Health Insurance Deductibles and Health Care-Seeking Behaviors in a Consumer-Driven Health Care System With Universal Coverage.

Importance: Characteristics of a health care system can facilitate forgoing of health care owing to economic reasons and can influence population health. Whether health insurance deductibles are associated with forgoing of health care in a consumer-driven health care system with universal coverage, such as the Swiss health system, remains to be determined. Objective: To assess the association between insurance plan deductibles and forgoing of health care with consideration of socioeconomic factors. Design, Setting, and Participants: This cross-sectional study was conducted in Geneva, Switzerland, using data collected from January 1, 2007, to December 31, 2019. Population-based samples were obtained yearly through random stratified sampling by age and sex of the general population aged 20 to 74 years. Participants were invited to an appointment at 1 of the 3 study sites in Geneva, where they completed a sociodemographic and health questionnaire. Exposures: Insurance plan deductible level. Main Outcomes and Measures: The main outcome was forgoing of health care owing to economic reasons. Unadjusted and multivariable Poisson models were used to assess the association between deductible level and forgoing of health care. Differences in forgoing health care across the range of health insurance deductibles or household income levels were quantified using the relative index of inequality (RII). Results: The study group included 11 872 participants (5974 [50.3%] male; median age, 48.1 years [interquartile range, 38.7-59.1 years]); 1146 (9.7%) reported forgoing health care. Participants with high-deductible plans reported forgoing health care more frequently than those with low-deductible plans (331 [13.5%] vs 591 [8.7%]). In adjusted analysis, higher-deductible plans were associated with a greater likelihood of forgoing health care (RII, 2.2; 95% CI, 1.7-3.0; P < .001) independently of socioeconomic status, known comorbidities, and cardiovascular risk factors. Deductible level was associated with forgoing of health care among participants younger than 40 years (RII, 2.5; 95% CI, 1.6-4.0; P < .001) and those aged 40 to 64 years (RII, 1.9; 95% CI, 1.3-2.9; P = .002) but not among those older than 65 years (RII, 2.9; 95% CI, 0.8-10.4; P = .11). Conclusions and Relevance: In this cross-sectional study, high insurance plan deductibles were associated with forgoing of health care independent of socioeconomic status and preexisting conditions in a universal consumer-driven health care system with good population outcomes in Switzerland. Uncovering health care system design features that could lead to suboptimal population care may help decision makers improve their current health care system design to achieve better outcomes.

Use of Health Savings Accounts Among US Adults Enrolled in High-Deductible Health Plans.

Importance: Health savings accounts (HSAs) can be used by enrollees in high-deductible health plans (HDHPs) to save for health care expenses before taxes. Expansion of and encouraging contributions to HSAs have been centerpieces of recent federal legislation. Little is known about how US residents who may be eligible for HSAs are using them to save for health care. Objective: To determine which patients who may be eligible for an HSA do not have one and what decisions patients with HSAs make about contributing to them. Design, Setting, and Participants: This cross-sectional national survey assessed an online survey panel representative of the US adult population. Adults aged 18 to 64 years and enrolled in an HDHP for at least 12 months were eligible to participate. Data were collected from August 26 to September 19, 2016, and analyzed from November 1, 2019, to April 30, 2020. Main Outcomes and Measures: Prevalence of not having an HSA or not making HSA contributions in the last 12 months and reasons for not making the HSA contributions. Results: Based on data from 1637 individuals (American Association of Public Opinion Research response rate 4, 54.8%), half (50.6% [95% CI, 47.7%-53.6%]) of US adults in HDHPs were female, and most were aged 36 to 51 (35.7% [95% CI, 32.8%-38.6%]) or 52 to 64 (36.8% [95% CI, 34.1%-39.5%]) years. Approximately 1 in 3 (32.5% [95% CI, 29.8%-35.3%]) did not have an HSA. Those who obtained their health insurance through an exchange were more likely to lack an HSA (70.3% [95% CI, 61.9%-78.6%]) than those who worked for an employer that offered only 1 health insurance plan (36.5% [95% CI, 30.9%-42.1%]; P < .001). More than half of individuals with an HSA (55.0% [95% CI, 51.1%-58.8%]) had not contributed money into it in the last 12 months. Among HDHP enrollees with an HSA, those with at least a master's degree (46.1% [95% CI, 38.3%-53.9%]; P = .02) or a high level of health insurance literacy (47.3% [95% CI, 40.7%-54.0%]; P = .03) were less likely to have made no HAS contributions. Common reasons for not contributing to an HSA included not considering it (36.8% [95% CI, 30.8%-42.8%]) and being unable to afford saving for health care (31.9% [95% CI, 26.2%-37.6%]). Conclusions and Relevance: These findings suggest that many US adults enrolled in an HDHP lack an HSA, and few with an HSA saved for health care in the last year. Targeted interventions should be explored by employers, health plans, and health systems to encourage HSA uptake and contributions among individuals who could benefit from their use.

