• Health savings accounts literature reviews

    I’m looking for health savings accounts (HSAs) and consumer directed health plan (CDHP) literature reviews (and by “literature,” I mean peer-reviewed health services and health economics papers). A few recent papers on these topics are listed below (with abstracts, or portions thereof, and excerpts). They likely cite much of the rest of the relevant literature.

    Judging from these alone, it doesn’t appear as if HSAs/CDHPs are a slam dunk for substantially lower costs, but we may not have enough experience with them yet to say this with much certainty. I haven’t seen anything that reports results on outcomes, but I’m going by abstracts alone.

    Consumer-Oriented Strategies for Improving Health Benefit Design, by Laurence Baker, Kate Bundorf, and Anne Royalty

    We found 11 published studies that provided evidence the prevalence or effects of CDHPs. Available evidence is insufficient to draw conclusions about the effects of CDHPs. Perhaps the most consistent point is that CDHPs are subject to selection bias. Evidence on the effects of CDHPs on utilization and spending was mixed and generally of limited strength. We conclude that further evidence synthesis will be most profitable after the literature has had further time to develop.

    We also found that the number of studies that appear likely to produce reviewable evidence about the impacts of tiered networks on utilization and costs is small. The literature on the impacts of quality data collection and dissemination is somewhat larger, but is much more diffuse, with little evidence specific to the context of consumer-oriented strategies of the type examined here. …

    There is insufficient published evidence to draw conclusions about the effectiveness of these CDHPs and tiered provider networks and the literature on the impacts of quality data collection and dissemination is diffuse.

    Evolution and early evidence of the impact of consumer-driven health plans: from e-commerce venture to health savings accounts, by S. Parente and R. Feldman

    Using results from peer-reviewed empirical analyses we describe the development and impact of the consumer-driven health plan market over the last 5 years. The results of these analyses show that consumers are responding to the financial incentives of these new health insurance benefits. Although the results may not always be what the consumer-driven health plan developers intended, there is clear evidence of `consumerism’, where individuals act in a way that generally increases their access to healthcare or investments, if the opportunity is present. Just as Medicare Part D enrollment demonstrated consumers could identify differences in prescription drug plans and make rational choices, so too are prospective patients able to function as consumers in the medical marketplace when give[n] the opportunity. …

    [W]e found that a cohort of enrollees in the CDHP had lower healthcare costs than those in a preferred provider organization (PPO) in the second year of enrollment, but higher costs than a Point of Service plan (POS). A follow-up analysis looking at an additional year of data found that the CDHP had become the most expensive plan by the end of the third year.

    Consumer-Oriented Health Care Reform Strategies: A Review of the Evidence on Managed Competition and Consumer-Directed Health Insurance, by T. Buchmueller

    Numerous studies provide consistent evidence that consumers’ health plan choices are sensitive to out-of-pocket premiums. The elasticity of demand appears to vary with consumers’ health risk, with younger, healthier individuals being more price sensitive. This heterogeneity increases the potential for adverse selection. Biased risk selection also is a concern when the menu of health plan options includes consumer-directed health plans. Several studies confirm that such plans tend to attract healthier enrollees. A smaller number of studies test the main hypothesis regarding consumer-directed health plans, which is that they result in lower medical spending than do more generous plans. These studies find little support for this claim.

    The experiences of employers that have adopted key elements of managed competition are generally consistent with the key hypotheses underlying that strategy. Research in this area, however, has focused on only a narrow range of questions. Because consumer-directed health care is such a recent phenomenon, research on this strategy is even more limited. Additional studies on both topics would be valuable.

    Health Savings Accounts and Health Care Spending, by Anthony T. Lo Sasso, Mona Shah, and Bianca K. Frogner

    The impact of consumer-driven health plans (CDHPs) has primarily been studied in a small number of large, self-insured employers, but this work may not generalize to the wide array of firms that make up the overall economy. The goal of our research is to examine effects of health savings accounts (HSAs) on total, medical, and pharmacy spending for a large number of small and midsized firms. … We employ difference-in-differences generalized linear regression models to examine the impact of switching to HSAs. … For total spending, HSA enrollees spent roughly 5–7 percent less than non-HSA enrollees. For pharmacy spending, HSA enrollees spent 6–9 percent less than traditional plan enrollees. More of the spending decrease was observed in the first year of enrollment. Our findings are consistent with the notion that CDHP benefit designs affect decisions that are at the discretion of the consumer, such as whether to fill or refill a prescription, but have less effect on care decisions that are more at the discretion of the provider.

    Consumer-Directed Health Care: Early Evidence About Effects On Cost And Quality, by Melinda Beeuwkes Buntin, Cheryl Damberg, Amelia Haviland, Kanika Kapur, Nicole Lurie, Roland McDevitt and M. Susan Marquis

    Demand for consumer-directed health care (CDHC) is growing among purchasers of care, and early evidence about its effects is beginning to emerge. Studies to date are consistent with effects predicted by earlier literature: There is evidence of modest favorable health selection and early reports that consumer-directed plans are associated with both lower costs and lower cost increases. The early effects of CDHC on quality are mixed, with evidence of both appropriate and inappropriate changes in care use. Greater information about prices, quality, and treatment choices will be critical if CDHC is to achieve its goals.

    Later: Be sure to read the comments for more references on HSAs.

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    • Prof. Frakt,

      From my reading of health savings accounts, it doesn’t seem like a blanket statement can be made about cost-control and HSAs. I mean after all, HSA’s do offer an opportunity to those consumers better educated about health care decisions to be incentivized to spend less, as well as, have a better understanding of their budget constraint, creating more efficient decisions. From what I’ve read, which are a few articles below, plus some more non-peer reviewed work from the commonwealth foundation, a lot of current criticism of cost-savings and moral hazard issues surrounding HSAs center around the recent tax deductibility created for HSAs under the Bush administration plan. Since people deposit pre-taxed dollars into their HSAs they are not experiencing a real budgetary tradeoff because their HSA is artificially inflated with money that should have been going to taxes anyways. It’s just a different sort of premium/reimbursement system, but instead of some private insurer footing the bill, the government does.

      Ryan S.

      Two peer-reviewed articles:

      Dahlia Remler, and Sherry Glied, “How Much More Cost Sharing Will Health Savings Accounts Bring?” Health Affairs, 25, no. 4, 2006

      Roger Feldman, Stephen T. Parente, Jean Abraham, Jon B. Christianson and Ruth Taylor, “Health Savings Accounts: Early Estimates of National Take-Up.” Health Affairs, 24, no. 6, 2005

      Two non peer-reviewed articles:

      Sara R. Collins and Karen Davis, “Transparency in Health Care: The Time Has Come,” http://www.commonwealthfund.org/usr_doc/TransparencyTe stimony_Collins_3-15-06.pdf

      Sara R. Collins, “Health Savings Accounts: Why They Won’t Cure What Ails U.S. Health Care,” June 28, 2006 http://www.commonwealthfund.org/~/media/Files/Publications/Testimony/2006/Jun/Health%20Savings%20Accounts%20%20Why%20They%20Wont%20Cure%20What%20Ails%20U%20S%20%20Health%20Care/Collins_WaysandMeans_Testimony__6%2028%2006%20pdf.pdf