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OBJECTIVE: To test whether out‐of‐pocket costs and negotiated hospital prices for childbirth change after enrollment in high‐deductible health plans (HDHPs) and whether price effects differ in markets with more hospitals. DATA SOURCES: Administrative medical claims data from 2010 to 2014 from three large commercial insurers with plans in all U.S. states provided by the Health Care Cost Institute (HCCI). STUDY DESIGN: I identify employer groups that switched from non‐HDHPs in 1 year to HDHPs in a subsequent year. I estimate enrollees' change in out‐of‐pocket costs and negotiated hospital prices for childbirth after HDHP switch, relative to a comparison group of employers that do not switch plans. I use a triple‐difference design to estimate price changes for enrollees in markets with more hospital choices. Finally, I re‐estimate models with hospital‐fixed effects. DATA COLLECTION: From the HCCI sample, childbearing women enrolled in an employer‐sponsored plan with at least 10 people. PRINCIPAL FINDINGS: Switching to an HDHP increases out‐of‐pocket cost $227 (p

The objective of this study is to evaluate the impact of high-deductible health plans on elective surgery (tonsillectomy) in the pediatric population.Cross-sectional study.Health claims database from a third-party payer.Data were reviewed for children up to 18 years of age who underwent tonsillectomy or arm fracture repair (nonelective control) from 2016 to 2019. Incidence of surgery by health plan deductible (high, low, or government insured) and met or unmet status of deductibles were compared.A total of 10,047 tonsillectomy claims and 9903 arm fracture repair claims met inclusion and exclusion criteria. The incidence of tonsillectomy was significantly different across deductible plan types. Patients with met deductibles were more likely to undergo tonsillectomy. In patients with deductibles ≥$4000, a 1.75-fold increase in tonsillectomy was observed in those who had met their deductible as compared with those who had not. These findings were not observed in controls (nonelective arm fracture). For those with met deductibles, those with high deductibles were much more likely to undergo tonsillectomy than those with low, moderate, and government deductibles. Unmet high deductibles were least likely to undergo tonsillectomy.Health insurance plan type influences the incidence of pediatric elective surgery such as tonsillectomy but not procedures such as nonelective repair of arm fracture. High deductibles may discourage elective surgery for those deductibles that are unmet, risking inappropriate care of vulnerable pediatric patients. However, meeting the deductible may increase incidence, raising the question of overutilization.

Objectives To examine changes in carve-out financial requirements (copayments, coinsurance, use of deductibles, and out-of-pocket maxima) following the Mental Health Parity and Addiction Equity Act (MHPAEA). Data source/study setting Specialty mental health benefit design information for employer-sponsored carve-out plans from a national managed behavioral health organization's claims processing engine (2008-2013). Study design This pre-post study reports linear and logistic regression as the main analysis. Data collection/extraction methods NA. Principal findings Copayments for in-network emergency room (-$44.9, 95% CI: -78.3, -11.5; preparity mean: $56.2), outpatient services (eg, individual psychotherapy: -$7.4, 95% CI: -10.5, -4.2; preparity mean: $17.8), and out-of-network coinsurance for emergency room (-11 percentage points, 95% CI: -16.7, -5.4; preparity mean: 38.8 percent) and outpatient (eg, individual psychotherapy: -5.8 percentage points, 95% CI: -10.0, -1.6; preparity mean 41.0 percent) decreased. Probability of family OOP maxima use (29 percentage points, 95% CI: 19.3, 38.6; preparity mean: 36 percent) increased. In-network outpatient coinsurance increased (eg, individual psychotherapy: 4.5 percentage points, 95% CI: 1.1, 7.9; preparity mean: 2.7 percent), as did probability of use of family deductibles (15 percentage points, 95% CI: 6.1, 23.3; preparity mean: 38 percent). Conclusions MHPAEA was associated with increased generosity in most financial requirements observed here. However, increased use of deductibles may have reduced generosity for some patients.

