 8 dec dr per err hu a cent u e lig tned slight d to CDHP s. colle nder th enrol Kaiser ctively as ly as e PPO. Family lm we ent has Foundation. ll. CDHPs) were strong Years on quality of three and fiv healt e . A 2002 also h care AHIP found 1 million people were enrolled in an HSA-eligible plan in 2005, when it first started the census. By 2010, O refer FFEe R nce RATE to S premiums also :Sour Ex Surveys sho cludes ce: www.aetna.c catastrophic w in o that m/news ccludes em laims >$50,000 employer /AHF_study plo and c .y pdf s offeri er contri apitated sng a C erbutio vices. D nHP i s to HSAs. ncreased from Premiums do less tha nn o 5 t inclu percent de em inployer co 2005 to bet ntributions ween Enrollment by Choic Sour Sour ce: Mer ce: www.aetna.c cer. e of Plan om/news.................................................................................................. /AHF_study.pdf .............................. 9 878, Washington, DC 20005. Editor, Dallas L. Salisbury, Employee Benefit Research Institute – Education and Research Fund, ________. "Sources of Coverage and Characteristics of the Uninsured: Analysis of the March 2009 Current Population Figure 13, Projected Trend, CIGNA Choice Fund vs. Traditional Plans ......................................................... 15 3 on small In eac more like A number o h year thbusin ly th f s san traditional tince t eudies sses, with hhave e introduction o en be plan rollees co en con enrol duct fl th ees ntinu e e d to use i CDHP, costs in in th ously enroll e past fe nforma ed w years t tcreased faster ion pr from March ior to hat joining th 2 have e for t 001 to h xe amine Jun e CDH non-C e d 20 P D the im 05. , but HP Th groups over pact o e a ti u th th fme, the CDHPs on an for ors used r the diff the CD er egr ence e HP use of ssion by receive experienc 1100 13 200 d9): . Stre e Wilson et d projected 207 et NW, 9 -209 al. Sui 2. PPO (2 t e 8 00 78, Washingto cost growth that was 9) examined 1 n, DC 20005. 1 HEDIS higher meas Managing Editor than ures (t act he H ual , e gr S al towth i ephen thcare E nBlake th ffectiv e C ly, Employee Be DHP. eness Data In year an nefit Re two, actua d Information search l cost Set) survey foun 10 mi 9 llion peo d tp hat 4 le wer 4 e perce in an nt HSA-e of larg ligi e em ble p pllan, u oyers wer p from e e8 xpecte million d to in off 20e 0r an H 9 and RA 6.1by 2 milli004. on in A 2008. 2004 E s nrollment urvey of mos in HtSA- ly to HRAs, as those are notional accounts and not funded. This section shows premium levels by plan type and growth 12–15 percent by 2009. Growth in offer rates can be seen across all firm sizes. Recently, the percentage of small firms Premiums ...................................................................................................................... See www.towerswatson.com/press/1895 (last accessed July 2010). ........................................... 11 th Survey." EBRI Issue Brief, no. 334 (Employee Benefit Research Institute), September 2009b. EBRI’s work advances knowledge and understanding of employee benefits and their analysis and f Sedj groups Analysis of o plan Institute – Ed health type o a care services. The studies . nd In was Cox th fucation a fer rate cha o e firs ( les und that sw 200 s pronou t year, co 9) took a nd Research Fund, 1100 13 nnc ges between itching to a s ed di ts declin ffer (Hiagre bbar ent ed hi e t appr 2005 a d 4 , gh-dedu h Gree at us perce oach from ne ne o d 2009 nt for ctibl and Stre f prev e h T the CD et us masks important variation e entive s NW, Su other HP grou alth ler 2 plan 0 studies. 0 ite 878, Washing erv 8ps ). ha ice , an d no im s did d 1 Th 1 not ey perc pact o evaluat chan ton, ent th nDC 20005. at has occur ge fbreast, cerv o er non d a (upwar n -educat CDHP 8) d or red Owner: F ica dow igroups o l, or color durin nal nwar program ug l l Name: t (Fh d ig e e ) a ctal ure s a 13). large employers foun from an increases NCQA-accredited h for the CDHP d that were e more than alth slightly plan below in two-fift 2006 the hs of res for C projecte DHP pd co ondent enrost incr llees s repo and al ease, rted t whi l other hlat th e in y enro ey ear lle were ei four, act es. Tth he stu er v ual a ed ry likely n y looked at d projected co (8 pe per rcent) sst ons eligi Figure 14, Projected Medi ble plans grew by 25 pe cal Cost rcent in 201 s, Aetna Health Fund vs. Traditi 0 after growing 33 percent in 200 onal Plans— 9 and 200 Full Repl 8. acement Plans ..... 17 that rates over tim offered a CDHP decli e from a num ned ber o whifl e larger fi different sources. rms continu ed to add a CDHP as an option. Enrollment by Firm Size importance to the nation’s economy among policymakers, the news media, and the public. It Employee Benefit Research Institute – Education and Research Fund. 9) Known Bondholders, Mortgagees, and Other Security Standardizing Results ......................................................................................................................................... 14 Tollen, Laura A., Murray N. Ross, and Stephen Poor. "Risk Segmentation Related to the Offering of a Consumer- cancer scre targete In year 200 10 result of 5 -2d two, 0 the at 09 inc eni period. Whe C costs increased 5.2 percent D n reasing ge g. HP. Th Concer e stu neri n examini dn yc dru ing also fo how gng use am und CDHP the th for the CDHP entir at enrol ong C s affect e em DlHP pr ees m ploy escr enr grou ment-based ay ha o ipti llees on p a on d ve substituted fully cov ndr 1 ug e ye 1 m .7 uarket, what ha perc s ae r after , stu ent d en iefor t s f rollin oh un e non d e g in dbeen red sc th th a -CDH t stea ove e CDH reening P rdy gro al gP l u roup. . T tests, such as fecal sew h of th i e In CDHP b the n ra o nfd t fer rates -hird name with growth dia w betes, ere e asthma, depr qual. ession, cardiovascular disease, low-back pain, and persons taking persistent medications for or s See omewhat www.ahipresearch.org/p likely (35 percent) dfs/2009hsace to offer an HSA- nsus.pdf elig for the most recent AHIP HSA cens ible plan in 2005 (Mercer 2004). T us (last accessed he same survey fou July 20 nd10 tha ). t Holders Owning or Holding 1 Percent or More o does this b f Total A y co monducting unt of Bond and p s, Mor ublishing policy re tgages or Other Sec sear urich, analysis, ties: None. 10) T and aspecial reports on x Status (For Fronstin, Paul, and Sara R. Collins. "Findings From the 2007 EBRI/Commonwealth Fund Consumerism in Health What we do Despite the fact that large firms are much more likely than small firms to offer a CDHP, workers in large firms are much Figure 15, Projected Trend, Aetna Health Fund vs As long as the CDHP population continues to grow, resea . Traditional Plans—F rch that examines p ull R oint- epl in- acement Plans time estimates, or .................. does not con 17 trol Roll of Risk Selection .......................................................................................................................................... 