Health literacy and health care spending and utilization in a consumer-driven health plan.

We examined health literacy and health care spending and utilization by linking responses of three health literacy questions to 2006 claims data of enrollees new to consumer-driven health plans (n = 4,130). Better health literacy on all four health literacy measures (three item responses and their sum) was associated with lower total health care spending, specifically, lower emergency department and inpatient admission spending (p < .05). Similarly, fewer inpatient admissions and emergency department visits were associated with higher adequate health literacy scores and better self-reports of the ability to read and learn about medical conditions (p-value <.05). Members with lower health literacy scores appear to use services more appropriate for advanced health conditions, although office visit rates were similar across the range of health literacy scores.

Medication adherence and enrollment in a consumer-driven health plan.

OBJECTIVE: To evaluate the impact of enrolling in a consumer-driven health plan (CDHP) on adherence to maintenance drugs. STUDY DESIGN: Two-year retrospective cohort study. METHODS: Consumer-driven health plan patients were enrolled in a traditional managed care plan in 2005 (pre-year) and a full-replacement CDHP in 2006 (post-year). Traditional-plan patients voluntarily enrolled in a traditional plan in both years. Adherence measures included (1) post-year continuation rate among continuous users, (2) time to refill the first prescription in the post-year, (3) change in the compliance rate from the pre- to the post-year, and (4) total days with continuous drug supply in the post-year. Analysis was conducted on 8 drug classes. RESULTS: The CDHP patients had a slightly higher illness burden and used more medication in the pre-year. The continuation rate was relatively high for all drug classes, although the CDHP cohort had a lower probability of continuing cardiac and cholesterol drugs. Consumer-driven health plan patients took slightly longer on average to refill their first prescription in the post-year for cardiac, hypertension, cholesterol, and thyroid drugs. The compliance rate dropped over time in both cohorts, but the reduction was bigger among CDHP patients for 3 drug classes (adjusted ratio of the odds ratios was 0.77, 0.78, and 0.69 for asthma, cardiac, and cholesterol drugs, respectively). The CDHP patients also terminated their continuous drug supply 21 days earlier for epilepsy drugs and 27 days earlier for cholesterol drugs. CONCLUSIONS: Adherence was lower for a few drug classes among CDHP patients.

Behavioral healthcare services use in health savings accounts versus traditional health plans.

BACKGROUND: Numerous studies have examined behavioral health services via employer-sponsored health insurance cost-sharing measures. Their results clearly indicate that health plan design matters a great deal with respect to behavioral health utilization. It is also clear that there remain a number of unresolved issues, particularly with respect to the effects of a switch from traditional plan designs to high deductible, consumer-driven policies. Health Savings Accounts (HSA) have been well described in the literature with some comparisons to traditional healthcare plans, however no reports have been made about their use for behavioral health treatment. AIMS: We sought to estimate the impact switching to a consumer driven health plan (CDHP) with a health savings account had upon the utilization of behavioral health care. Utilization of behavioral health services were reviewed from claims data over three years (2005 through 2007). Comparisons were made between members who switched from traditional health plans to consumer driven health plans in 2007 with health savings accounts and members who remained in traditional health plans. METHODS: A pre-post study design was applied to two cohorts, stayers and switchers. The stayer cohort consisted of traditional health plan members enrolled from 2005 through 2007. Stayers were offered a health savings account in 2006 and 2007, but opted to remain in traditional health plans. The switcher cohort consisted of members enrolled in traditional plans in 2005 who opted to switch to a health savings account for two years thereafter (2006 and 2007). The use and intensity of behavioral health services in each study year were generated from claims data. Logistic and OLS regression analyses were applied to behavioral health services use and outpatient intensity measures respectively with independent variables post years, cohort and their interaction terms. Both analyses controlled for demographic variables. Additional behavioral disorder variables were added to the intensity regression. RESULTS: Members who switched to a health savings account plan were slightly less likely to initiate behavioral health services in each post year relative to members who stayed in traditional health plans. Of those who sought outpatient behavioral services, there was no difference between cohorts in the intensity of behavioral health services they received. DISCUSSION: Our results suggest enrollment in CDHPs moderately affects the use of behavioral health services but do not affect the intensity of outpatient behavioral health services conditioned on initiating these services. These finding are somewhat limited in that specific information about benefits were not included in the study. These results are also subject to self-selection bias. Members who switched to CDHP may be influenced to do so by other unknown factors that bear on their behavioral health. IMPLICATIONS FOR FURTHER RESEARCH: Recent growth in the number of health savings accounts and current attention to mental health legislation warrant answers about behavioral health spending and efficacious utilization of behavioral health services. Further studies which include behavioral health services outcomes and quality of care gleaned from claims data can answer questions about the efficiency of health savings accounts.