Objective To study whether the negative association between enrollment in high-deductible plans and health care utilization is driven by reverse moral hazard or favorable selection, by examining adults with and without a choice of plans. Data source 2011-2016 Medical Expenditure Panel Survey Household Component data on nonelderly adults enrolled in employer-sponsored insurance. Study design Four types of plans were examined: high-deductible health plans (HDHPs), consumer-directed health plans (CDHPs), low-deductible health plans (LDHPs), and no-deductible health plans (NDHPs). Multivariate logistic regressions of various measures of health care utilization were conducted to estimate the differences in utilization across plan types among those who had a choice of plans and those who did not. Principal findings Among adults with a choice of plans, HDHP enrollees had lower levels of utilization compared with those of the NDHP enrollees for any ambulatory visit, any specialist visit, and most preventive services. Among adults without any choice of plans, the differences between HDHP enrollees and NDHP enrollees were not statistically significant. Conclusions The differences between those with and without choice of plans in the relationship between HDHP enrollment and health care utilization might possibly be explained by favorable selection.

Objectives To measure the size and timing of changes in utilization and costs for employees and dependents who had major access barriers to primary care removed, across an 8-year period (2007 to 2014). Study design and methods Retrospective observational study examining patterns of utilization and costs before and after the implementation of a worksite medical office in 2010. The worksite office offered convenient primary care services with no travel from work, essentially guaranteed same day access, and no co-pay. Trends in visit rates and costs were compared for an intervention fixed cohort group (employees and dependents) at the employer (n = 1211) with a control fixed cohort group (n = 542 162) for 6 types of visits (primary, urgent, emergency, inpatient, specialty, and other outpatient). Difference-in-differences methods assessed the significance of between-group changes in utilization and costs. Results The worksite medical office intervention group had an increase in primary care visits relative to the control group (+43% vs +4%, P

Accurate information on individuals' health service use is important for evaluating health policies and analyzing health care demand. Although register data are considered to be more reliable than survey data, little is known about the extent and effect of censoring of the expenditure distribution in register data. We exploit a recent change in the health provider remuneration system in several Swiss cantons to empirically investigate whether censoring occurs when individuals do not have to disclose their health service use below their deductible level. Applying a difference-in-differences approach, we find that between CHF 6.70 (1.7%) to CHF 9.64 (2.4%) of all health service use paid out-of-pocket are not observed (per capita per year). This effect seems to be driven by high-deductible plans where observed out-of-pocket expenditures declined by CHF 30.34 (7.6%) after the change. Although statistically significant, these effects are almost negligible in economic terms. We therefore concluded that, if anything, censoring is a very limited issue in Swiss health insurance claims data.

Patient cost-sharing change was implemented on August 1, 2007, for outpatient care in the clinic setting in Korea from copayment to coinsurance. This study aims to estimate the effect of the policy change on medical care usage and expenditure in older Koreans. By using national health insurance claims data from the Health Insurance Reimbursement Assessment Service, this study analyzed the entire 137 million claims for a total of approximately 4.1 million patients aged 60 to 69 years who had been diagnosed and/or treated for outpatient care in clinics from January 1, 2007, to December 31, 2008. Medical care usage was defined as the proportion of all beneficiaries in each group who visited clinics and the mean number of visit days per beneficiary. Medical care expenditure per visit day was expressed as total costs, reimbursed amount, and patient's out-of-pocket payment. Data on January through June of 2008 were analyzed as compared with the same months of 2007. Raw difference-in-difference and multiple regression analyses were performed. The interaction coefficients, which measured the impact of cost-sharing change, was -0.078 in model 1 and -0.039 in model 2 (P < .0001). In conclusion, a cost-sharing change from copayment to coinsurance reduced medical care usage and expenditure.

