1. Department of Planning, Public Policy & Management The University of Oregon Consumers’ Use of Preventive Care in CDHPs Jessica Greene PhD Judith Hibbard DrPH

2. Prevention & Cost Sharing Little is known about consumers’ use of preventive care in CDHPs Generally co-pays, co-insurance & deductibles have lowered rates of preventive care (Blustein 95, Karter 00, Solanki 00, Liang 04,) There have been recent calls for targeted cost sharing (Fendrick 06, Chernew 07) –Alcoa increased cost sharing and exempted prevention, resulting in no change in preventive care (Busch et al 2006)

3. Research Question Do consumers alter use of preventive care in a CDHP, when prevention is excluded from the deductible?

4. Methods Employees of a large company offered CDHPs alongside traditional coverage in 2004 and 2005 18,025 adults (employees & spouses) Use medical claims to examine 3 NCQA prevention measures –Cervical Cancer Screening –Colorectal Cancer Screening –Breast Cancer Screening Fixed effects analysis used to examine the estimated impact on prevention from enrolling in a CDHP Three year cohort study (2003-2005)

5. Plan Details Family Coverage 2004 High Deductible CDHP Lower Deductible CDHP PPO Premium Hourly Salaried $420 $420-$1,128 $1,260 $1,260-$2,600 $1,260 $1,260-$3,600 Deductible Level Personal Care Account Gap (Deductible-PCA) $3,000 $1,500 $2,000 $1,500 $ 500 $600/$1,050 n/a Enrollment 2004 2005 13% 23% 41% 60% 43%

6. Cervical Cancer Screening (Percentage of women 21-64 who had screen during year)

7. Colorectal Cancer Screening (Percentage of people 51-80 who had screen during year)

8. Breast Cancer Screening (Percentage of women 52-69 who had screen during year)

9. Odds Ratios from Fixed Effects Models Cervical Cancer Screening Colorectal Cancer Screening Breast Cancer Screening High Deductible CDHP 1.10.90.5* Lower Deductible CDHP 1.0 0.6*** Year 2 0.9**1.01.1 Year 3 0.9*1.01.1 *p<.05, **p<.01, ***p<.001

10. Summary Those who selected CDHPs were equally likely to receive preventive care in the baseline year as those remaining in PPO Enrollment in a CDHP, which exempted prevention from the deductible: –did not impact rates of colorectal or cervical cancer screening –appears to have reduced breast cancer screening

11. Strengths & Limitations Strengths Fixed effects technique addresses selection bias by controlling for all individual characteristics that do not change over time Limitations One employer, offering a Health Reimbursement Account model Company changed information systems and we were unable to include ~1/3 of the sample in the third year (2005)

12. Implications Targeted cost sharing (exempting prevention from deductibles) has potential to maintain preventive care rates, but it requires consumers to understand greater detail about their health plan Monitoring of preventive care in CDHPs that do not exempt prevention- as well as other quality care indicators in all CDHPs- is warranted –Only 22% of CDHP enrollees have prevention exempted (Claxton, 2006) CDHP providers and employers should consider exempting prevention from the deductible- and examine its impact on utilization

13. The authors wish to acknowledge both the participating employer and CDHP for their openness and commitment to research. We also would like to thank “The Changes in Health Care Financing and Organization” (HCFO), a program of The Robert Wood Johnson Foundation, for providing support for this research. Acknowledgements