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.

Framing Flexible Spending Accounts: A Large-Scale Field Experiment on Communicating the Return on Medical Savings Accounts.

Tax-preferred health savings devices such as Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) offer employees potentially valuable financial instruments for directing pre-tax earnings to eligible medical expenses. Despite their increasing popularity as an employee benefit, however, there is little causal evidence around individual demand for these accounts. This paper seeks to address this gap in the literature, reporting on a randomized controlled field experiment conducted with over 11,000 U. S federal employees in 2017 in order to evaluate the effectiveness of targeted messages designed to increase FSA contributions. Our results suggest that the provision of basic information about FSAs delivered via an emailed employee newsletter did not affect the likelihood of contribution or the contribution level. The addition of statements about the absolute returns or relative returns offered by the accounts similarly had no significant effects, and these null effects are observed despite relatively high email open rates. We discuss explanations for the null results and the policy implications of findings from what appears to be the first health economics experiment analyzing tax incentives around health care savings.

Health insurance design and conservative therapy for low back pain.

OBJECTIVES: To determine the association of health insurance benefit design features with choice of early conservative therapy for patients with new-onset low back pain (LBP). STUDY DESIGN: Observational study of 117,448 commercially insured adults 18 years or older presenting with an outpatient diagnosis of new-onset LBP between 2008 and 2013 as recorded in the OptumLabs Data Warehouse. METHODS: We identified patients who chose a primary care physician (PCP), physical therapist, or chiropractor as their entry-point provider. The main analyses were logistic regression models that estimated the likelihood of choosing a physical therapist versus a PCP and choosing a chiropractor versus a PCP. Key independent variables were health plan type, co-payment, deductible, and participation in a health reimbursement account (HRA) or health savings account (HSA). Models controlled for patient demographic and clinical characteristics. RESULTS: Selection of entry-point provider was moderately responsive to the incentives that patients faced. Those covered under plan types with greater restrictions on provider choice were less likely to choose conservative therapy compared with those covered under the least restrictive plan type. Results also indicated a general pattern of higher likelihood of treatment with physical therapy at lower levels of patient cost sharing. We did not observe consistent associations between participation in HRAs or HSAs and choice of conservative therapy. CONCLUSIONS: Modification of health insurance benefit designs offers an opportunity for creating greater value in treatment of new-onset LBP by encouraging patients to choose noninvasive conservative management that will result in long-term economic and social benefits.

How does membership in local savings groups influence the determinants of national health insurance demand? A cross-sectional study in Kisumu, Kenya.

BACKGROUND: Rotating savings and credit associations (ROSCAs) are highly active in many sub-Saharan African countries, serving as an important gateway for coping with financial risk. In light of the Kenya's National Hospital Insurance Fund's (NHIF's) strategy of targeting ROSCAs for membership enrolment, this study sought to estimate how ROSCA membership influences the determinants of voluntary health insurance enrolment. METHODS: A cross-sectional survey of 444 households was carried out in Kisumu City between July and August 2016. A structured questionnaire was administered on health insurance membership, household attributes, headship characteristics and health-seeking behaviour. We assessed the influence of ROSCA membership on the associations between NHIF enrolment and the explanatory variables using univariate logistic regression. RESULTS: The study found that education was associated with NHIF demand regardless of ROSCA membership. Both ROSCA and non-ROSCA households with high socioeconomic status showed stronger health insurance demand compared with poorer households; there was, however, no evidence that the strength of this association was influenced by ROSCA status (p-value = 0.47). Participants who were self-employed were significantly less likely to enrol into the NHIF if they did not belong to a ROSCA (interaction test p-value = 0.03). NHIF enrolment was found to be lower among female-headed households. There was a borderline effect of ROSCA membership on this association, with a lower odds ratio amongst non-ROSCA members (p-value = 0.09): the low treatment numbers amongst the insured infers that ROSCA membership may play a role on the association between gender and NHIF demand. CONCLUSIONS: Our findings suggest that ROSCA membership may play a role in increasing health insurance demand amongst some traditionally under-represented groups such as women and the self-employed. However, the strategy of targeting ROSCAs to increase national health insurance enrolment may yield exiguous results, given that ROSCA membership is itself influenced by several non-observable factors - such as time-availability and self-selection. It is therefore important to anchor outreach to ROSCAs within a broader, multi-pronged approach that targets households within their social, economic and political realities.

