1. How does enrollment in CDHPs impact on consumerist behaviours? Anna Dixon, Jessica Greene and Judith H Hibbard University of Oregon Funding provided by The Changes in Health Care Financing and Organization (HCFO) initiative, a program of The Robert Wood Johnson Foundation, and the Commonwealth FundThe Robert Wood Johnson Foundation

2. Research questions Do consumer directed health plans influence enrollees health and health care behaviors? Compared to employees who remained in a PPO are employees who enrolled in CDHPs more likely to begin to – use health and cost information, – make cost-sensitive utilization decisions and – undertake regular healthy activities?

3. Analysis Dependent variables: self reported behaviors – Information seeking – Cost sensitive decisions – Healthy behaviors Cross sectional analysis of behaviors in 2003 by plan type Analysis of behaviors in 2004 & 2005 among those who were not doing the behaviors in the previous year by plan type (bivariate and multivariate) Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode

4. Selection High deductible CDHP enrollees different – Younger, more educated, less likely to have a chronic illness – More likely to be male Lower deductible CDHP enrollees similar to PPO enrollees – Similar health status and number of chronic conditions – More likely to be female – More likely to have internet access Greene J et al (2006 in press) Which Consumers Are Ready For Consumer-Directed Health Plans? Journal of Consumer Policy forthcoming

5. Information seeking pre-enrollment year by plan type (bivariate) High Deduct CDHP Lower Deduct CDHP PPO % sample (N) Used any website for health information other than their plan’s 48.3%51.8%39.8%***45.8% Used website or booklet that compares the quality of hospitals 6.2%7.7%5.6%6.4% Used website or book that helps you figure out how to handle symptom or problem 40.1%46.3%36.0%***40.1% Used website or booklet that compares prescription drug costs 15.7%22.0%15.7%***17.5% *p<.10 **p<.05 ***p<.01

6. Initiated information seeking during first 6 months enrollment by plan type in 2004 (multivariate) Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode. Denominator in each case is those who did not report doing the behavior in 2003 *p<.10 **p<.05 ***p<.01 High Deduct CDHP Lower Deduct CDHP PPO % sample (N) Used any website for health information other than their plan’s 1.312.20***(1.0) 6.6% (1123) Used website or booklet that compares the quality of hospitals 0.714.23***(1.0) 1.8% (1944) Used website or book that helps you figure out how to handle symptom or problem 0.711.49(1.0) 10.4% (1237) Used website or booklet that compares prescription drug costs 2.22**3.42***(1.0) 4.8% (1711)

7. Initiated information seeking during 2 nd year of enrollment by plan type in 2005 (multivariate) Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode. Denominator in each case is those who did not report doing the behavior in 2004 No statistically significant relationship *p<.10 **p<.05 ***p<.01 High Deduct CDHP Lower Deduct CDHP PPO % sample (N) Used any website for health information other than their plan’s 1.061.18(1.0) 21.0% (637) Used website or booklet that compares the quality of hospitals 0.980.80(1.0) 5.7% (1084) Used website or book that helps you figure out how to handle symptom or problem 0.801.12(1.0) 25.0% (713) Used website or booklet that compares prescription drug costs 0.57*0.88(1.0) 9.1% (957)

8. Summary of findings: Information Active information seekers more likely to select low deductible CDHP Enrollees in low deductible CDHPs more likely to initiate health and quality information seeking than enrollees in either high deductible CDHP or PPO within first 6 months Enrollees in both CDHPs more likely to initiate cost information seeking than enrollees in PPO within first 6 months

9. Cost sensitive behaviors pre-enrollment year by plan type (bivariate) High Deduct CDHP Lower Deduct CDHP PPO % sample (N) Decide not to go to the doctor when you thought you should have to save money 16.1%18.1%18.6%17.7% Not fill a prescription to save money 8.2%9.8%10.9%9.8% Take a lower dose of a prescription drug than was recommended in order to save money 3.7%4.6%4.8%4.4% Postpone or delay having a medical procedure or surgery to save money 9.2%9.5%10.3%9.7% Decide to have a less expensive diagnostic test to save money 4.9%5.0%4.7%4.8% No statistically significant relationship *p<.10 **p<.05 ***p<.01

