• Sex differences in utilization with high-deductible coverage

    Jason Hockenberry comments on a new study by Katy Kozhimannil and colleagues:

    This study includes interesting descriptive evidence that suggests that men’s use of the ED decreased to a greater extent than women’s during the period immediately following their employers’ switch from an HMO to an HDHP [high deductible health plan]. The pattern of reduction by sex was also quite different by severity of the visit. Womens’ relative reduction in ED use was concentrated in low-severity visits, whereas men’s relative reductions were similar in magnitude in the low and intermediate category but was markedly higher in the high severity category. In addition, there was an immediate reduction in inpatient hospitalizations in the first year among men who worked for employers who switched to HDHPs, followed by what could be interpreted as a reversion to the preperiod level in the second year.

    Naturally, there are a number of limitations of the study, upon which Hoceknberry comments. However, the study’s findings are consistent with a body of evidence that men use health care differently than women. The investigators summarize,

    [Men] are less likely to seek and receive needed health care. [10–14] Sex differences in health care utilization are well documented; females use more preventive care and prescription medications than males. [12,15,16] Women also use emergency care with greater frequency [15] and resource intensity than men. [16] These discrepancies in care patterns may be partially explained by sex differences in health care needs across the age spectrum, and sex-specific types health care services (reproductive health care, sex-specific cancers, etc.). [14,15] But other factors are also at play. Behavioral and attitudinal differences (such as masculinity beliefs) also influence health care use and health seeking behaviors. [13,17–19]

    In light of the evidence, Hockenberry suggests we might observe sex-specific sorting into health plans in the new marketplaces (formerly “exchanges”). Offered plans will vary in their degree of cost sharing and deductible levels, but premiums will not vary by gender within plan. Will men preferentially select higher deductible plans? This is just one of many questions that might be studied when the data start flowing. Who’s on it?


    10. Courtenay WH. Key determinants of the health and well-being of men and boys. Int J Men’s Health. 2003;2:1–30.

    11. Williams DR. The health of men: structured inequalities and opportunities. Am J Pub Health. 2003;93:724–731.

    12. Owens GM. Gender differences in health care expenditures, resource utilization, and quality of care. J Manag Care Pharm. 2008;14(suppl):2–6.

    13. Springer KW, Mouzon DM. “Macho Men” and preventive health care implications for older men in different social classes. J Health Soc Behav. 2011;52:212–227.

    14. Vaidya V, Partha G, Karmakar M. Gender differences in utilization of preventive care services in the United States. J Womens Health. 2012; 21:140–145.

    15. Pinkhasov RM, Wong J, Kashanian J, et al. Are men shortchanged on health? Perspective on health care utilization and health risk behavior in men and women in the United States. Int J Clin Pract. 2010;64:475–487.

    16. Bertakis KD, Azari R, Helms LJ, et al. Gender differences in the utilization of health care services. J Family Pract. 2000;49:147–152.

    17. Addis ME, Mahalik JR. Men, masculinity, and the contexts of help seeking. Am Psychol. 2003;58:5–14.

    18. O’Brien R, Hunt K, Hart G. “It’s caveman stuff, but that is to a certain extent how guys still operate”: men’s accounts of masculinity and help seeking. Soci Sci Med. 2005;61:503–516.

    19. Green CA, Pope CR. Gender, psychosocial factors and the use of medical services: a longitudinal analysis. Soc Sci Med. 1999;48:


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    • After 20+ years of private LTC insurance offerings, carriers have finally started to charge gender-distinct premium rates. Largely due to their relative longevity, females have higher actual (and actuarial) LTC costs: a higher chance of living longer entails more costs incurred in later years. But until 2012 insurance carriers had never charged them different rates, instead bearing the risk of assuming the correct M / F distribution, and tracking the gender-specific costs through in-house valuation.

      Now that Genworth has jumped the shark, all other carriers must follow since Genworth’s rate structure drives disproportionately more females to its competitors, giving them the disadvantage.

      The moral of this story is that insurers who charge the same premiums for males and females bear a certain mix-of-business risk, and they are keenly aware of it. They will push at the margin to encourage lower costs through sex-sorting (be it through benefit offerings or structure) wherever legal and possible.