Financial burden of healthcare utilization in consumer-directed health plans.

OBJECTIVES: To evaluate the impact of enrollment in a consumer-directed health plan (CDHP) on out-of-pocket (OOP) spending and on the financial burden associated with healthcare utilization. STUDY DESIGN: Using commercial claims data from 2011 through 2013, we estimated difference-in-differences models that compared changes in outcomes for individuals who switched to CDHPs (CDHP group) with outcome changes for individuals who remained in traditional plans (traditional plan group). METHODS: We estimated the impact of CDHP enrollment on OOP spending at the point of care and on having high financial burden, defined as whether an enrollee spent 3% or more of household income on OOP spending. Additionally, we assessed these outcomes for 2 subgroups: those with lower household income and those with chronic conditions. RESULTS: Within the first year of CDHP enrollment, CDHP enrollees experienced a mean marginal increase in OOP spending of $285 (41% increase; 95% CI, $271-$299; P <.001) relative to traditional plan enrollees. The lower-income and chronic conditions subgroups experienced mean marginal increases in OOP costs of $306 (44% increase; 95% CI, $257-$353; P <.001) and $387 (56% increase; 95% CI, $339-$435; P <.001), respectively. The probability of an enrollee having excessive financial burden increased by 4.3 percentage points (95% CI, 4.0-4.6; P <.001) for the full CDHP sample. These effects were about 3 times larger for the lower-income subgroup (12.3 percentage points; 95% CI, 10.7-13.8; P <.001) and 2 times larger for the chronic conditions subgroup (8.0 percentage points; 95% CI, 6.9-9.1; P <.001). CONCLUSIONS: CDHP enrollment led to a significant increase in financial burden associated with healthcare utilization, especially for those with lower incomes and those with chronic conditions.

Impact of consumer-directed health plans on low-value healthcare.

OBJECTIVES: To assess the impact of consumer-directed health plan (CDHP) enrollment on low-value healthcare spending. STUDY DESIGN: We performed a quasi-experimental analysis using insurance claims data from 376,091 patients aged 18 to 63 years continuously enrolled in a plan from a large national commercial insurer from 2011 to 2013. We measured spending on 26 low-value healthcare services that offer unclear or no clinical benefit. METHODS: Employing a difference-in-differences approach, we compared the change in spending on low-value services for patients switching from a traditional health plan to a CDHP with the change in spending on low-value services for matched patients remaining in a traditional plan. RESULTS: Switching to a CDHP was associated with a $231.60 reduction in annual outpatient spending (95% CI, -$341.65 to -$121.53); however, no significant reductions were observed in annual spending on the 26 low-value services (--$3.64; 95% CI, -$9.60 to $2.31) or on these low-value services relative to overall outpatient spending (-$7.86 per $10,000 in outpatient spending; 95% CI, -$18.43 to $2.72). Similarly, a small reduction was noted for low-value spending on imaging (-$1.76; 95% CI, -$3.39 to -$0.14), but not relative to overall imaging spending, and no significant reductions were noted in low-value laboratory spending. CONCLUSIONS: CDHPs in their current form may represent too blunt an instrument to specifically curtail low-value healthcare spending.

China's medical savings accounts: an analysis of the price elasticity of demand for health care.

Although medical savings accounts (MSAs) have drawn intensive attention across the world for their potential in cost control, there is limited evidence of their impact on the demand for health care. This paper is intended to fill that gap. First, we built up a dynamic model of a consumer's problem of utility maximization in the presence of a nonlinear price schedule embedded in an MSA. Second, the model was implemented using data from a 2-year MSA pilot program in China. The estimated price elasticity under MSAs was between -0.42 and -0.58, i.e., higher than that reported in the literature. The relatively high price elasticity suggests that MSAs as an insurance feature may help control costs. However, the long-term effect of MSAs on health costs is subject to further analysis.