16 occult blood test, for tests sub enrolle year, costs inc appe prescript D ars ires w e to h c ion ted hdr a o He ve s reased ugs receive alth lowe fell Pd and 5.9 per lan d th i:n A e th mos e C d ere cent a ucationa js ect to t firm s ewas S for th tu s d the iz y o o l out e C me e categor deductible. f H D reach offs HP uma et group an n ies wer from i a I . n e Note that B c m ." etwee nc d 11.3 percent oH re like reas ealn th Servic ed the study 20 ly to us 08 e o and have convert es Research f for t gene 20 do09, h es not ric e the non-C dru e perc d to lo appe 3 g9 sD , no. , althou HP enta ar to wer-cost group. 4 (Au ge o hav gh s g f A e small f o ust 20 controll me enro gene nd in ric a 04): th irms (t ed fo llees e l tern fourt hree– r sative th oppe d Nearly 8 million people had coverage through the employment-based market, while an additional 2 million had it comp Figure leti8 shows p on by nonprofi remiums t organi for employee- zations authorized only cove to mail at n rage onpro fofr HRAs, HSAs, and non it rates) The purpose, funct-ion CDH , and nonprof Ps from 2005 it stat - us of 200thi 9 using s orga nd iza ata tion ENROLLMENT: Overall, 19.1 million, emplo or 11 yee benef percein ts issues; holding educational br t of individuals with private insura iefings for EBRI memb nce, were enroll ers, congressional and ed in a CDHP in 73 specific perc con ent were very ditions. Th likely e stu (19 dy foun perc d t ent) or hat C somewhat DHP enrolle lik es rece ely (5iv 4 percen ed hight) to o er quality o ffer suc f ch are in a plan are inas re 2006. lated to lo Anothew-back r survey Survey." EBRI Issue Brief, no. 315 (Employee Benefit Research Institute, March 2008). more like 11 ly to have a choice of plans, whereas workers in small firms that offer health coverage are typically offered for how long an individual has been in a CDHP, will likely continue to find that the CDHP population is healthier along a and the exempt status for federal income tax purposes: Has not changed during preceding 12 months: 501(c)(3). 11) Publication’s name: See 116 www.aappo.org 7 -1187. /userfiles/File/2009%2 federal agen 0CDHP%20Study/CDHP_Final_Sm.pdf cy staff, and the news media; and sponsoring public opinion survey for the 2008 report and s on employee variation i antihypertensi year, costs inc 199 workers) t UnitedHea their use of n lthc th pre dedu are, w ve medication, escription reased hat offered a hich ctibl 6.5 per dr acquired D e lue g CDHP vel amon compare cent s. CD for th decli HP efin g d enr n e C enr iwit ty ed from oD Health i o h llees i llees HP enro group an n 13 perc with llees crease n 200 a h in4 d ent to d 10.9 percent the C ,igh re their cent de D 11 perc ducti use of HP ly re who ble le the mail ent ased f for t and did not a did not (alt hindings e hou -or non-C rec d ger h e f iv pharm the ch D ccount fo rom a f e the HP group. e ange acy opt id ve-y ucatio r em w ea as not statistic ployer co ion. An r comparison nal outr d overa each. ntributions ally ll use of its Impac through t on the in Use of Health dividual mark Care Servic et. AHIP’s anal es ......................................................................................... ysis includes workers, nonworking adults, and children. T......................... 19 he AHIP estimate 200 from the 9. More r Kaise er Fami cent data ly Fo su un ggest t dation hannu at by al 201 employer 0, 10 m surv illion peopl ey. Genera e wer lly, e in premiums an HSA-el for igible CDHPs w plan. e re lower than premiums pain, Figure 16, Projected Medi eye exams, and nephrcal Cost opathy ss, Aet creenina Health Fund vs. Tr ng for diabetes. No diff aditi eren onal Plans ce was fou ............................................... nd for medication management 18 for conducted at about the same time found that 61 percent of large employers were likely to offer an HSA in the near EBRI Employee Benefit Research Institute Issue Brief. 12) Issue Date for Circulation Data Below: August 2010. 13) Extent and only one plan. As a result, the percentage of benefit issues. workers EBRI’s Ed with covera ucation and Re ge in a C searD ch HP is Fund hi(EBRI-ERF) performs gher in small firms than i the char n la itable rge , number www.aappo of di .or mensions than g/fncDownload.cfm?newsID=140 the population not for the 20 enrolled 09 report (last accessed in a CDHP. According to t July 201 he American Academy o 0). f Actuaries, to the H Increases i signific HRA-bas of prescriptio 4ant). R eA i d n H pl u nn an w s the cases dru o e of wever, ith its glower s amon larger PP in -co w g O. It st gen hich a CDHP e firms co foun e nric a HRA nd t ntinu rolle lh ternative m w at in t eed to as availabl s with he add a certai firs edi e. t C cations were ob ye n D chronic co ar, costs associated HP as an o ndit ptserved for th ion. ions fell, The perc with or tdi e treatm hentage of fi e HRA d not i were n ent o crease rms with f10 de when perc pression, 1,000 o ent enrolle higher th e r more s met an of 10 million individuals in HSA-eligible plans represents about 6 percent of the combined employment-based and for non-CDHPs in all years except 2005, when premiums for HRA plans were higher than premiums for non-CDHPs. By Preventive Services ............................................................................................................................................. 19 future. Gree persons with Nature of ne, J Cie rcul ssica, Judit a depr tion: a. ession an Tot h H. H al Number of d asthma, ibbard, An Copi ann na es: Av D ual monitor ixon, a erage No. Copies Each Issue nd Mart ing fo in T r persons usler. "Wh Du taking persistent ring Preceding 12 Mon ich Consumers are medi ths: Rea cations, cholesterol 1,555; dy for No. Consumer Copies of- Single 21 educational, and scientific functions of the Institute. EBRI-ERF is a tax-exempt organization firms. By Figure 17, Projected Trend, Aetna 2009, 10 18 percent of workers in Health Fund vs. Tr small firms were en aditional Plans rolled in a CDHP, ........................................................... compared with 8 percent of workers in . 18 Wharam, Whil over time, e the cost J. enr Fro ank, Alison A. gro llment wth in C has been DHPs has gener Galbraith, higher for Kenally incr the P. Kl non einma e-ased CDH n, P fr Steph gro om year ue p than n B. So to y th e umerai, e C ar when DHP Den offered grou nip eac s Ross-Degna in a h ye choic ar, a en n envi , an import d Br ronment ant uce question E. . For workers that PREMIUMS: Issue Published o Generally, Neares ffered a C t to F pr iD ling em HP Date: increased iums for 1,555. CDHP b fro . Paid m s were 22 and p/ e lo or R rcent wer t eq i uested n 2 han 008 Cir premiums to culat 28 ion (1 perce for ) Paid nt in non-CDHP /Req 2uest 009 ed . s. A n Outs id ue-C mber oun ty Ma of studi il Sub es hav scriptie ons tried cholesterol, a those in the PPO. their deductibn le d ul . O cers, but n nTher e stueafte dy found that orne , the were HRA- stati the ba fina sstically signi ed ncial plan inc reali feic n zan tives of ed s t. aThe outr vin the gs of plan ar each intervent 5 perce e not nt, 4 pe suffiicient on rce did not incre n in t, 1 dr 1 pe ivin rce g a beh nse t, and med avior a 1 ication 6n d that indivi 12 dual markets. 