Direct medical costs attributable to acute myocardial infarction and ischemic stroke in cohorts with atherosclerotic conditions.

BACKGROUND: The cost of acute ischemic events in persons with established atherosclerotic conditions is unknown. METHODS: The direct medical costs attributable to secondary acute myocardial infarction (AMI) or ischemic stroke among persons with established atherosclerotic conditions were estimated from 1995-1998 data on 1,143 patients enrolled in US managed care plans. RESULTS: The average 180-day costs attributable to secondary AMI or stroke were estimated as USD 19,056 in the AMI cohort having a private insurance (commercial; n = 344), USD 16,845 in the AMI cohort having government insurance (Medicare, age >/=65 years; n = 200), USD 10,267 for stroke commercial (n = 108), USD 16,280 for stroke Medicare (n = 113), USD 15,224 for peripheral arterial disease commercial (n = 170), and USD 15,182 for peripheral arterial disease Medicare (n = 208). CONCLUSION: These estimates can be used to study the cost-effectiveness of interventions proven to reduce these secondary events.

Occurrence of secondary ischemic events among persons with atherosclerotic vascular disease.

BACKGROUND AND PURPOSE: Few data exist for large managed care populations on the occurrence of subsequent acute ischemic events in persons with established atherosclerotic vascular disease. We estimated the occurrence of secondary stroke, acute myocardial infarction (AMI), and vascular deaths among 2 large, managed care samples. METHODS: With the use of International Classification of Diseases, Ninth Revision, Clinical Modification codes, patients aged > or =40 years and with stroke, AMI, or peripheral arterial disease (PAD) were identified from administrative data of UnitedHealthcare plans during 1995-1998. Stroke, AMI, and PAD cohorts were identified within a commercial insurance sample and a Medicare sample. Cumulative occurrences of subsequent stroke, AMI, or vascular death were estimated by survival analysis. RESULTS: In the stroke commercial cohort (n=1631; mean age, 62.1 years), cumulative occurrence of subsequent events was 4.2%, 6.5%, 9.8%, and 11.8% at 0.5, 1, 2, and 3 years, respectively; cumulative secondary event occurrence in the AMI commercial cohort (n=6458; mean age, 56.0 years) was 3.5%, 4.8%, 7.3%, and 8.5% and in the PAD commercial cohort (n=5813; mean age, 59.2 years) was 1.5%, 2.8%, 4.8%, and 6.5%, respectively. Cumulative secondary event occurrences were even higher in stroke (n=1518; mean age, 79.5 years), AMI (n=2197; mean age, 76.2 years), and PAD (n=5033; mean age, 76.6 years) cohorts of the Medicare sample: 18.1%, 17.0%, and 8.7%, respectively, at 3 years. More than 75% of each stroke cohort's secondary events were strokes; more than 75% of each AMI cohort's secondary events were AMIs. Of the PAD cohorts' secondary events, 27% to 39% were strokes, 48% to 57% were AMIs, and 13% to 16% were vascular deaths. CONCLUSIONS: Among these managed care enrollees with existing atherosclerotic vascular disease, subsequent ischemic events represent a significant symptomatic disease burden. Given these findings, it is very important to determine whether secondary prevention strategies are being effectively used to manage patients with diagnosed atherosclerosis.