Medical Savings Account balance and outpatient utilization: Evidence from Guangzhou, China.

Medical Savings Account (MSA) is a financing instrument designed to reduce consumer-side moral hazards. The Urban Employee Basic Medical Insurance (UEBMI) scheme in China has an MSA component in addition to a Social Risk-pooling Fund. This study examines the association between MSA balance and outpatient utilization in Guangzhou, China, and determines MSA's impact on utilization under different circumstances. It also seeks to ascertain whether MSA has achieved its intended functions of "Cost-containment", "Saving for the future" and "Enabling utilization". The first group of 114,657 MSA account-holders, including both employees and retirees, who consistently insured with UEBMI from 2002 to 2007, are selected for this study. A two-part model is employed to estimate the effect of the MSA balance on the probability of outpatient services utilization and on the level of outpatient expenditure. Results show that MSA balance is significantly associated with the likelihood of using outpatient services as well as the level of outpatient expenditure. The association is a non-linear U-shaped relationship for working individuals, and an inverted U-shaped relationship for the retirees. The observed U-shaped relationship for working individuals implies that at lower MSA balance levels, a negative balance-expenditure relation exits, while at higher MSA balance levels, the relationship is positive--suggesting possible improper utilization when MSA balance reaches high levels. Setting a maximum MSA balance limit and/or allowing enrollees to use MSA funds to purchase private insurance appears to be desirable. The observed inverted U-shaped relationship for retirees suggests that many retirees have to spend whatever funds they have in their MSA for outpatient care, but the less healthy individuals are able to shift the spending to inpatient care which is mainly financed by the Social Risk-pooling Fund. The results of this study also affirm the usefulness of MSA in performing its intended functions.

Health Insurance, Health Savings Accounts and Healthcare Utilization.

Assuming symmetric information, we show that a high-deductible health plan (HDHP) combined with a tax-favored health savings account (HSA) induces more savings and less treatment compared with a full coverage plan under reasonable risk preferences. Furthermore, a higher tax subsidy increases savings in any case but decreases medical utilization if and only if treatment expenses are above the deductible. A larger deductible increases savings but does not necessarily decrease healthcare utilization. Whether an HDHP/HSA combination is preferred over a full coverage contract depends on absolute risk aversion. A higher tax advantage increases the attractiveness of an HDHP/HSA combination, whereas the effects of changes in the deductible are ambiguous. The paper shows that a potential regulator needs to carefully set the size of the deductible as only in a certain corridor of the probability of sickness, its effect on aggregate healthcare costs are unambiguously favorable.

The effect of Health Savings Accounts on group health insurance coverage.

This paper presents new empirical evidence on the impact of tax subsidies for Health Savings Accounts (HSAs) on group insurance coverage. HSAs are tax-free health care expenditure savings accounts. Coupled with high deductible health insurance plans (HDHPs), they together represent new health insurance options. The tax advantage of HSAs expands the group health insurance market by making health care more affordable. Using individual level data from the Current Population Survey and exploiting policy variation by state and year from 2004 to 2012, I find that HSA tax subsidies increase small-group coverage by a statistically significant 2.5 percentage points, although not coverage in larger firms. Moreover, if the tax price of HSA contribution decreases by 10 cents, small-group insurance coverage increases by almost 2 percentage points. I also find that for older workers or less-educated workers, HSA subsidies are associated with 2-3 percentage point increase in their group insurance coverage.

Health Savings Account Balances, Contributions, Distributions, and Other Vital Statistics, 2014: Estimates from the EBRI HSA Database.