2009, annual premiums averaged $4,274 for HRA-based plans, $4,517 for HSA-eligible plans, and $4,902 for non-CDHP management for persons with cardiovascul supported b ar disease, y contributions or HbA1c and grants. testing and low-density lipoprotein screening for Directed Health Plans?" Journal of Consumer Policy 29, no. 3 (September 2006): 247 -262. See Impact of Enrollee Knowle http://healthtrakglobal.codge of Cost m/Docs/CHS20 Sharing .................................................................................. 10.pdf (last accessed July 2010). ................ 20 Figure 15 Figure 17 Figure 6 Figure 9 large Stated on F Landon. firms (Fi orm "Canc 3526: Average N gure e 5). r Screeni on . Copi g Be es fore and Aft Each Issue Duri er Switc ng Prec Figure 13 hin edig to ng 12 M a High onths -Deduct : 1107; No ible Health . Copies o Pl f Singl an." e Iss Anu nals o e Publfis I hed Nearest nternal to that is not example, whil addressed i e early resear n the r ch on eport is HRAs fo why t und that t he cost trhend i e CDsHP ha increasin d initia g fo l favora r the CDHP ble sel gr ection, over oup, when ti th me the e cost tren CDHd is P to explain the differences in premiums. One found savings ranged from 15.5 percent to a low of –4.7 percent, with persistence, percent relativ educational o but was ue treach a to the evaluat lPPO. so matters. The first-ye ed at a pointar in cos time t di instea fferenc d of co e findintinuo ng was usly. T differe hnt from e autho rs note th that found at re by views of Cigna an the d Aet na. Predictions for strong growth in CDHPs continued. In 2005, the U.S. Treasury Department predicted that 25–30 million plans. Note that the $4,517 premium for HSA-eligible plans includes an average $688 employer contribution to the HSA persons with diabetes. Projected Trend, Aetna Health Fund vs. Filing Date: 1107. (2) Paid In-County Subscriptions Stated on Form Figure 3 3526; Average No. Copies Each Issue During Preceding 12 Months: 213; Impact of En Medication A rollee Knowl dheren Pe ce rcenta ............................................................................................................................... Pr edge of ojected ge Premium Chang of Eligib Cos Trend, t Sharing le Aetna Worker es, Health Fund s Emplo Enrolled yee-Onl in CDHP vs. y TrCo aditional ,vera by Tg ye pe of CDHP ,Plans , .......... 20 Figure 11 decreasi popul However, 13 Medicine ation ng for even amon ha d a 14 the 8, signi non no. 8 g lar f-icant Pr CDH (May g ojected e employ lP y higher gro 2008): up. T ers, offer rat 6 illn If rend, 4 th ess bur 7 - ese tren 65 CIGNA 5.d en es an ds con (Par d Choice Fund vs. ente, grow tinueth Fel on th rates v dman e a and Christia ary by lmost straight-l Trfirm si aditional Plans nze. I son 20 ine 5 npath 2009, 04). they Fo 42 percent llow-up resear are takin of g, afch ter AAPPO: The Association of Preferred Provider Organizations (AAPPO) reports that there were 23 million average savings of 4.8 percent. However, the study found that most of the savings was due to younger, healthier literature Greene, J people No e Personal communication. xplanatio woul hav essica, Judit d e n was be cov shown give eh that red by Hi n bbard, James fo e an HSA d r the ucationa di EBRI Issue B ffer -ell ma igi e F. nc b lterial a Murray, Steven M. e. e plan a riefs lone n are period d wo is in uld eff icals providing exp have eTeutsch, ctive an a on c various healt and Ma count ert evaluati by 2 rc L. 0B h 1e outcome m 0rger. . ons of emplo Simi "The I larly, i ey m a ee benefit issues and s n pact O ures. Instea 2005, f Con Forrester sumer- d, the No. Copies of Single Issue Published Nearest to Filing Date: 213. (3) Sales Through Dealers and Carriers, Street Vendors, Counter Sales, and account. Hence, premiums for HSA-eligible coverage was $3,829 for employee-only coverage in 2009. 2009 CDHP Traditional Plans Offer Rates, –Full Replacement 2009 and 2010 Predictions, Plans Among Large Employers Offering a Choice of Health Plan, 2009 by Type of Health Plan, 11 2006–2009 Premium Changes, Employee-Only Coverage, Many of Impac the t on E 14% studies mergenc reviey Room Use wed in this repor .................................................................................................. t note that it is unclear whether enrollees understand when preve ..................... 22 ntive another found that employers There is five evide some but not wit oh r seven y nce th 5,000 at em –9, ears, CDHP all 99 er 9 of t gency workers o he room u costs w higher ffe r illness burden se ill e dec d a be CDH increasin lined P o wp hen was due to tion, an g faster tha pland en 43 pe rol n p lees nt-u non-C ercent were p D deman of HP cos subj firms dect to , but t with s. CDHP also conc 2 high 0,0 costs will e 00 o r deductibles, t lude r more d still thworker at th beh below e ough s Other N peop le oenroll n-USPS Paid Di ed in a CDHP stributi in on: 20 Average No. 09, trends, as well up fro Copi m 18 es Eac millio as cr h Iss itical analy n i ue n 2 Duri 008. ng Preced ses of The r emplo ing 12 Month e yport ee benefit po does s: 0; not contain N licies an o. Copid proposals. es of a m Single Is ethodology EB suRI Notes e Publ secti ished is a on Enrollment by Choice o workers choosing CDHPs af n Plan d concluded that once typical risk- and benefit-adjustment factors were taken into account, authors sugge Our 9%st that an intervention is necessary to encourage CDHP enrollees to utilize lower-cost alternatives. Research Directe pre d H dicted that C ealth Plans On DHP Pr enro escription llment c Dru ould g Use." account Healt for 19 h Affa percent irs 27, no of the market . 4 (July/Augu in 2009 a st 2008): nd 24 percent 1111 -1119. by 2010 Selected Firm Sizes 14 Wharam, J. Frank, Bruce E. Landon, Alison A. Galbraith, Ken P. Kleinman, Stephen B. Soumerai, and Dennis Ross- by y Typ ype of Health Plan,, 2006 006–2009 009 Nearest to Filing Date: 0; (4) Other Classes Ma monthly iled Through periodical providing cu the USPS: Average No. rrent information on a variety Copies Each Issue During Pr of employ eceding 12 Month ee benefit topics. s: 0; No. services are not subject to Detailed meth 20% odological infor either t mation can be he deductible found in (Fronsti or any other n, Findings from the 2009 E form of cost sharing. Despite BRI/MGA Consumer Engagem the fact that 84 percent of ent in non-C specific offered Impact of E Parente, the research s D it. CDH HP cos Feldman an Unlike P m h tstudied ha ployer Con sould not , but small b d Xu with be generali d to u C (200 sinesses, tD ribution 6o little HP cos 8) ex cost sh z amin t wher ed to ss gro on ed t e the CDHP tends to w Health a CDHP aring to contr ing he fas impact settin tCare er th that an non g o Use an . l use o Th movin be t e -r CDH e fd Spe healt g h is al t e o P o total replac cos so evide nly optio h nding care ts, it is service nce t n onl avai ement ha h ys at CDHP a matter lable to and there d o enro workers, large busin of n fhealth or time b lle total s ees rec care co efor e pived e en th di sts for os h ng e igher e sses and Impac it is uncle t on Qu 20% ar how it ality ............................................................................................................. arrived at the 23 million estimate; it presents data from Mercer in its 2009 report ................................... 