Objective Did mental health cost-sharing decrease following implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA)? Data Source Specialty mental health copayments, coinsurance, and deductibles, 2008–2013, were obtained from benefits databases for “carve-in” plans from a national commercial managed behavioral health organization. Study Design Bivariate and regression-adjusted analyses compare the probability of use and (conditional) level of cost-sharing pre- and postparity. An interaction term is added to compare differential levels of pre- and postparity cost-sharing changes for plans that were and were not already at parity pre-MHPAEA. Findings Controlling for employer/plan characteristics, MHPAEA is associated with higher intermediate care copayments ($15.9) but lower outpatient ($2.6) copayments among in-network-only plans. Among plans with in- and out-of-network benefits, MHPAEA is associated with lower inpatient ($23.2) and outpatient ($2.5) copayments, but increases in inpatient and intermediate in-network and out-of-network coinsurance (about 1 percentage point). Among the few plans not at parity pre-MHPAEA, changes in use and level of cost-sharing associated with MHPAEA were more dramatic. Conclusion Mixed evidence that MHPAEA led to more generous mental health benefits may stem from the finding that many plans were already at parity pre-MHPAEA. Future policy focus in mental health may shift to slowing growth in cost-sharing for all health services.

OBJECTIVE: To evaluate the association between employer-mandated enrollment into high-deductible health plans (HDHPs) and contraception and birth rates among reproductive-age women. DATA SOURCES/STUDY SETTING: Using data from 2002 to 2008 we examined 1559 women continuously enrolled in a Massachusetts health plan for 1 year before and after an employer-mandated switch from an HMO to a HDHP compared with 2793 matched women contemporaneously enrolled in an HMO. STUDY DESIGN: We used an individual-level interrupted time series with comparison series design to examine level and trend changes in clinician-provided contraceptives and a differences-in-differences design to assess annual birth rates. DATA COLLECTION/EXTRACTION METHODS: Employer plan and member characteristics were obtained from enrollment files. Contraception and childbirth information were extracted from pharmacy and medical claims. PRINCIPAL FINDINGS: Monthly contraception rates were 19.0-24.0 percent at baseline. Level and trend changes did not differ between groups (p = .92 and p = .36 respectively). Annual birth rates declined from 57.1/1000 to 32.7/1000 among HDHP members and from 61.9/1000 to 56.2/1000 among HMO controls a 40 percent relative reduction in odds of childbirth (odds ratio = 0.60; p = .02). CONCLUSIONS: Women who switched to HDHPs experienced a lower birth rate which might reflect strategies to avoid childbirth-related out-of-pocket costs under HDHPs. (c) Health Research and Educational Trust.

Mail order pharmacies (MOPs) dispense medications by mail to the patient's home, offering convenience and eliminating access barriers (e.g., time, mobility, transportation), the benefits of which may be compounded for patients using multiple medications (Choudhry et al. 2011). Currently, one-third of all chronic disease prescriptions in the United States are dispensed by mail (Wroblewski et al. 2005). We have previously demonstrated better adherence (Duru et al. 2010), better LDL-C control (Schmittdiel et al. 2011), and no substantive safety concerns (Schmittdiel et al. 2013) among diabetic patients using MOPs. Better adherence among those using MOPs has been reported in other studies as well (Devine, Vlahiotis, and Sundar 2010; Zhang et al. 2011; Visaria, Frazee, and Devine 2012). Compared to walk-in pharmacies, MOPs can also be cost-saving for the health plan, depending on differential wastage rates between the two delivery modes, the cost of increased drug utilization, and the size of any MOP incentives (Carroll et al. 2005; Carroll 2006; Valluri et al. 2007; Devine, Vlahiotis, and Sundar 2010). The World Health Organization recommends seeking effective and low-cost, structural (system-level) approaches to improving adherence as an alternative to the frequently expensive, individual-level interventions (Sabate 2003). Financial incentives for MOPs may represent such a system-level approach if they increase the use of MOPs and secondarily improve adherence and health outcomes. However, structural changes can simultaneously improve population-level quality metrics, while also increasing social inequalities in health access and outcomes. We have previously reported lower use of MOPs among minorities and those living in deprived neighborhoods (Duru et al. 2010). While MOP use has been increasing steadily over the past two decades (Carroll et al. 2005), underuse in vulnerable groups has been observed at Kaiser Permanente Northern California (KPNC) since MOPs were introduced in 1999 (unpublished data). For example, in 2000, the prevalence of MOP use was 11 percent in Latinos, 12 percent in African Americans and Filipinos, 20 percent in Asians, and 24 percent in Caucasians. A decade later, in 2010, MOP use grew considerably, but it still lagged substantially in minorities: 37 percent in Latinos and African Americans, 46 percent in Filipinos, 63 percent in Asians, and 65 percent in Caucasians. It remains unknown whether and how financial incentives might impact disparities in MOP use (Trinacty et al. 2009). We studied a natural experiment which included a pharmacy benefit change that increased cost sharing but promoted the use of MOPs by discounting medications (i.e., reducing the increase in out-of-pocket costs) if patients prepaid two copayments and refilled using MOPs. We evaluated the following: (1) the overall effect of rolling out the benefit change on subsequent uptake of MOPs for dispensing of cardiometabolic medications among patients with diabetes, and (2) whether the rollout's effect on MOP uptake was uniform across social strata (defined by ethnicity, educational attainment, household income, English proficiency, or health literacy).