The Employee Benefit Research Institute (EBRI) maintains a wealth of data collected from various health savings account (HSA) providers. The EBRI HSA Database contains 2.9 million accounts with total assets of $5 billion as of Dec. 31, 2014. This Issue Brief is the second annual report drawing on cross-sectional data from the EBRI HSA Database. It examines account balances, individual and employer contributions, annual distributions, investment accounts, and account-owner demographics for 2014. Enrollment in HSA-eligible health plans is estimated to be about 17 million policyholders and their dependents, and it has also been estimated that there are 13.8 million accounts holding $24.2 billion in assets as of Dec. 31, 2014. Almost 4 in 5 HSAs have been opened since the beginning of 2011. The average HSA balance at the end of 2014 was $1,933, up from $1,408 at the beginning of the year. Average account balances increased with the age of the owner of the account. Account balances averaged $655 for owners under age 25 and $5,016 for owners ages 65 and older. About 6 percent of HSAs had an associated investment account. End-of-year 2014 balance averages were higher in accounts with investment assets. Thirty-seven percent of HSAs with investment assets ended 2014 with a balance of $10,000 or more, whereas only 4 percent of HSAs without investment assets had such a balance. Among HSAs with investment assets, accounts opened in 2014 ended the year with an average balance of $6,544; whereas those opened in 2005 had an average balance of $19,269 at the end of 2014. HSAs with either individual or employer contributions accounted for 70 percent of all accounts and 86 percent of the assets in 2014. Four percent of these accounts ended the year with a zero balance. On a yearly average, individuals who made contributions deposited $2,096 to their account. HSAs receiving employer contributions received $1,021 a year, on average. Four-fifths of HSAs with a contribution also had a distribution for a health care claim during 2014. Among HSAs with claims, the average amount distributed for health care claims was $1,951. Distributions for health care claims increased with age, with the exception of those ages 65 and older. Average annual distributions were $636 for account owners under age 25; $2,373 for account owners ages 55-64; and $2,124 for account owners ages 65 and older. Average annual distributions were higher for accounts that were older. However, the likelihood of taking a distribution for health care claims was higher among accounts opened more recently.

HSA growth and the associated opportunities/challenges presented by pharmacy benefits.

Consumer-driven health plans (CDHPs) have grown steadily and significantly over the past ten years in terms of covered employees, enrollment and assets under management. The authors explain the reasons for this growth and how CDHPs address health care costs. They discuss how pharmacy benefits present some of the greatest opportunities and challenges for CDHP growth. Challenges center on recent research that revealed decreased utilization and adherence among members of a CDHP population in four out of the five therapeutic categories examined. Although an influx of generic drugs has entered the marketplace, specialty pharmacy drugs will more than offset those savings, increasing the threat of noncompliance. Nonetheless, with appropriate design and implementation, CDHPs can be very effective for both employers and their employees.

Prescripción enfermera: ¿contribuye a la sostenibilidad del sistema? / No disponible

Estudio cuasi experimental del tipo antes-después sobre las prescripciones de absorbentes realizadas por facultativos y enfermeros del AGS Norte de Huelva en los periodos que abarcan desde noviembre 2011a mayo 2012 y noviembre 2012 a mayo 2013 con el objetivo de analizar la eficacia de la implantación de una estrategia para la prescripción enfermera de absorbentes de incontinencia urinaria (AIU).Resultados: Hay un ahorro en la prescripción de absorbentes de 32.780,51 euros en siete meses. La reducción de envases justifica el65,06% de la disminución del gasto y los cambios en el tipo de absorbente, el 34,94%.Conclusiones: La intervención enfermera consistente en elaboración, difusión e implantación de una guía para la prescripción adecuada de absorbentes, la valoración del paciente incontinente por enfermería, así como la prescripción enfermera de absorbentes, han permitido una adecuación en la prescripción del AIU, contribuyendo a un descenso en el gasto sanitario

Almost experimental study type before-afterwards about the prescriptions of absorbers carried out by doctors and nurses of the AGS Norte de Huelva in the periods that cover nov11-may12 vs from nov12-may13 with the aim of analyzing the efficiency of the implementation of a strategy for the nurse prescription absorbers of urinary incontinence (AUI).Results: There is saving in the prescription of absorbers of 32,780.51 (Euros) in 7 months. The reduction of packaging justifies 65,06% of the decrease of the expense and the changes in the type of absorber, 34,94%.Conclusions: The nurse intervention consists on: elaboration, diffusion and implementation of a Guide for the adequate prescription of absorbers, the valuation of the incontinent patient by nurses as well as the prescription of absorbers by nurses, have allowed an adequacy in the prescription of the AUI, contributing to drop in health expense