22 but does not Growth in premiums varies both by type of plan and over time. Growth rates for the premiums presented in Figure 8 CDHPs saved only 1.5 percent. There is strong evidence that initially CDHP enrollees will be healthier than non-CDHP (or about 42 30% million peop 8.0% le). 11.7% Actual Spending When workers 50% are offered a choice of CDHP they are more likely to choose an HRA over an HSA. Figure 6 shows that Copies of Single Issue Published 17.8% Nearest to Filing Date: 8.0% 0; c. Total Paid and/or Requested Circulation [Sum of 15b. (1), (2), (3), and (4)] EBRI’s Pension Investment Report provides detailed fin 23 ancial information on the universe of 11.3% Health Care Su Degnam. 12%"Emerge rvey 2009). ncy Department Use and Subsequent Hospitalizations Among Members of a High-Deductible publications 11.0% HSA-eligible 45% plans provided first-dollar coverage for preventive services in 2007, 57 percent of CDHP enrol 47% lees Chen, L Hibbar costs are com (Feldma four tend to of quality employer d care th e , Ju nvin, a , Par fer dit 8% tp h s. Examini h e n an mem arabl nte H., Jessica e C d Gartn D and Chris e HP a abe gers o r ain. lng on (2010) Gree gside full tfianson 2007). other replaceme ne, other exami types and 2009 Predicted in av nMartin ed a ailabl n of plans i As th t pl dher ans contr Tusler. e o 2008 e e ch p nce t n tions ar ara "Does En e oo such as a ct ls mainte s 2009 Actual relate eristics of t for arollm n nd to a h y e ancfe ent i e l fa h e odr le CDHP po cts of th maint w- 2010 Predicted in ugs using 33 employe nback a CDHP difpain, fenan erpulation become e Stimulat n eye 2009 ce organizat t types exams e of Cos rs who individuals c , a 10.9% io t-Effe nd n (HMO more like the nep a ctive Util dopt hropat ) a heoosi n d a d ihy zn ation?" ful g t l he cite a source for the data in its 2008 report. In the 2009, AAPPO refers to Mercer’s estimate that CDHP enrollment Only one enrolle are show es, but study was fo n in Fig that over t ure 9. I un n d t ime 2006, h the at e pr CDHP xamine emium po d s for HSA the im pulation pact t has -elig hia a b signi tle em pla ploy fns incr icantly er co h eased ntributio igher17.8 illness burden. n p s to ercthe acco ent, whil unt e no had on total n-CDHP premi health ums Average No. Copies Each Issu Impact of Employer Contri e During Preceding 12 Mon butions on Health Care Us ths: 1320; No e and Spen . Co 7.2% pies of Singl ding .............................................................. e Issue Published Nearest to Filing Date: 1320. d.. 22 HRA enrollment averages 27 percent 27% in a choice environ HRA ment, wherea HSA-Eligible s HSA enrol Non-CDHP 16.2% lment averages 16 percent. Workers defined benefit, defined contribution, and 401(k) plans. EBRI Fundamentals of Employee 7.3% Projected Spending on 45% Health Plan." Journal of the American Medical Association 297, no. 10 (March 2007): 1093 -1102. reported that their deductible applied to all medical care HRA in 2007 (Fro HSA-nstin an Eligible d Collins 2008) and this has remained at re popul 15 CDHP over pref s Frcee Dist p reenin lace erre ation m rid g but eprovider for n tra wit it CD on diab h d by M traditional itional HP etes organ ai in l (Samp 20 covera . No 06 izati c l. es, c dif o on ( ge t D verage, fa o ere ta f mpli PPO hat mi nce rment om 20 the ). was ght ary, and ot a foun 05 vexist erage and d when her f cost of for m 200r6 ee) of e we dication : (1) Out f CDHPs ering re u multi sed and were mana siwill de-C p in o le gement unt crease, brin plans. y as St compar for Th ated p e st gi on Form 3526: Average No. Copi eng it ed rs udy ons with en more foun withd mi in de rol li lpres ee x ne e ex d r with sion a p ee sults on ri the end nce av a es Ea from 4 s erage costs. thma, ch 7 This report su accounte Medical d45% for Care mmarizes 9 percent Research of wha t and h t is known a e market. Review 65 T bo out CDHPs. , der no. 4 ive a (An ug es It us timate that exam t 2008 in ): 43 es tr 2 7ends in 3 - million 449. offer peopl raetes and enro were enrolled in llment. It a CDH look P wh s at en increased 12.7 percent, and premiums for HRA-based pl Benefit Programs offers a straightforward, b ans decreased 5.3 asic exp percent. lanation of HRA prem emploium yee b s increase enefit programs in d by spending. Lo Sasso, Helmchen, and Kaestner (2010) used Traditional Plan data from an insurer that offered mostly HRA plans in the See http://newsroom.cigna.com/images/56/1209_CIGNA%20ChoiceFund_Study.pdf 43% for the 2009 stud 43% 43% y, Conc might lus be more likely to cho ion .................................................................................................................... ose an HRA over an HSA 7.7% because they do not have to contribut ........................................... 23 e their own money to the 10% Issue During Preceding 12 Months: 144; No. Copies of Single Issue Publ 42% ished Nearest to Filing Date: 144; (2) In-County as Stated on Form The Cigna stu 40% 15%dy raises a number of other questions. First, the study uses data from 425,000 HMO and PPO enrollees. 25% 15% 7% the private and public sectors. The EBRI Databook on Employee Benefits is a statistical 57 IMPACT percent t OF CD hroH ugh Ps ON P 2009REVENTI (Fronstin 2 VE SER 009a). VI It has CES: The st also be udies en fo agre und that e that use o patient 41% 14.7% f know preventive serv ledge of cost s ices did not haring declin 7.0% change ed with employers cost dif Two o annual fere of fnces monito t tra he d wit itio fo in premiums ur em h ring for nal traditional covera ployers perso bet ge. cstudied e o Furthe n w verage. s taking persi een CDH rmore, distinctions in use xperi The Ps ence a re may s nd tent medicati oth d ae dec be r sel tyre pes e ase in ction ons, of ins cholester of total co issues info uranc r ma not controll ests, while , and dis otion on l mana cos geme c two us ed s te a for in experienc nt for snd the drivers qual the pe study as the ity by rsons with ed a o n fplan incr the premium type car ease i tradit d may iova n t io o scular not nal tal be http://newsroom.cigna.com CDHP enrollment accounted for /im 39.1% ages/56/825638_ChoiceFund_Study.pdf 9 percent of the market, 13.3% AAPPO woul for the 2008 stud d have to assu 7.3%me that y, and the market included 255 small grou 6.2 percent i p m n arket. 