Objective To determine whether increased cost sharing in health insurance plans induces higher levels of consumer sophistication in a non-elderly population. Study design This analysis is based on the collection of survey and demographic data collected from enrollees in the RAND health insurance experiment (HIE). During the RAND HIE, enrollees were randomly assigned to different levels of cost sharing (0, 25, 50 and 95%). Methods The study population compromises about 2000 people enrolled in the RAND HIE, between the years 1974 and 1982. Effects on health-care decision making were measured using the results of a standardized questionnaire, administered at the beginning and end of the experiment. Points of enquiry included whether or not enrollees' (i) recognized the need for second opinions (ii) questioned the effectiveness of certain therapies and (iii) researched the background/skill of their medical providers. Consumer sophistication was also measured for regular health-care consumers, as indicated by the presence of a chronic disease. Principal findings We found no statically significant changes (P

High deductible health plans (HDHPs) have become an increasingly common form of benefit design used by employers to manage health-care costs. Numerous studies have evaluated the uptake and impact of HDHPs on health-care utilization. Most studies have employed the standard difference-in-differences (DID) methodology. In this paper, we employ three alternative methodologies to evaluate a natural experiment in which a traditional health plan was fully replaced by a HDHP. We implement the standard DID and the quantile difference-in-differences (QDID) estimators to evaluate the impact of the HDHP on following six outcomes: overall cost, medical cost, pharmacy cost, outpatient visit count, inpatient visit count and emergency room visit count. We compare these results to a changes-in-changes (CIC) estimator, a generalized version of the standard (DID) estimator. We find that both the DID and CIC models yielded similar results, while the QDID model provided additional insights on the HDHP impact across different parts of the outcome distributions. Overall, introduction of HDHP had no impact on health-care costs, positive impact on the number of outpatient visits and mixed impacts on the inpatient and emergency room visit counts. The QDID estimates suggest HDHP introduction generally impacted subjects in upper percentiles (50th, 75th and 90th).

For most insurers, traditional methods of controlling health-care demand include deductibles, co-payments, stop-losses, and insurance ceilings. This paper examines the effect of the patient reimbursement method of health insurance (immediate reimbursement or later reimbursement) on individuals' health-care utilization decisions. We find that immediate reimbursement significantly increases the likelihood of patients seeking outpatient treatment in China. We also empirically explore the channels through which immediate reimbursement affects individual's incentives on health-care demand. Copyright © 2010 John Wiley & Sons, Ltd.

In 1998, Israel's national health insurance system introduced a modest co-payment for visits to specialist physicians. This study takes advantage of a natural experiment in which 15% of the population--the poor and disabled--was exempted from these co-payments. It used the micro-level panel data of three large health plans on the physician visits of 50,000 members per plan in 1997-2001. The data indicate that, following introduction of the co-payment, specialist visits increased among non-exempt members, relative to exempt members, of two health plans that together account for two-thirds of the population. This paper illustrates how, unlike the Health Insurance Experiment and other US studies of cost sharing, the structure of the co-payment in Israel may have inadvertently limited the incentive to decrease consumer demand and may have created an incentive for the health plans to increase visit rates, especially among the non-exempt members. Other countries that have implemented co-payment systems with exemptions may benefit from the Israeli experience in designing and evaluating their systems.