Seeing Health Insurance and HealthCare.gov Through the Eyes of Young Adults.

PURPOSE: We describe young adults' perspectives on health insurance and HealthCare.gov, including their attitudes toward health insurance, health insurance literacy, and benefit and plan preferences. METHODS: We observed young adults aged 19-30 years in Philadelphia from January to March 2014 as they shopped for health insurance on HealthCare.gov. Participants were then interviewed to elicit their perceived advantages and disadvantages of insurance and factors considered important for plan selection. A 1-month follow-up interview assessed participants' plan enrollment decisions and intended use of health insurance. Data were analyzed using qualitative methodology, and salience scores were calculated for free-listing responses. RESULTS: We enrolled 33 highly educated young adults; 27 completed the follow-up interview. The most salient advantages of health insurance for young adults were access to preventive or primary care (salience score .28) and peace of mind (.27). The most salient disadvantage was the financial strain of paying for health insurance (.72). Participants revealed poor health insurance literacy with 48% incorrectly defining deductible and 78% incorrectly defining coinsurance. The most salient factors reported to influence plan selection were deductible (.48) and premium (.45) amounts as well as preventive care (.21) coverage. The most common intended health insurance use was primary care. Eight participants enrolled in HealthCare.gov plans: six selected silver plans, and three qualified for tax credits. CONCLUSIONS: Young adults' perspective on health insurance and enrollment via HealthCare.gov can inform strategies to design health insurance plans and communication about these plans in a way that engages and meets the needs of young adult populations.

The high-deductible trap. Will the increasingly popular option undermine accountable care?

High-deductible health plans are on the rise, but patients fearful of upfront costs can be reluctant to seek care under the plans. That undermines the goals of accountable care, which rely on timely care. "What the high-deductible health plans do is they very effectively address the cost of care, but they don't have a positive impact on the quality of care or on access," says Dr. David Shulkin, left, president of the Atlantic Accountable Care Organization.

Reducing patient financial liability for hospitalizations: the physician role.

With increasingly strict guidelines for insurance coverage, hospitals have adopted meticulous resource utilization review and management processes. It is important for physicians to appreciate that careful documentation of certain patient parameters may not only optimize the facility's reimbursement but have profound impact on the patient's out-of-pocket expenses. Hospital utilization teams have access to the frequently changing national payor guidelines for policy benefits, usually revolving around whether the patient meets medical necessity criteria for being classified as an "inpatient" vs. an "observation" outpatient. Those statuses are not merely time-based, and lead to marked differences in patient deductibles and coverage for medication, room, procedure, laboratory, and ancillary charges. There are nationally-recognized guidelines for classification, based on severity of illness and intensity of services provided. By participating in case management activities, physicians can have an important patient advocate role, and thereby minimize the financial burden to these individuals and their families.

Medicare Part D: simplifying the program and improving the value of information for beneficiaries.

Many Medicare beneficiaries signed up for the new Part D benefit during the program's first two years. Subsequently, a significant majority of them reported that the benefit was too complicated, and some observers suggest that the complexity may have thwarted some beneficiaries from finding the plan that was best for them. Meanwhile, more than 4 million of those eligible failed to enroll at all. Although some degree of standardization may occur naturally as the market evolves, steps can be taken to simplify the program and make it easier for beneficiaries to make good choices among plans--and for them to enroll in the first place. This issue brief considers specific options for simplifying Part D in several areas: standardizing the benefit descriptions and procedures used by plans and the Medicare program; further standardization of the plan's benefit parameters, particularly the rules for cost-sharing; and changes to the rules governing plan formularies.