2007 and The study 14.7 perc foun ent d tha in 20 t for 08 but each then addi HRA HRA fe tional ll 4.HSA HSA 3 dollar perce -Eligible Eligible c nt i ontribut n 2Non Non 009. -e CDH CDH d by Prem P P the em iums for H ployer SA- into the account, total eligible plans HRA, whereas the employer may choose to not contribute to the workers’ HSA. 3526: Average No. Copies Each Issue During Preceding 12 Months: 41; No. Copies of Single Issue Published Nearest to Filing Date: 41. (3) Wilson, Amy R., et al. "Comparing Quality of Care Between a Consumer-Directed Health Plan and a Traditional Plan: An References .............................................................................................................................................................. 24 39% reference work on employee ben 5.9% efit programs and work force-related issues. www.ebri.org Jaffe, Yet th While th Jim. e ch e ove 40% art t "Executive rh all of at compar ferSumm rate es may have ary." In CDHP a Pau nd non pea l Fronstin, ed., ked, i -CDHP ncreases costs is labele C in o onsumer-D ffer rat d “Proje es rivhave stalled en Hea cted Costs.” I lth Ben in some areas. efits: A Co t is unclear ntin ho uing Evolution The KFF survey does w projected c ? osts (upwar the com d or plex do ity of cost sha wnward) as a rin result of the C g (Marquis, 19D 83; HP. Ree d et al. 2008). The three studies examined in the previous section coverage a goo http://cigna.te costs. diseasd e, or in enro dicat Hbko llees h A1c tes group.com/im r of dif ad the tfin erg a enc n option to ages/56/CIGNA_CDHP_Study. e d lo s in w- be dens havior enro ity ll in , as lipoprote the hea CDH lth in s pla P c rpdf ns but c eenin have start for the 200 hg ose not for per ed to mak 7 study (last ac to enroll. sons with e i dia The nfo b employ rmation avail cessed etes. July 20 ers maay or may 10 ble to all ). covered not all dif million ferenpeo ces. ple. Th How e literatur ever, a e o ccordin n CDHPs’ im g to EB pact on RI estimates o use of prevent f Census data, ive serv the ices, medi combin cat ed em ion aploym dheree nce nt-based an , and quality o d nongrou f carep increase Other Classes d faMa ster tha iled Throug n oth h the er premiums USPS: Average No. in 2006. C I opines 2 Ea 00c7 h, Iss prem ue Diums for uring Prec HSA-e eding 12 M ligibole nt p hsl:ans incr 0; No. Co eased pies o 10. f Singl 1 perce e Issue nt Published spending increased $1.2 Ac 0tual Spending , with the entire amount spent on outpatient services and prescription drugs. In contrast, 8% Analysis of HEDIS Measures Related to Management of Chronic Diseases." Population Health Management 12, no. 35% 12.7% Endnotes ...................................................................................................................... ............................................ 26 differ not find an from act inc 6%u rease in al experien offer ce. Seco rates among fi nd, Cigna exclu rms withd three es all cl -199 aims a work bove ers bet $50,0 wee 00 n and 200 capitate 8 and 20 d servi 09, bu ces from t Mercer sho its study. ws an Nearest Washin to Filigton, ng Date: DC: Employ 0. e. Free Distr ee Ben ibution O efit Resea utside the Ma rch Institut il (Carriers of o e, 2002. ther mea ns): Average No. Copies Each Issue During Preceding 12 20% on the impact of CDHPs on use of preventi9.4% ve services did not find an increase in use when those services were not have lives, regardl is summarized, as are other been par ess of the type t of UnitedHea of studies. lthcare, as health pla all n a person of the aut has. hors wer e affiliated with the insurer. The study tried to limit the Enrollment markets cover mae y be d ab driv out 17 en 7 by million the employee individua share ls under and lev 10.1% age 6 el of 5 in the 200 pr 8 em (Fronstin ium. Accor 2009d ). If ing to the data po from pulation insur Mercer, on ed under out-of-pocket compared wit spending h 13.3 perc was ent not among non affected -C by the amo DHPs. Similar unt lthat the em y, in 2008, pr ployer contribut emiums for HSA-eli ed to the acco gible plan unt. s increased 2.6 per- 16 20% 2 (Apr35% il 2009): 61 -67. Contact EBRI Publications, (202) 659-0670; fax publication orders to (202) 775-6312. Months: 0; No. 10% 10% Copies of Single Issue Published Nearest to Filing Date: 7.8% 0. f. Total Free Distribution (Sum of 15d. And 15e.): Average No. See Exhibit 7.26 in http://ehbs.kff.org/pdf/2009/7936.pdf (last accessed July 2010). IMPACT OF CDHPs ON ME 8.2% DICATION ADHERENCE: The studies found that overall use of brand-name prescription drugs It is unc A number o Most of the research to increase from 8 learf fr in om the stu de percent pendent date has foc to 15 d studies y if epercent xclu have du ins g th ed amo also tried to o ese claims c n in ng firms with 10 dividuals exh pl i aain th n HRA- nge -s the 49 e bas dif worker d fere e ifferences in costs an d n plans s, and ces in . Little s pr an i emi ncr uy ease from ms bet stematic research has d cost trend wee 14 n CDHPs an percent to s betwee been d no n CD 18 n- percent HPs Projected Spending on subject to the deductible. Just as important, the studies did not find a decline in use of preventive services. Given the analysis to people with asthma, cardiac conditions, diabetes, epilepsy, hypertension, cholesterol, rheumatoid arthritis, average, Medicare em and plMedicai oyers that o d wer ffer a C e incluD de HP d in th price it e “mark preferent et,” th iall ere y as compar would be ed with 255 millio the other pla n individuals n o with ptions. coverage, Employ but ers ar the e cent compared with 6% 5.6 percent among non-CDHPs. In 2009, HSA-eligible premi 7.7% ums increased slightly faster than non- Subscriptions to EBRI Issue Briefs are included as part of EBRI membership, or as part of a Copies Each Issu 30% e During Preceding 12 Months: 185; No. Copies of Single Issue Published Nearest to Filing Date: 185. g. Total Distribution Traditional Plan Lo Sasso, Anthony T., Lorens A. Helmchen, and Robert Kaestner. "The Effects of Consumer-Directed Hea 6.5% lth Plans on 5% fell and, Orders/ while there was some offset from increased use of generic drugs, some enrollees stopped their use of and among firms with 50 CDHPs. Actu conducte non-CDH d ona P HSA-eli ries at Mi s. According to Employ - g199 ible llima workers. In contrast, Mercer shows slig en nrollees. studiedWh six ee ilBene e e HRAs an mployers fit Resear d H with SA-eli ch In roug stitut ghly ible225, pla e es ht d n 0 timates from e s look a 00 clin workers, es in lot al the CDHP the 3 ike, the 0,00 200 0 offer ra o 6 M diff f weere h dic om tes among fir n al Expen ces are were enroll sign diture m if ed icant Pane s with in a l 4.9% 16% complex 17 The authors r (Sum of 15c ities o . And 15f efport t CDH .): Average No. Copi P h cost s at the h insurer aring,$199 annual sub studi es was u Eace hs may ne niqu Issue e Du in scription that rin ed to g P i rec n control to divi edEBR indual g 12 M I Notes for t cont ont hhs