1. THE COMMONWEALTH FUND Early Experience With High- Deductible and Consumer-Driven Health Plans: Findings from the EBRI/Commonwealth Fund Consumerism in Health Care Survey Paul Fronstin, EBRI and Sara R. Collins, The Commonwealth Fund EBRI Policy Forum, Washington, D.C. December 8, 2005

2. THE COMMONWEALTH FUND Methodology The Consumerism in Health Care Survey was conducted online using Harris Poll Online, Harris Interactives online sample of Internet users. Eligibility:Americans ages 21 to 64 with private health insurance coverage. Stratification:Gender, age, and region. Final sample is skewed towards higher income, more educated, and also under represents minorities. Weighting:The national sample is weighted by gender, age, region, and education to reflect the actual proportions in the population. The CDHP and HDHP samples are unweighted, since population data does not exist. Analysis Groups:Comprehensive insurance, HDHP, CDHP Sample Groups:National sample Oversample n=1204 (1061 Comprehensive, 126 HDHP, 17 CDHP) n=505 (337 HDHP, 168 CDHP) 1. Comprehensiven=1,061 (all from national sample) 2. HDHP samplen=463 (126 – national, 337 – oversample) 3. CDHP samplen=185 (17 – national, 168 – oversample)

3. THE COMMONWEALTH FUND Health Plan Definitions Comprehensive – plan with no deductible or <$1000 (individual), <$2000 (family) HDHP – plan with deductible $1000+ (individual), $2000+ (family), no account CDHP – plan with deductible $1000+ (individual), $2000+ (family), with account

4. THE COMMONWEALTH FUND Respondent Profile Comprehensive (n=1061) HDHP (n=463) CDHP (n=185) Age21 to 3429%17%*21%* EducationHigh school graduate or less 328*5* College graduate or some graduate work 2338*46* Graduate degree1117*21* Household Income$150,000 or higher439* Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

5. THE COMMONWEALTH FUND Respondent Profile Comprehensive (n=1061) HDHP (n=463) CDHP (n=185) Self-Rated Health Status Excellent/very good45%47%57%* Obese363326* Smokes cigarettes2314* No regular exercise2415*16* Firm SizeSelf-employed with no employees 29*8* 2-491531*38* 50-199998 200-4991075* 500 or more5537*36* Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

6. THE COMMONWEALTH FUND Distribution of Individuals Covered by Private Health Insurance, by Type of Health Plan Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

7. THE COMMONWEALTH FUND Number of Years Covered by Current Health Plan, by Type of Health Plan Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

8. THE COMMONWEALTH FUND Familiarity with Consumer Driven Health Plans Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

9. THE COMMONWEALTH FUND Deductibles, by Type of Health Plan Comprehensive (n=1061) HDHP (n=463) CDHP (n=185) Individual DeductibleNo deductible47% $1 - $49929 $500 - $99913 $1,000 - $1,9996439 $2,000 - $3,4992349 $3,500 or higher810 Family DeductibleNo deductible48 $1 - $49917 $500 - $99914 $1,000 - $1,99913 $2,000 - $2,9995031 $3,000 - $4,9992243 $5,000 or higher2024 Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

10. THE COMMONWEALTH FUND Satisfaction with Quality of Health Care Received, by Type of Health Plan Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

11. THE COMMONWEALTH FUND Satisfaction with Out-of-Pocket Costs for Health Care, by Type of Health Plan Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

12. THE COMMONWEALTH FUND Satisfaction with Choice of Doctors, by Type of Health Plan Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

13. THE COMMONWEALTH FUND Overall Satisfaction with Health Plan, by Type of Health Plan Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

14. THE COMMONWEALTH FUND Likelihood of Recommending Health Plan to Friend or Co-Worker, by Type of Health Plan Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

15. THE COMMONWEALTH FUND Likelihood of Staying With Current Health Plan If Had the Opportunity to Change, by Type of Health Plan Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

16. THE COMMONWEALTH FUND Agreement With Statements About Health Plan: Percent Reporting That They Strongly or Somewhat Agree, by Type of Health Plan Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

17. THE COMMONWEALTH FUND Attitudes About Consumerism and Quality Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

18. THE COMMONWEALTH FUND Percentage of Individuals Covered by Employment-Based Health Benefits With No Choice of Health Plan, by Type of Health Plan Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

19. THE COMMONWEALTH FUND Among Individuals with a Choice of Plan, Reasons for Choice Comprehensive –Low out of pocket costs, good benefits (54%) CDHP (n=63) –Opportunity to save money in the account, and rollover funds for future years (62%) HDHP –Cost of the premium (64%) Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

