Employers began offering consumer-driven health plans in 2001, when a handful started offering HRAs. They then started offering HSA-eligible plans after the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 included a provision to allow individuals with certain high-deductible health plans to contribute to an HSA.
Since the introduction of CDHPs in 2001, the percentage of employers offering them has grown. Surveys show that the percentage of employers offering an HRA- or HSA-eligible plan increased from below 5 percent in 2005 to between 12−15 percent by 2009. Growth in offer rates can be seen across all firm sizes. However, recently, the percentage of small firms that offered a CDHP declined while larger firms continued to add a CDHP as an option.
Overall, 19.1 million, or 11 percent of people with either employment-based coverage or individually purchased insurance, were enrolled in a CDHP in 2009. More recent data suggest that by 2010, 10 million people were in an HSA-eligible plan. There are no comparable data yet for HRA enrollment.
Generally, premiums for CDHPs were lower than premiums for non-CDHPs. Growth in premiums varies both by type of plan and over time. In 2009, HSA-eligible premiums increased slightly faster than non-CDHP premiums, increasing 3.5 percent and 2.8 percent, respectively. Premiums in HRA-based plans decreased 4.3 percent.
However, CDHP premiums may be lower than non-CDHP premium simply because the CDHP population is healthier, and there is some evidence of this. One study found that while actual savings ranged from a high of 15.5 percent to a low of −4.7 percent, and average savings were 4.8 percent, most of the savings were due to fact that younger, healthier workers choose CDHPs; the study concluded that once typical risk- and benefit-adjustment factors were taken into account, CDHPs saved only 1.5 percent on premium costs.
A number of studies have been conducted in the past few years that have examined the impact of CDHPs on the use of health care services. The studies agree that use of preventive services did not change (upward or downward) as a result of the CDHP.
Concerning how CDHPs affect prescription drug use, studies found that overall use of brand-name prescription drugs fell and there was some offset from increased use of generic drugs, although some enrollees stopped their use of prescription drugs. CDHP enrollees increased their use of the mail-order pharmacy option. And overall use of prescription drugs among CDHP enrollees with certain chronic conditions fell, or did not increase when enrollees met their deductible.
One study found that the financial incentives of the plan are not sufficient in driving behavior and that educational outreach also matters.
There is evidence that emergency room use declined when plan enrollees were subject to higher deductibles, though the research should not be generalized to a CDHP setting.
There is also evidence that CDHP enrollees received higher quality care than members of other types of plans in areas related to low-back pain, eye exams, and nephropathy screening for diabetes.
No difference was found for medication management for persons with depression and asthma, annual monitoring for persons taking persistent medications, cholesterol management for persons with cardiovascular disease, or HbA1c testing and low-density lipoprotein screening for persons with diabetes.
Most of the research to date has focused on individuals in HRA-based plans. Little systematic research has been conducted on HSA-eligible enrollees. While HRAs and HSA-eligible plans look a lot alike, the differences are significant enough to warrant separate analyses of the impact of the plans.
Also, most of the research to date has focused on plan design and has ignored the impact of the consumer-driven account on use of health care services and overall spending.
Individual contributions to HSAs and employer contributions to both HSAs and HRAs may affect the use of health care services. Furthermore, account balances may have an effect as well: Individuals may use health care services differently, depending on how much money is being contributed to the account, especially relative to the eductible; amounts rolled over; and portability of the account.
Despite the growing body of evidence on the effect of CDHPs on cost and quality, there are many unanswered questions.