We estimate the causal impact of having full health insurance on healthcare expenditures. We take advantage of a unique quasi-experimental setup in which deductibles and co-payments were zero in a managed care plan and nonzero in regular insurance, until a policy change forced all individuals with an active plan to cover a minimum amount of their expenses. Using panel data and a nonlinear difference-in-differences strategy, we find a demand elasticity of about -0.14 comparing full insurance with the cost-sharing model and a significant upward shift in the likelihood to generate costs. Copyright © 2015 John WileySons, Ltd.

To evaluate the role of health plan benefit design and price on consumers' decisions to purchase health insurance in the nongroup market and their choice of plan.Administrative data from the three largest nongroup insurers in California and survey data about those insured in the nongroup market and the uninsured in California.We fit a nested logit model to examine the effects of plan characteristics on consumer choice while accounting for substitutability among certain groups of products.Product choice is quite sensitive to price. A 10 percent decrease in the price of a product would increase its market share by about 20 percent. However, a 10 percent decrease in prices of all products would only increase overall market participation by about 4 percent. Changes in the generosity of coverage will also affect product choice, but have only small effects on overall participation. A 20 percent decrease in the deductible or maximum out-of-pocket payment of all plans would increase participation by about 0.3-0.5 percent. Perceived information search costs and other nonprice barriers have substantial effects on purchase of nongroup coverage.Modest subsidies will have small effects on purchase in the nongroup market. New product designs with higher deductibles are likely to be more attractive to healthy purchasers, but the new benefit designs are likely to have only small effects on market participation. In contrast, consumer education efforts have a role to play in helping to expand coverage.

Increasing drug costs in the US have prompted employers and insurers alike to turn to higher drug copays for cost containment. The effect of rising copays on compliance with statins (HMG-CoA reductase inhibitors) treatment has received surprisingly little attention in the applied literature. This paper uses pharmacy claims data from a commercially insured adult population to determine the effect of copay change on compliance at the individual level. Fixed effect logit and Poisson regressions estimate the effect of copays on monthly likelihood of high compliance and average monthly days of supply respectively. Higher copays reduce compliance among statin users, with less compliant patients responding more strongly to copay change than compliant patients. These results suggest that specific financial incentives given to less compliant patients could improve compliance with statin treatment at a relatively low cost.

Patients in the United States are paying more for their health care, in part through additional or higher copayments. This increased cost-sharing could improve efficiency if patients reduce unnecessary use of resources, but also could result in worse health if patients avoid necessary care (Phelps 1992; Rubin and Mendelson 1995; Zweifel and Manning 2000). Currently, we have limited information on whether cost-sharing has harmful clinical effects. Studies including the RAND Health Insurance Experiment (HIE) have found that cost-sharing reduces both health care use and expenditures (O'Grady et al. 1985; Newhouse and The Insurance Experiment Group 1993; Selby, Fireman, and Swain 1996). Previous work by members of our team found that emergency department (ED) copayments reduced ED visits and expenditures, and appeared to decrease ED visits for low severity diagnoses preferentially (O'Grady et al. 1985; Selby et al. 1996). These and other studies also had limited ability to detect possible changes in unfavorable clinical events associated with ED care (i.e., adverse effects of ED cost-sharing resulting from delayed or avoided ED visits), given the large population sizes needed to assess changes in these typically rare events (Keeler et al. 1985; Lohr et al. 1986; Shapiro, Ware, and Sherbourne 1986; Lurie et al. 1989; Solanki, Schauffler, and Miller 2000; Wong et al. 2001). There is, however, substantial evidence of poor health outcomes associated with being uninsured, which represents an extreme version of cost-sharing (Weissman, Gatsonis, and Epstein 1992; Ayanian et al. 1993; Braveman et al. 1994; Blustein 1995; Baker et al. 2001; Institute of Medicine 2001; McWilliams et al. 2003). We evaluated whether the amount of cost-sharing for emergency care decreased ED visits, and whether there was any association between the cost-sharing amount and unfavorable clinical event rates within a 2.7 million member, integrated delivery system (IDS). In this manuscript, we report on the impact of the ED copayment level on ED visits, hospitalizations, ICU admissions, and deaths between 1999 and 2001 for populations with Medicare and with commercial insurance. In this natural experiment, over half of each population experienced an increase in their ED copayments on January 1, 2000, and 13–21 percent of each population experienced another increase on January 1, 2001.