ributions e e and : 1505; ffect EBR 5.9% of I Issue Brie No to th tim . Copi e HRA e in esfs. the ofIn Si wer plan a dividual ngle e al Issue P lowed, even t s cop a pro iu es bli x a sry for hed Neares e avail hough ablet t a o and thyroid conditions. These are all chronic conditions, which could mean everyone examined in the CDHP reaches more like 9 percent l of y no wt to re orkers with quire an a CDHP shou y premium co ld not take ntribution into in a a CDHP ccount th than e Me in an HMO dicare an or d Me PPdicai O. Pdayroll popul deductio ations as ns are those lower CDHP premiu 30%ms, increasing 3.5 percent and 2.8 percent, respectively. The most recent release can be found at www.aetna.com/news/AHF_study.pdf (last accessed April 2010). Impact on Use of Health Care Services 5.6% CDHP Offer Rates 19 28% 28% 6.8% Health Care Spending." The Journal of Risk and Insuran 5.2% ce 77, no. 1 (March 2010): 85 -103. prescript Filing Date: ion 1505. drugs. C h. Copi D es HP not en Drollees i istributed: Av ncreas erage No ed th.eir Co use o pies Eafch Issue Dur the mail-oirder pharm ng Preceding 12 Month acy option. Overal s: 50; No. Copi l uses e of of Si prescri ngle Issue ption Survey, only 1,00 CDHP. enough to 0 -4, Th 999, war e st 0.5 percent 10,0 rant sepa udy 00 foun -19,999, an rate of d tha adults a analyses of th t actual d with prepa 20,000 ges savings ranged 18 - e impact of th or more, a y 64 me incurr nt for $25 each ed from nd $50, e pl a large i a h ans. Also, most of the rese 00 (f igh or printed 0 or m n of 15.5 percent creas ore in ecopie in the offer he s). alth c Change of Address: to a are claims r low of ate amon arch to -4. tha dat g 7 fir percent. tEBRI, 1100 13th St. e year, m has s with focuse but t Average 5,000 ho d son e - 15% 7.6% knowle key feat dge ure of (al 4% bene so noted in fits, with ththe e e paper xpectatio ) of HRAs is that n that time individua in the plan ls are shoul not abl d increase k e to contr noiw bute to th ledge of cost sharin e account. It g. T is hu en clear the deductible each year, which changes the impact o 6.2% f the deductible on behavior. The study found that utilization of for work populations i ers choosing a 25%n large part ar CDH e not P over eligibl an HM e fo O or PPO. r CDHPs. For example, with respect to employee-only coverage, the average Subscriptions 5% There There are ma have be 5%ny surveys tha en a number of studi t track th es con e perd centage of em ucted in the past fe ployers of w ye feri ars that ng a CDHP have pl exa an m —either ined the as the impact that C only health DHP s have Published Neares 4%t to Filing Date: 50. i. Total (Sum of 15g. And 15h.): Average No. Copies Each Issue During Preceding 12 Months: 1,555; 4.0% NW, Suite 878, Washington, DC, 20005-4051, (202) 659-0670; fax number, (202) 775-6312; 18 6.7% drugs among CDHP enrollees with certain chronic conditions fell, or did not increase when enrollees 3.5% met their 9,99 claims accounted saving plan desi 9, s was wher gn an e i 4.8 percent. Howe td has increase for a igno bout dred fro 14 m the im 28 perc ver, pent o pact o the ercent study fo f ftotal claim to 42 the consum 24% p und that ercent costs. er-driven between most of the HSA-e accoun 2008 and 2009. ligib sa let on use vings w plans hav as due of he eY se talth car t, KFF sho atutory maximum out-o to facte that servi ws an ov yces and overal o4.3% unger, erall he inc f-pocket alth rease l ier 25% Similar tr See www.uniprise.com ends can be seen /about/media/dox/ with respect toCDHvsPPOS premiums tfor udyResultsBrochure. family coverage. I pdfn (last accessed each year durJuly 20 ing 200 10 5 - ).20 09, premiums studies how this was were a possible. lso limite The d to plans th authors also n at were o HRA-base te that they d. were not HSA-based pl able to separate employee contr ans may have a different efifbutions ect on use o from f prescription drugs decreased in both types of plans, but decline Ac Actual tual Spending Spending d more for the CDHP population. 7 This raises a side 22 8 premium No. Copies was of Singl $64 e Is /month sue Publ in ished Neares the CDHP a t tond $1 Filing D 10 at/month e: 1,555. in the j. Perc PPO ent P in aid 2 and/o 009 (Fi r Reques gure 7 ted Ci ). Furthermor rculation: Average No e, on aver . Coage, pies E the ach Marquis, M. Susan. "Consumers' kno e-m wale il: dge a subscriptions@ebri.o bout their healtrg h i nsura Membe nce cover rship Information: age." Health Ca Inquiries reg re Financing R arding EBRI eview 5, on use of health care services. Th ese studies are summarized below and are grouped by type of service studied. coverage option or as one among other options. The annual Kaiser Family Foundation (KFF) survey and the Mercer in deductible. offer rates among firms with 1,000 O 2%ne study found that the fi or more nancial i work ncent ers, iveincre s of th asi e ng plan fro a m re not 22 pe suffi rcent cie in 2 nt in 008 drivi to n28 g behavior, a percent in 2 nd t 009 h. at workers choos limits. In spending. 2 I0n1dividual 0 e CDHPs , the max contri an imu d butions to HSAs conclud m out-oed f-pocket limit that and em once typical was ployer $5 risk- an ,950 contributions for d in ben divi efit-a dual to both HSAs d coverage justment factors and $ and HR 11, were t As 900 may for fam aken i 2.8% affec ntily cov to acco the ue se unt, rage. of Issue During Pre CD 20% 20% MR: ceding 12 Mon According to ths: 88% enroll ; No. ment estimat Copies of Siengl s from th e Issue Pe Co ublished Neares nsumer Dtr iven to Fili Market ng Date: Repor 88%. 1 t (C 6. P DMR), ublicati 1 on 1 of .4 S mill tatem ion ent of prevent employer for HRAi-ve ser base cont d pla v ributions ices. ns an in d HS the data A-eligible set. plan Thus, it is s were below uncle ar premiums if the result for s from this non-CDHPs (Fi study can gure 1 be 0). gen Groew raliz th rat ed to CD es for HPs, question as to why utilization would drop in the traditional plan, which was not addressed in the paper. It terms of the portion of the premium 20% 20% paid by work membership and/or contributions to EBRI-ERF ers is l 20% 20% ower in the CDHP than in the HMO 2.6% should be directed to EBRI President/ASEC or PPO. Workers paid an average of 19 no. 1 (Fal 3%l 1983): 65 -80. survey are 10% perhaps the two 19% most well-known. Both survPr ey ojec s are ted Spending nation on ally representative. The K 9% FF survey examines See www.mill 20% iman.com/expertise/healthcare/publications 12 /rr/pdfs/consumer-driven-impact-studyRR-04-01-08.pdf (last 13 Ownership Publication: Will be printed in the August 2010 issue of this publication. 14) Signature and Title of Editor, Publisher, Business educational outreach also matters. CDHPs saved In contrast, health care services. 