Arkansas Experience with Health Savings Accounts in a Medicaid Expansion Population

Transcription

1 Arkansas Experience with Health Savings Accounts in a Medicaid Expansion Population Joseph W. Thompson, MD MPH Anthony Goudie, PhD Jeral Self, MPH Anuj Shah, MS J. Mick Tilford, PhD June 14, 2017

2 Background: Consumer Driven Health Care and Medicaid Medicare Modernization Act (2003): Health Savings Accounts enabled as tax shelter associated with high deductible plans Deficit Reduction Act (2005): 10-state demonstration of Health Opportunity Accounts with Medicaid funding (SC only participant) Medicaid 1115 Waivers: cost-sharing strategies MI Health Accounts IN Personal Wellness and Responsibility Accounts AR Health Independence Accounts

3 Objectives: Profile the experience of the Arkansas Health Independence Accounts (HIA) Assess characteristics of participating individuals Evaluate the financial impact of the HIA Contribute to the ongoing policy dialogue

4 Arkansas Policy Environment Arkansas Health Care Independence Act Section 1115 Waiver utilizing premium assistance to purchase plans on the private individual marketplace Private sector cost-sharing for those >100% FPL (e.g., $8-10 for clinic visit; $4 for generic drugs) Implemented January 1, 2014 Health Independence Accounts (HIA) Operational 1/1/15 Originally for individuals % FPL / only implemented for those % FPL

5 Legislative Intent for HIA Citizens to gain knowledge about appropriate healthcare services and how much those services cost Citizens to gain experience paying cost-sharing requirements and introduction of the concept of paying premiums for insurance Promote personal responsibility for health care decision making Accrue funds to offset premiums and foster a cost-sharing model in the Insurance Marketplace when beneficiary incomes are over 138% FPL

6 Health Independence Accounts: Individual accounts for those % FPL Individuals required to contribute or generate a debt to the state (no collection mechanism) % FPL $10/mo / % FPL $15/mo Payment resulted in state-funded cost-sharing protection for following month Activation of account gained 2 months protection followed by payment expectations State debits account only for failed payment State matches individual s contribution up to $200 if timely payments / annual roll-over Funds available for premium payments upon exit

7 Study Data and Methods Employed Data: Enrollment files for Medicaid beneficiaries between % FPL in premium assistance Claims data from Qualified Health Plans (2014) Financial transactions (collection and distribution) from third-party HIA administrator ( ) Individuals (N=57,079) profiled and compared for those making/not making contributions on: Demographic characteristics Charlson co-morbidity index Payment contribution frequency and amounts Cost-sharing protection received Net economic impact individual and programmatic

8 Results: Participants by Income Federal Poverty Level Required Monthly Payment Made No Payments Made At Least One Payment Total % $10 22,184 (86.9%) 3,332 (13.1%) 25,516 (44.7%) % $15 27,823 (88.2%) 3,740 (11.9%) 31,563 (55.3%) Total 50,007 (87.6%) 7,072 (12.4%) 57,079 (100%)

9 Results: Demographics of Participants Age p< Category Made No Payments Made At Least One Payment Total ,154 (94.1%) 1,508 (5.9%) 25,664 (45.0%) ,279 (88.0%) 1,954 (12.0%) 16,233 (28.4%) ,572 (76.2%) 3,610 (23.8%) 15,182 (26.6%) Gender Male 20,130 (87.7%) 2,831 (12.3%) 22,961 (40.2%) Female 29,877 (87.6%) 4,241 (12.4%) 34,118 (59.8%) Race / Ethnicity P<0.001 White 32,073 (87.9%) 4,400 (12.1%) 36,473 (63.9%) Black 7,595 (87.9%) 1,050 (12.1%) 8,645 (15.2%) Hispanic 1,865 (85.2%) 324 (14.8%) 2,189 (3.8%) Other 8,474 (86.7%) 1,298 (13.3%) 9,772 (17.1%)

10 Results: Prior Utilization / Risk Profile Prior hospitalization(s) greater for participants 7.1% vs 5.1% * Prior emergency room less for participants 25.7% vs 27.7% * Charlson Co-Morbidity Indices * * p<0.0001

11 Outcomes: Cost-sharing protections A total of $476,843 in cost-sharing protections associated with payments were achieved: median cost-sharing payment was $8 (IQR $0, $64) mean payment of $67 (Std Dev=$141) Type Number $$ Pharmaceuticals 31,805 $289,522 Physician 9,198 $79,482 Non-MD Clinician 7,339 $59,095 Hospitals 2,884 $41,744 Other 710 $7,000 Total 51,936 $476,843 *An additional $118,294 were paid during free two-month start-up period

12 Outcomes: Economic Impact Premium payments for the ~7,000 individuals totaled $426,670 Median total $40 (IQR $15, $90): 4 months payments Mean total $60 (Std Dev $141): 6 months payments Cost-sharing protections exceeded HIA payments by $50,172 ($476, ,670) Cost-avoidance (individual co-payment protections greater than monthly payments) was realized by 23.4% of participants Administrative costs to maintain program and accounts were ~$9M over 18 months

13 Limitations Our results are based upon observational information related to individual actions; we lack information on beneficiaries : Health literacy related to insurance design Awareness of program design or purpose Experiences in program participation Perceived value or risk of participating Ability to anticipate cost-sharing events Relative income stability within households Reasons for intermittent payment patterns

14 Conclusions: Introduction of savings accounts into Medicaid demonstrated limited participation Medicaid beneficiaries that are likely to participate in personal savings accounts are likely to be older, have more conditions, and previously hospitalizations Participating individuals demonstrated rational economic behavior with some achieving economic advantages Operational and fiscal costs of such efforts should be considered prior to implementation

15 Postlude: The Arkansas General Assembly terminated the Healthcare Independence Accounts in 2016 and replaced them with nominal monthly premiums Individuals with account balances (n=2253) received program termination checks No awareness of individuals directly utilizing account balances for private sector premium payments

16 Thank you Quality Cost Access