10. Initiated cost sensitive behaviors during first 6 months of enrollment by plan type in 2004 (multivariate) Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode. Denominator in each case is those who did not report doing the behavior in 2003 *p<.10 **p<.05 ***p<.01 High Deduct CDHP Lower Deduct CDHP PPO % sample (N) Decide not to go to the doctor when you thought you should have to save money 3.47***1.67(1.0) 3.8% (1715) Not fill a prescription to save money 2.84**1.04(1.0) 2.6% (1873) Take a lower dose of a prescription drug than was recommended in order to save money 3.25**0.74(1.0) 1.6% (1983) Postpone or delay having a medical procedure or surgery to save money 2.73**1.70(1.0) 2.6% (1877) Decide to have a less expensive diagnostic test to save money 2.160.79(1.0) 1.4% (1949)

11. Initiated cost sensitive behaviors during 2 nd year of enrollment by plan type in 2005 (multivariate) High Deduct CDHP Lower Deduct CDHP PPO % sample (N) Decide not to go to the doctor when you thought you should have to save money 1.99**1.56(1.0) 9.2% (1020) Not fill a prescription to save money 1.250.71(1.0) 5.0% (725) Take a lower dose of a prescription drug than was recommended in order to save money 1.442.89**(1.0) 5.6% (750) Postpone or delay having a medical procedure or surgery to save money 1.822.43**(1.0) 4.8% (1073) Decide to have a less expensive diagnostic test to save money 2.08*1.75(1.0) 5.0% (1091) Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode. Denominator in each case is those who did not report doing the behavior in 2004 *p<.10 **p<.05 ***p<.01

12. Summary of findings: Cost saving Enrollees in high deductible CDHPs more likely to have started taking risky cost sensitive behaviors within 6 months of enrollment Similar issues emerging for low deductible CDHPs during year 2 with drug use and procedures

13. Healthy behaviors baseline in 2004 by plan type in 2005 (bivariate) High Deduct CDHP Lower Deduct CDHP PPO % sample (N) Limit how much fat is in your diet on most days per week 50.5%51.7%43.5%*** 47.9% (2094) Exercise on most days per week 56.2%51.4%48.3%*** 51.6% (2102) Eat 5 or more fruits or veggies a day on most days per week 36.6%36.3%35.2%*** 35.9% (2101) *p<.10 **p<.05 ***p<.01

14. Initiated healthy behaviors during 2 nd year of enrollment by plan type in 2005 (multivariate) High Deduct CDHP Lower Deduct CDHP PPO % sample (N) Limit how much fat is in your diet on most days per week 1.69*0.93(1.0) 27.6% (580) Exercise on most days per week 1.470.92(1.0) 30.2% (569) Eat 5 or more fruits or veggies a day on most days per week 0.760.82(1.0) 18.3% (749) Control variables: health status, chronic conditions, age, income, ethnicity, gender, work type, and survey mode. Denominator in each case is those who did not report doing the behavior in 2004 *p<.10 **p<.05 ***p<.01

15. Summary of findings: Healthy behaviors Enrollees in CDHPs more likely to do regular healthy activities than enrollees in PPO Emerging trend that enrollees in high deductible CDHPs are more likely to regularly limit fat in diet compared to low deductible and PPO

16. Implications for US policy Cost exposure may result in ‘bad’ decisions – Design of CDHPs is critical: size of ‘gap’ – Monitor impact of HSAs/HRAs on utilization Availability of information tools may result in greater use of health and cost information – Do some people make greater use of tools than others? Information + financial incentives may increase level of healthy activities – Who are these people? Are behaviors maintained? Are people who select these plans predisposed to the behaviors already? Is there selection?