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Studies Show Achieving ACA Goals Demands Trial, Error and Patience

04.18.2016

Macro shot of silver bullet caught in flight

No one really expected the Affordable Care Act (ACA) to be the silver bullet that would stop health care cost inflation dead in its tracks. Yet, perhaps understandably, many employers remain frustrated by the substantial challenge of managing these expenses. A pair of new studies, however, yield some practical insights into the fine-tuning and persistence needed to control costs and keep employees as healthy as possible.

AMA analysis

The first study is entitled “Cost-Sharing Obligations, High-Deductible Health Plan Growth, and Shopping for Health Care: Enrollees With Skin in the Game.” Published as a “research letter” earlier this year in the Journal of the American Medical Association, it addresses the relationship between employees’ level of cost-sharing and their efforts to obtain competitively priced medical services — specifically in relation to high-deductible health plans (HDHPs).

HDHPs were designed under the assumption that, when faced with high deductibles, employees would be motivated to shop for the most economical health services. These plans have been on a steady upward march over the past decade. Currently, about 25% of employees are enrolled in an HDHP, according to a Kaiser Family Foundation survey. That number was only 4% in 2006.

“The wide variation in costs across physicians and hospitals implies considerable opportunity for enrollees to save money by switching to lower-cost providers,” states the AMA research letter. But its authors found that theoretical savings opportunities in the absence of easy ways for employees to recognize and take advantage of them aren’t doing the job. Early indications that HDHPs are cutting employers’ costs aren’t attributable to employee consumerism, the researchers say, but rather primarily to decreased use of care.

Data points

The data behind the AMA research letter was based on a survey of nearly 2,000 individuals, roughly half of whom are covered by HDHPs. Members of the HDHP group, based on the questionnaire’s responses, appear to be good candidates for smart medical consumers: Most (60%) were aware that significant variations in the cost of care exist from one provider to the next, and few (32%) believed higher prices necessarily correspond to higher service quality.

However, the traditional plan enrollees hold virtually the same views: 58% were aware of large differences in prices (but not necessarily the details), and only 36% believed prices correspond to quality.

Similarly, when asked whether they’d considered changing health care providers the last time they received care, only 11% of the HDHP enrollees and 10% of the traditional plan enrollees reported doing so. And less than half of those who did switch providers had conducted cost comparisons before making the change. Slightly more than half (56%) of the HDHP enrollees reported they’d “use information on prices if available,” and 50% of the other group said they would.

What does all of this mean? According to the authors of the AMA research letter, it suggests that “simply increasing a deductible, which gives enrollees skin in the game, appears insufficient to facilitate price shopping.” The researchers went on to conclude: “If encouraging price shopping is viewed as an important goal, then there is a need for greater availability of price information and innovative approaches to enrollee engagement with this information.”

EBRI study

The second study of note is entitled “Impact of Workplace Wellness-Program Participation on Medication Adherence” and comes from the Employee Benefit Research Institute (EBRI). It provides mixed results about another ACA goal: promoting employee health through wellness initiatives.

This EBRI study is a follow-up to an earlier study about the impact of employee participation in health risk assessments and biometric screenings — staples of most wellness programs — on prescription drug utilization. That study determined that prescription drug use did increase among employees who received biometric screenings. The screenings (in which blood samples are taken) often pinpoint medical problems such as hypertension, high cholesterol and others that can generally benefit from medication.

But a key factor the earlier study didn’t assess was whether employees who participate in wellness programs stick with the prescriptions they have been given or eventually fall off. In other words, it didn’t address their “adherence” rate.

This is a critical question because, according to the follow-up study’s authors, “the link between medication adherence and decreased other non-drug medical services use and spending has been clearly established” and an increase in adherence rates “may be an early indicator” of wellness program success.

Likely disappointment

Among the basic challenges in learning lessons from wellness programs is that, because participation is generally voluntary, results can be biased by typically higher participation rates by healthy or at least health-conscious employees. So the authors of the EBRI study used elaborate statistical methods to adjust for such bias — including comparing results from programs that featured financial incentives for participation with those that didn’t.

The study examined drug adherence with respect to six chronic conditions:

  1. Hypertension,
  2. High cholesterol,
  3. Diabetes,
  4. Congestive heart failure,
  5. Asthma / chronic obstructive pulmonary disease, and depression


The results, in a nutshell, were that program participation had a statistically observable impact on adherence to drugs for only two of the six conditions examined: high cholesterol and depression.

What observations can be drawn from these results? The authors concluded that, when employers are looking for short-term results from health risk assessments and biometric screenings, they’ll probably be disappointed. And disappointment is particularly likely when they provide financial incentives for employees to participate.

“However,” the authors add, “longer-term medical cost offsets and productivity enhancements may be possible through improved medication adherence made possible via information captured through biometric screenings.”

Ron M. Present, CALA, CNHA, LNHADo you have questions about your health care strategy? 

Contact Ron Present, Partner and Health Care Industry Group Leader, at 314.983.1358 or rpresent@bswllc.com

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