41 percent only 1.5 Furth p of H ercent. eM rmore, accou O enroll ees, n14 t bala perc nces ma ent of PPO en y have a rollees, and 19 n effect as wepercent of poi ll: Individuals m nt-of-service plan ay use health car enrollees e individuals were in an HSA-eligible pla Chairman Dallas n by early 2 Salisbur 010. A y at the nother above 7.7addr milless, ( ion w 202) 659-0670; ere enrolled in H e-mail: salisbur RA-based y@ebri.org plans. changes in family premiums are shown in Figure 11. Between 2006 -2008, premiums for HSA-eligible plans increased especially given the complicated plan design. For instanc Te raditional Plan , inpatient stays and outpatient surgery were not main findings, 0% after enrolling in the CDHP individuals became less likely to refill drugs for cardiac conditions and 20 percent of the premium in the CDHP, 23 percent of the premium in the HMO, and 24 percent of the premium in the 0% Manager, or Owner: Dallas Salisbury, editor; Employee Benefit Research Institute, publisher; Stephen Blakely, managing editor. Date: reviewed July 2010). offer rates for employers wit 16% h three -199 emp 16 loyees, 200 -999 employees, and 1,000 or more employees. Mercer does When it come 0%s to the type of CDHP offered, by 2009, employers were more likely to offer an HSA than an HRA across Preventive Services 13.2% 15% 2006 2007 2008 2009 did not services di have fferaenntly, out-o depen f-pock die nt limit g on ho inw m 200u 9ch money . Hence, is cost sharin being contri g may buted to differ su the acco bstant unt, especially ially for very relative high users of to the h ealth Overall, CDMR finds that 19 million people were enrolled in HRAs or HSA-eligible plans as of January 2010, up from reimbursa less than pre ble from the accou miums for non 1st year-CDHPs. nt, nor were 2nd y they subject ear to the deducti 3rd year ble: There was 4th year a separate ho 5th y spital/sur ear gery Mercer. cholesterol. 08/13/2010. Surv T ey on hey ha Hed alpoore th Savi r dru ngs A g com ccounts: Summary pliance for asthm of Results. a, cardiac, an New York: d cholesterol, Mercer Human and terminat Resoe urces Consulti d the drug sun pply g, PPO in 2009. M edication Adher 2% ence 15% 1st year 2nd year 3rd year 4th year not collect data for the smallest emp Editorial Board: Dallas L. Salisbury, publisher loyers ; Stephen Blakely (those with fewe , editor.r t Any han views 10 workers), but h expressed in this publicat as detai ion and th led da ose o ta for t f the author he larger s should NEED FOR FURTHER RESEARCH: Despite the growing body of evidence on the effect of CDHPs on cost and quality, all firm sizes. Overall, 2 percent of employers offered an HRA while 10 percent offered an HSA (Figure 2). Even among care servic 20 Parente, deductible; a Feldman an es m by plan ty ounts rolle d Xu pe. d (200 over; an Ultimately, u 8) exd amin port ed nability o derstanding h four employers f the ao ccount. w hi that a gh-cost c Dd eopted a spitle the aims affect ov f gro ull re wpl inag cement erall co body oCDHP. fst evide diffe T nce on rences is he study the impo e ex ffamined ertant, ct of 15.1 million in January 2009. The CDMR estimates are about 10 percent larger than the AHIP estimates for HSA- 5% Roll of Risk deductible. Furthermore, Selection prescription drugs used to treat chronic conditions were not reimbursable from the account, earlier See not be 200 than www.ehealthinsurance.com/content/Re 4. ascribed to the officers, traditional plan patients. trustees, T meh me bers, or authors’ portNew/0215 other sponsors of the E greate052004HSA1st st concernm is ploye poor complian YrRev.pdf e Benefit Research (lastce w reviewed Institute, the EBRI Educ ith chJuly 201 olesterol me 0). dicati ation and ons. 12.3% 12.3% -2% This section reviews five studies have examined the96 9 impact of .6% % moving to a CDHP on adherence to medication regimens. there employers are m ban y the following sizes: 10 y unanswered questions abo -49, 50 ut these pl -199, 20ans 0 -4 . 99, 50 Most of the 0 -999, 1,00 research to 0 -4,999, date 5,00 has 0 - focused on HRA- 9,999,-4 10,0 .3% 00 -b 19,9 ased 99 , jumbo employ 10% 10% ers, 20 percent offered an HRA and 33 percent offered an HSA. As will be discussed below, worker There was much more volatility in premiums for HRA-based plans. They increased nearly 40 percent in 2006. The es the im CDHPs on I ce pecial rtResear ifypact o th ly w at ch Fund, cost and quality, t all -5he % f in moving to n cos fo or rmat their t s ion harin staffs. f a C urnish g Nothin D face hHP on e ere d on g her d are m tby i of his e fo in is to be co fice ndiv any rm i visits for pr iduals unans s truenstr an with were ued as an attem d co ev hi mplet d entive c g questions. h cos e: Ali p t claims t to aid or c are, ia Wi u llis s e of co , hi varies Co nder mmu the adoption by lonoscopy, screen nic pla ation nstype. As of a so nc yiat pending le e. ings for cerv Date: gislat 08/1ion, 3/20 r ical c 10. egulation, ancer, eligible enrollees. nor were t10% hey subject to the deductible. Enrollees were subject to prescription drug co-payments, which could not be Adherence wa -5 1% %s consistently and significantly lower for CDHP patients by all measures. It should be note 8.5% d that the There is strong evidence that the population enrolled in CDHPs is different from the population enrolled in more 5.8% and Fairman, 21 20,000 Sun or d more. ar and Cox Other (2 007 surveys tend ) studied t tw o be o em more ployers foc us that b ed oe n a gan of spefcering ific s an lice o HSA- f the em based ployer plan i market, s n 2006. Th uch e s as tu the dy plans. preferenc or interpretative Little s es foyr the stematic rese rule, or as type of legal, Carch has D acco HP unting, do not be actuarial, o en co conducted on rrespond r other such prof with HSA-e employer essional advice. ligib pr le e efn erences rollees. for Thw e hich ty differen pe to ces of between fer. these plans -5.3% growth See www.actuary.org/pdf/health/cdhp_may09.pdf rate fell to 9.6 percent in 2007, which was low (last accessed er than the no July 20 n-CDHP 10). premium increase and higher than the and mammo Nair, Kavita V. gr, aphy. R Jinhee Park, Pamela Wol egression analysis fwa e, Joseph s used, J. but Sas thee study en, Richar did d not appear Read Allen, an to ha d Ra ve controll hul Ganguly. "Co ed for then size sume of t r- he paid from the account. study did not control for pla 7.3% n design differences. 