Overuse and insurance plan type in a privately insured population

Abstract

Objectives: A substantial portion of healthcare spending is wasted on services that do not directly improve patient health and that cause harm in some cases. Features of health insurance coverage, including enrollment in high-deductible health plans (HDHPs) or health maintenance organizations (HMOs), may provide financial and nonfinancial mechanisms to potentially reduce overuse of low-value healthcare services.

Study design: Using 2009 to 2013 administrative data from 3 large commercial insurers, we examined patient characteristics and health insurance plan types associated with overuse of 6 healthcare services identified by the Choosing Wisely campaign.

Methods: We explored associations between overuse and patient characteristics using multivariate logistic regression models, including patient age, gender, enrollment in an HMO, enrollment in an HDHP, an indicator of primary care fragmentation, and number of outpatient visits as explanatory variables.

Results: Measurement of services highlighted as potential overuse by the Choosing Wisely recommendations revealed low to moderate prevalence, depending on the service. HMO coverage and enrollment in HDHPs were significantly associated with differences in prevalence of all 6 services, albeit differently in terms of the direction of the effects. Primary care fragmentation was significantly associated with higher rates of overuse.

Conclusions: Neither HDHPs nor HMO plans, with their closed networks and referral requirements, consistently reduced overuse, although HMO plans were never associated with higher rates of overuse. As policy makers seek levers for reducing low-value healthcare utilization, health insurance plan features may prove a valuable target, although the effect may be complicated by other factors.

FIGURE

Association Between HDHPs and Overuse of 6 Low-Value Services^a DEXA indicates bone densitometry; HDHP, high-deductible health plan. ^aOveruse was defined as receipt of low-value care: low back imaging early in an episode of pain, vitamin D deficiency screening in low-risk patients, prescription opioid use in patients with migraine, cardiac testing in asymptomatic patients, short-interval DEXA testing, and preoperative cardiac testing for low-risk surgery. Source: Authors’ calculations based on data from the Health Care Cost Institute, 2009–2013.