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A two-employer, five-year study suggests that health account plans could lead to a long-term decrease in use of outpatient care and prescription drugs, mixed effects on use of hospital care, and a temporary drop in use of cancer screening services.

A team of researchers led by Paul Fronstin, an analyst at the Employee Benefit Research Institute (EBRI), has published the health account program data in an article in Health Affairs, a health finance and health policy academic journal.

Fronstin and his colleagues conducted the study by gathering data from two large employers for a period that started Jan. 1, 2006, and ended Dec. 31, 2010.

On Jan. 1, 2007, one of the employers replaced a traditional preferred provider organization (PPO) plan with a program that included a high-deductible plan and a health savings account (HSA). The HSA program option was the employer’s only health coverage option.

The second employer — the control group employer — continued to offer a traditional moderate-deductible PPO program.

The researchers tried to match the 13,278 active workers and dependents in the first employer’s HSA program with control-group plan enrollees with similar characteristics.

The researchers then adjusted for many different variables and looked at how plan enrollees at each employer compared from 2006 through 2010 in terms of measures such as inpatient hospital admissions, inpatient hospital days, emergency department visits, outpatient care use, prescription drug fills, and use of three recommended types of cancer screening.

The cancer screening measures used were breast cancer screening for women ages 40 and older; cervical cancer screening for women ages 21 and older; and colorectal cancer screening for people ages 50 and older.

The researchers found that the HSA program enrollees clearly used less outpatient care and fewer prescription drugs from the time they entered the health account program until the end of the study period.

In 2007, for example, the typical HSA program enrollee program had about 2.7 outpatient office or clinic visits, or about half a visit fewer than the typical control-group enrollee. 

In 2010, the typical HSA program was still using about one-quarter fewer outpatient visits per year than the typical control-group enrollee.

Similarly, the typical HSA program enrollee filled about eight prescriptions in 2007, or 1.4 fewer prescriptions than researchers would have expected if the enrollee had still been in a traditional plan. In 2009 and 2010, the typical HSA program enrollee was still filling about one fewer prescription per year than a comparable traditional plan enrollee would have filled.

Measures of use of hospital care were mixed. The HSA plan enrollees were less likely to get inpatient hospital care throughout the study period. During the first two year the program was in effect, they were also less likely than the members of the control group to use the emergency room. But, in the third program year, the HSA plan enrollees were 9 percent more likely to use the emergency room. The gap widened to 13 percent in 2010.

For the HSA plan enrollees, measures of use of preventive care improved over time. The enrollees were significantly less likely to get the recommended screenings during the first program year, but significantly more likely to get the screenings during the third and fourth program year.

The researchers said they were surprised by the HSA plan enrollees’ increasing use of the emergency room and the initial lack of use of preventive screenings.

The employer that sponsored the HSA program had exempted preventive screenings from the deductible and was paying 100 percent of the cost of the screenings, the researchers said.

HSA plan enrolles may have been more likely to end up in the emergency room because they were less likely to have physician office visits and less likely to use the prescription drugs needed to control chronic conditions, the researchers said.

“However, more research is needed to better understand what may have caused the longer-term increase in [emergency department] use,” the researchers said.

The researchers suggested that the first-year drop in HSA plan enrollees’ use of cancer screenings might also be the result of the reduction in the number of outpatient care visits.

The measure also “may suggest that enrollees did not sufficiently understand their health insurance coverage,” the researchers said.

“Given these findings, employers should consider providing periodic, ongoing communications to enrollees regarding services that are exempted from the deductible,” the researchers said. “This may improve screening rates.”

Plan sponsors also should consider monitoring use of recommended preventive services, the researchers said.

The Patient Protection and Affordable Care Act (PPACA) now requires plans to offer basic preventive services, including checkups, without imposing deductibles or other cost-sharing requirements.

Policymakers should continue to support efforts to make sure that consumers can — and know they can — get high-value preventive services without paying large deductibles, the researchers said.

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