7.5% Variation in deductibles was not accounted for an5.6% d neither were -4% -4.0% traditional coverage, at least initially. Researchers have examined differences related to age, health status, use of 5% looked at the use of prescription drugs before and after the adoption of the HSA plan. It found that the overall use of large are signific -group or ant 0% enou small-group gh to wa market, or ar rrant separate analyses. e based on rela Also, mo tively small sa st of the research mple sizes. to date has ignored the impact of the Aetna has also been conducting a series of studies to compare the experience of its members in the HRA- and HSA- EBR 5%I/MGA: According to the 2009 EBRI/MGA Consumer Engagement in Health Care Survey, 11.2 million premium increase for HSA-eligible plans. The premium increase for HRA-based plans fell again in 25.4% 008 to less than 2.3% deductible or Driven Health employer Plans: Im cont -8.ributions pact 1% on Utilitzat to the accou ion and E nt. xWhile pendit tu hres for ese vari Chroni ables shou c Disease ld no Su t have fferers." an impact on Journal of preventive 0% 22 differences in cost sharing above the deductible. And cost sharing for traditional coverage was not controlled for. The Average Enrollment Median Enrollment health EBR care I Issu se e Brief rvices, en is register gage ed in the U. ment in S. Patent and T personal h radem ealth, ark an Office. d in IS come. SN: 0887 Tol ?13 len, Ross a 7X/90 0887 ? n13 d 17 7X/90 $ . Poor (2004) 50+.50 found that there did In 2008, employers were asked their likelihood of offering a CDHP option in 2009. The percentage of employers Nair, et al. (2009) is mentioned only in this endnote because of unanswered questions regarding the study. It examined brand-name prescription drugs fell and there was some offset from increased use of generic drugs. Furthermore, some account on the use of services and on spending. Individuals may use health care services differently depending on how eligible plans -10%with what 1s thei t yearr expected costs woul 2nd year d be had th 3rd y ey rema ear ined in a P 4th y PO. ear In Aetna’s 5th y report, separate ear adults ages 21–64, with either employment-based coverage or individually purchased insurance, were enrolled in an 1 percent, and less than the premium increase for both HSA-eligible plans and non-CDHPs. And in 2009, premiums for services that Occupation are covere al and Env d in ironm full ental M (not sue bjec dicine t to the 51, no. deduc 5 (Ma tible y 20 ), if09 worke ): 07 0 594 .7% % rs do not -603. completely understand their benefits, -10% -6% authors concl 0%ude that controlling for such information would not change the conclusions of the study. Since the impact of moving to a full replacement HRA on use and the introduction of CDHPs in 2001, the percentage of spending fo employer rs members with chro offering them has gro nic cow nditio n. Bns fo oth the r on KFF e large and the not appear to be a difference in risk profiles between employees choosing an HRA and those with more traditional reporting in 2008 0% that they were very likely to offer a CDHP in 2009 is shown in Figure 3 alongside actual offer rates for enrollees stopped their use of prescription drugs. Some CDHP enrollees increased their use of the mail-order pharmacy much money is being contributed to the account, especially relative to the deductible, amounts rolled over, and analyses are conducted for employers that offer the CDHP as an option and for those that offer the CDHP as the only HRA- or HSA-eligible plan, up from 9.8 million in 2008. This estimate represents 8.9 percent of adults ages 21–64 with HRA-based plans increased by 8.5 percent, higher than the 5.4 -5.6 percent increases seen in non-CDHPs and HSA- 2006 2007 2008 2009 they may think that Source; prevent EBRI estimates ive services based on data in are subject http://newsroom.c to th igna.c e dedu om/imactibl ges/56 e/, 12which 09_CIGNA% coul 20Ch d ioic meF pact th und_Study e us .pdfe of those services. employer in 2005. It found a 35.7 percent decrease in outpatient visits, 34.3 percent decrease in diagnostic visits, 31 percent Source: EBRI estimates based on data in www.aetna.com/news/AHF_study.pdf Source: Mer 500–999 cer. 1,000–4,999 5,000–9,999 10,000–19,999 20,000 or more Mercer s coverageurv bas eys eSour d on show that ce d : Kais emogra er Fa th milye p p F hic oundation ercenta data . alon ge of em e, but it ployers appea offeri red t ng hat those on th an HRA- or He HRA SA-eligi were h ble plaen i alth ncrea ier tshed from an those el belo ec w ting 2009. In all but one Source: firm EBRI es siz timates e cate based on data in gory (5,000 www.aetna.c -9,999), t om/news h/A e Hpercentage report F_study.pdf ing that they were very likely to offer a Excludes catastrophic claims >$50,000 and capitated services. option. The study also examined a control group of traditional plan enrollees and found that the switch rate to generic portability of the account. option. Medical costs are benchmarked to $226 per month prior to the introduction of the CDHP. Under the full private insurance (up © 2010, Emplo from 7.9 perc yee B ent einefit n 200 Research Institute 8). ?Education and Research Fund. All rights reserved. decrease in nu eligible plans. mber of prescriptions, 90 percent lower chance of having an emergency room visit, 65 percent lower chance of Source: Kaiser Family Foundation. Source: Mercer. ebri.org A research rep ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Issue Issue Issue Issue Issue Issue Issue ort from the EBRI e e e e e e e e e e e e e e e e e effffffffffffffffff • August 201 • August 201 • August 201 • August 201 • August 201 • August 201 • August 201 • August 201 • August 201 • August 201 • August 201 • August 201 • August 201 • August 201 • August 201 • August 201 • August 201 • August 201 Brief Brief Brief Brief Brief Brief Brief Brief • • • • • • • • August August August August August August August August Education and R 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 0 • No. 345 2010 2010 2010 2010 2010 2010 2010 2010 • • • • • • • • No. No. No. No. No. No. No. No. 345 345 345 345 345 345 345 345 esearch Fund © 2010 Employee Benefit Research Institute 18 10 17 13 12 15 6 8 27 24 25 14 21 20 19 26 23 16 22 11 3 4 7 9 2 5 Figure 4 a b Enrollment in HRAs and HSA -Eligible High-Deductible Health Plans, 2005–2010 h c d e f g KFF/HRET Survey AHIP AAPPO CDMR EBRI/MGA ICDC Workers Universe All All All Adults 21–64 All HRA or HSA- HRA or HSA- HRA or HSA- HRA or HSA- j Type of CDHP HSA-eligible eligible plan eligible plan eligible plan eligible plan HRA or HSA-eligible plan Employment- Employment- Employment- Employment- Employment- based and direct based and direct based and direct based and direct based and direct Employment-based Source of Insurance purchase purchase purchase purchase purchase HSA-eligible Total Total Total Total Total HRAs HSA-eligible (millions) 2005 1 4.7 2.4 – – 2006 3.2 10 6.0 3.8 2.7 1.3 1.4 2007 4.5 12.5 8.4 8.3 7.8 3.8 1.9 1.9 2008 6.1 18 11.9 9.8 10.7 5.4 2.2 3.2 2009 8 15.1 11.2 2010 10 19 (percentage) 2005 1% 3.9% 4% 2% 2% 2006 2 6% 3% 3.2 4 2 2 2007 3 7 5 6.6 4% 5 3 3 2008 3 10 7 7.9 6% 8 3 4 2009 5 9 8.9 8 3 6 2010 6 11 a Health reimbursement arrangements. b Health savings account. c America's Health Insurance Plans, www.ahipresearch.org/pdfs/hsa2010.pdf d American Association of Preferred Provider Organizations, www.aappo.org/userfiles/File/2009%20CDHP%20Study/CDHP_Final_Sm.pdf (last accessed March 2010). e Consumer Driven Market Report, personal communication, Sept. 2009. f EBRI/MGA. See Fronstin (2009). g Inside Consumer-Directed Care (not available online). h Kaiser Family Foundation/Health Research and Educational Trust, http://ehbs.kff.org/pdf/2009/7936.pdf j Consumer-driven health plans.