20. THE COMMONWEALTH FUND Health Plan Choice and Premium Cost Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

21. THE COMMONWEALTH FUND Percentage of Individuals With Comprehensive Employment-Based Health Benefits Offered CDHP or HDHP Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

22. THE COMMONWEALTH FUND Reasons HDHP Members Give for Not Selecting a CDHP Plan That Was Available Note: HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

23. THE COMMONWEALTH FUND Issues Not Addressable Employer contributions Individual contributions Rollover amounts Choice: –Reasons why those in CDHP chose plan –Reasons why those in comprehensive did not choose CHDP

24. THE COMMONWEALTH FUND Implications of Consumerism For: Out-of-pocket costs Access to health care services Information on cost and quality of providers Health care decision making

25. THE COMMONWEALTH FUND Percent of Income Spent Annually on Out-of- Pocket Medical Expenses Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. **Health problem defined as fair or poor health or one of eight chronic health conditions. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005. Percent of adults 21-64 spending 5% of income Total Health Problem** <$50,000 Annual Income 5 20* 11 8 29* 16 14 45* 23 6* 8* 15* 731133 (n = 61) (n = 90)

26. THE COMMONWEALTH FUND Percent of Income Spent Annually on Out-of- Pocket Medical Expenses, Including Premiums Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. **Health problem defined as fair or poor health or one of eight chronic health conditions. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005. Percent of adults 21-64 spending 5% of income TotalHealth Problem** <$50,000 Annual Income 12 42* 31* 17 38* 34 92* 66 53* 13* 9* 18* 12* 10 33* 21 34 (n = 61) (n = 90)

27. THE COMMONWEALTH FUND Percent of Adults Who Have Delayed or Avoided Getting Health Care Due to Cost Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. **Health problem defined as fair or poor health or one of eight chronic health conditions. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005. Percent of adults 21-64 (n = 61) (n = 90)

28. THE COMMONWEALTH FUND Percent of Adults Who Have Not Filled a Prescription Due to Cost Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. **Health problem defined as fair or poor health or one of eight chronic health conditions. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005. Percent of adults 21-64 (n = 61)(n = 90)

29. THE COMMONWEALTH FUND Percent of Adults Who Have Skipped Doses to Make a Medication Last Longer Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. **Health problem defined as fair or poor health or one of eight chronic health conditions. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005. Percent of adults 21-64 with prescriptions in last twelve months (n = 50) (n = 85)

30. THE COMMONWEALTH FUND Availability and Use of Quality and Cost Information Provided by Health Plan ComprehensiveHDHP/CDHP Health plan provides information on quality of care provided by: Doctors 14%16% Hospitals 1415 Health plan provides information on cost of care provided by: Doctors 1612 Hospitals 1512 Of those whose plans provide info on quality, how many tried to use it for: Doctors 4254 Hospitals 2545* Of those whose plans provide info on cost, how many tried to use it for: Doctors 1536* ( n = 76) Hospitals 1432* ( n = 76) Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

31. THE COMMONWEALTH FUND Most Trusted Sources for Information on Health Care Providers, by Insurance Source Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005. Percent of adults 21-64

32. THE COMMONWEALTH FUND Percentage of Adults who Agree that Terms of Coverage Make Them Consider Cost When Deciding to Seek Health Care Services Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005. Percent of adults 21-64 who strongly or somewhat agree

33. THE COMMONWEALTH FUND Cost Conscious Decision-Making, by Insurance Source Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. *Difference between HDHP/CDHP and Comprehensive is statistically significant at p 0.05 or better. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005. Percent of adults 21-64 who received health care in last twelve months

34. THE COMMONWEALTH FUND Conclusion Low diffusion of consumer-driven plans Among adults with plans, lower satisfaction with quality of care, out-of-pocket costs, plan overall; few would recommend plan to friends/co-workers High out of pocket costs + premiums amount to substantial share of income, especially among those with lower income and health problems No differences in service use, but higher reported rates of cost-related delays, avoidance, or skipping care or Rx, esp. lower income and health problems More cost-conscious decision making behavior Little quality/cost information provided by plans Consumerism gives disproportionate responsibility for cost control to those with health problems and low incomes

35. THE COMMONWEALTH FUND Acknowledgements Dallas Salisbury, President & CEO, EBRI and EBRI-ERF Karen Davis, President, The Commonwealth Fund Cathy Schoen, Senior Vice-President, The Commonwealth Fund Michelle Doty, Senior Analyst, The Commonwealth Fund Jennifer Kriss, Program Assistant, The Commonwealth Fund Visit EBRI and the Fund at: ebri.org cmwf.org