Consumer-Oriented Strategies for Improving Health Benefit Design: an Overview

Responding to persistently rising health care costs and continuing concerns about the quality of health care, many health insurance purchasers have become interested in consumer-oriented strategies to improve health plan design that hold the promise of reducing health care costs and improving quality. While a number of specific activities fall within the general umbrella of consumer-oriented strategies, most of the recent developments in this area can be classified in three categories....
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Responding to persistently rising health care costs and continuing concerns about the quality of health care, many health insurance purchasers have become interested in consumer-oriented strategies to improve health plan design that hold the promise of reducing health care costs and improving quality. While a number of specific activities fall within the general umbrella of consumer-oriented strategies, most of the recent developments in this area can be classified in three categories. Consumer directed health plans (CDHPs) are health insurance plans that use high deductibles coupled with personal health spending accounts to increase consumer accountability for health care spending. Tiered networks are health benefit structures that group providers into tiers based on their costs or quality, and reward consumers with favorable prices if they choose providers in higher quality or lower cost tiers. These strategies, which place greater financial responsibility on consumers for health care decision-making, can also be accompanied by initiatives to provide consumers with better information about the cost and quality of health care, including, for example, information about the quality of health care providers, to enable them to make more informed decisions. While these three strategies have been increasingly discussed, there remains little consensus about their likely impacts on the health care system or how purchasers can most effectively use these strategies, either alone or in combination, to achieve the goals of reducing costs and improving quality. Over the past several years, several studies and reviews have been published that appear to offer some insight into how consumer-oriented strategies can affect the provision of care, costs, and outcomes. However, many of these studies have examined narrow ranges of consumer oriented strategies and often do so in a very tightly focused setting such as a single employer. A synthesis of the existing literature may be able to provide valuable information about the potential for consumer-oriented strategies to bring about beneficial outcomes in health care. Discussion concerning the relative newness of the topic and the possibility of limited scope of literature prompted the decision to conduct an initial exploratory analysis and draft a feasibility report, with the goal of developing a foundation for further evidence review work in this area. AHRQ further determined that this initial analysis should address three issues. First, a conceptual framework should be developed that identifies important factors determining the impacts of consumer-oriented strategies, within which questions about the impacts of consumer oriented strategies on health care utilization, costs, and quality can be addressed. Second, a review of published, peer-reviewed literature on CDHPs should be conducted. Several guiding questions were identified: What are prevalence rates and expected trends for CDHPs? What is the evidence on the effect of CDHPs on quality improvement or lack of improvement? What is the evidence that CDHPs affect utilization of health care services, including doctors visits, ER visits, medications, and diagnostic tests? Is there evidence to determine whether effects on utilization are necessary vs. unnecessary services? What is the evidence that CDHPs discourage access to appropriate care? Is there evidence that effects of CDHPs on utilization vary depending on the underlying health status, income or education of individuals? What is the evidence that CDHPs reduce health care expenditures? Third, preliminary evidence should be gathered about the ability of the literature on tiered networks and provider quality collection and dissemination to support further productive evidence review.