Study Objective. To measure the association among prescription copayment, drug adherence, and subsequent health outcomes among patients with chronic heart failure (CHF). Design. Retrospective cohort study. Data Source. Database of a large, national health insurance plan. Patients. Patients with CHF receiving commercial and Medicare supplemental benefits. Measurements and Main Results. We estimated adherence to therapy with β-blockers or angiotensin-converting enzyme (ACE) inhibitors in 2002 by using the medication possession ratio, an estimate of the proportion of days a patient was exposed to a drug while taking a drug regimen. For 2003, we measured the annualized total cost of health care and identified hospitalizations with a diagnostic code for CHF. We used a two-stage regression approach to model the association among copayment, adherence, and patient outcomes. For patients taking ACE inhibitors, a $10 increase in copayment was associated with a 2.6% decrease in the medication possession ratio (95% confidence interval [CI] 2.0–3.1%). This change in adherence was associated with a predicted 0.8% decrease in medical costs (95% CI-4.2–2.5%) but a predicted 6.1% increase in the risk of hospitalization for CHF (95% CI 0.5–12.0%). Among patients taking β-blockers, a $10 increase in copayment was associated with a 1.8% decrease in the medication possession ratio (95% CI 1.4–2.2%). This change in adherence was associated with a predicted 2.8% decrease in medical costs (95% CI −5.9–0.1%) and a predicted 8.7% increase in the risk of hospitalization for CHF (95% CI 3.8–13.8%). Conclusion. Among patients with CHF, higher drug copayments were associated with poorer adherence. The change was relatively small and did not affect predicted total health care costs, but it was sufficient to increase the predicted risk of hospitalization for CHF.

Since 1980, many Medicaid programs have instituted, adjusted, or abolished pharmaceutical copayments or limitations on the number of prescriptions per patient (caps). Studies indicate that prescription caps can harm patients and increase Medicaid costs. However, because there is little information on how state policy makers select and evaluate such policies, in-depth telephone interviews were conducted with key informants in Medicaid programs that had recently made changes in cost-sharing policies. Among the barriers to evidence-based policy making were lack of political power, skills, and infrastructure; crisis-oriented decisions; compartmentalized budgeting; lack of advocates for disadvantaged patients; and the absence of timely research. Research was applied successfully when the interests of patient advocates and the drug industry were aligned and when Medicaid analysts were able to identify and communicate relevant research to policy makers at the time, or “teachable moment,” that policy was being changed.

During the last decade, policy makers in a large number of countries have attempted various reforms of their health care systems. Health care reform has been described as a 'global epidemic' (Klein, 1993). All health care reforms consist of very complex policy choices, some of which are examined in this article. After an introductory exploration of ideological issues, the objectives of health care reformers are considered. Three major policy objectives of health care reform are examined: cost containment; efficiency; and, equity. Three types of reform which have been advocated are also considered: public planning; market regulation; and provider-advocated reforms such as a 'basic package' with copayments and alternative means of finance. Finally, appropriate features of efficient health care reform are suggested, addressing explicit policy goals.

Dental insurance has been the fastest growing fringe benefit during the 70s. Further, it has evolved into a cost-effective means for getting more people to seek dental treatment. Early worries of the purchaser and the profession about the uninsurability of dental care have largely been solved; to this day, though, no one has developed a model to successfully deliver individual coverage. In the 80s, dental insurance is facing some significant new challenges, mainly because purchasers of care perceive the need to trim all health care costs due to the rapid escalation of medical and hospital costs. Two avenues being pursued are "alternative delivery" and a "health tax" on fringe benefits. These two cost-containment efforts significantly threaten both the form and growth of dental insurance. It is important that the profession recognize the significance of these challenges and, recognizing the causes, become involved in finding solutions that do not diminish the quality of dental care.