Providing first-dollar coverage for primary preventive screenings appears to increase utilization of screenings, according to an observational study released Friday from Health Services Research. However, the finding raises questions about the impact of such coverage on those in high-deductible health plans (HDHP).
Investigators analyzed preventive screening use among 44,106 individuals enrolled in a PPO through a large multinational company between 2001 and 2006. The plans waived deductibles for four tests (lipid screening, mammography, fecal occult blood testing, and pap smears).
First-dollar coverage resulted in a moderate increase (2.3-7.8 percent) in the screenings. Between 23 (mammography) and 78 (pap smears) more patients per 1,000 enrollees received screens after the policy change. Rates were unchanged among a control group of 60,107 individuals enrolled in a low-deductible PPO. (Endoscopy was not made deductible-free; rates did not increase in either group.)
However, among those with HDHPs the increase was smaller than for the entire cohort, reports Daniella Meeker, Ph.D., information scientist at the RAND Corporation. "Waiving deductibles alone may not be sufficient to encourage enrollees to seek preventive services."
Addressing costs to drive prevention
The paper adds to the growing evidence that reducing patients' cost sharing for high value medical services leads to increased utilization, says A. Mark Fendrick, co-director of the University of Michigan's Center for Value-Based Insurance Design in Ann Arbor. "While we have known for quite a while that making people pay more leads to decreased use of high value screenings, laboratory tests and therapies, there was some doubt that lowering patients' out of pocket costs would enhance care. This study confirms that if you lower prices, people will buy more."
The findings support an important part of the health reform legislation: Sec. 2713 of the Affordable Care Act requires certain recommended preventive care services be provided without patient cost sharing, he notes. Private and public health plans should extend the cost-sharing exemption to "secondary" preventive services such as essential medications for diabetics and long-acting inhalers for those with asthma, Fendrick argues. Elimination of financial barriers to evidence-based care for diabetes, cardiovascular diseases, asthma and cancer would yield a much greater impact on both clinical and economic outcomes, he says.
The same distinction may arise between those with high and low deductibles. Meeker says that she and her colleagues have forthcoming paper on medication adherence, including diabetes medications and cardiovascular medication. "Preliminary results suggest that in certain medications there is reduced adherence among high deductible enrollees, despite drugs having the same costs."
Researchers found a significantly greater increase in screening among people in low-deductible plans than in HDHPs. In fact, mammography rates actually dropped among high-deductible enrollees. "[O]ur results suggest that introducing first dollar coverage for preventive services may have only a limited effect on use among high-deductible enrollees, despite the reduction in patient costs," the paper states.
What accounts for the differences between low- and high-deductible enrollees? The authors suggest the groups may differ "in ways that cannot be observed and therefore cannot be controlled for statistically." For example, they speculate that HDHP enrollees may, on average, be less risk-averse or place less value on health—or it could be that they are less predisposed to interact with the health care system than low-deductible enrollees "and therefore may be less aware of the need or availability of preventive screens."
It's exceptionally difficult to identify those reasons, says Fendrick; but whatever they are, the findings demonstrate cost isn't the sole barrier to care. Copayment reduction for evidence-based care (the premise for value based insurance design, his field of research) works best when combined with other tools and incentives—pay for performance programs, disease management, coaching, etc., he says.
The authors, too, call for other levers to drive preventive services' use. Patient and physician reminders and education have demonstrated some success, the authors note. "Future research should investigate the efficacy of such approaches with respect to people that select high-deductible plans."