Majority of plan sponsors prefer barriers to access when given the choice

A research report from the EBRI Education and Research Fund found that employers will remove barriers to access certain procedures and medications designed to address chronic conditions when encouraged to do so by federal agencies. But that does not immediately translate into increased utilization by plan members.

EBRI decided to follow up on IRS Notice 2019-45. The notice gave permission to health savings account (HSA)-eligible health plans to cover, on a pre-deductible basis, 14 medications and other health services that were shown to effectively treat or manage chronic conditions. EBRI studied claims data between 2018 and 2021 to quantify the effect of expanding pre-deductible coverage.

Here’s what the study showed:

• The notice increased the use of three of the seven medical services by more in HSA-eligible plans, compared with non-HSA-eligible plans. The services: low-density lipoprotein (LDL) testing; hemoglobin A1C (HbA1C) testing; and retinopathy screening.
• Among the drugs approved for use, selective serotonin reuptake inhibitors (SSRIs); statins; and angiotensin-converting enzyme (ACE) inhibitors increased by a larger percentage among enrollees in HSA-eligible plans than in non-HSA plans.
• Most sponsors substituted copays or coinsurance rather than make the permitted items free to members.
• Utilization did not increase substantially for most of the items on the list.

EBRI said even when plan sponsors did not eliminate all barriers to access, they did replace the deductibility with copayments and/or coinsurance, thus likely discouraging utilization.

“Past EBRI research found that the percentage of employers that eliminated cost sharing for the preventive services identified in the IRS notice ranged from a low of 25% to a high of 40% depending on the service examined. In other words, 59% to 75% of employers substituted either copayments or coinsurance for the deductible, depending on the service or drug,” the report said. “Employers would exclude additional preventive services if allowed by the IRS, according to past EBRI research.”

The research revealed that plan members in general are not availing themselves of the pre-deductible prevention services and medications. Increases in use of several of the items included in the IRS notice were marginal among HSA plan members, and most of the 14 drugs and services permitted under the notice showed little or no increased use.

EBRI said in part that could be because most of the data examined was generated during the pandemic, when medical care generally was down. But other factors likely contributed that could be overcome in time with better internal communications and further elimination of barriers such as copayments and coinsurance.

“Our analysis confirms that use of health care services has so far been unaffected by the IRS notice,” EBRI said. “This may be because the majority of employers substituted copayments and/or coinsurance for deductibles instead of eliminating cost sharing completely. It may also be due to lack of enrollee knowledge about plan design changes that were introduced to incentivize use of preventive services.

Employers would exclude additional preventive services if allowed by the IRS, according to EBRI’s survey results. However, if their goal is to increase use of those services, they should consider their approach toward cost sharing.

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“Employers and policymakers have an appetite for more flexible plan designs or “smarter” deductibles because rising health care spending has created serious fiscal challenges. Smarter deductibles accommodating services preventing the exacerbation of chronic conditions might be a natural evolution of health plans.

Value-based reimbursement promotes the delivery of evidence-based, high-quality care that encourages use of — rather than creating barriers to — high-value services. Interventions that improve patient-centered outcomes while maintaining affordability may be found in the form of a clinically nuanced HSA-eligible health plan that better meets workers’ clinical and financial needs,” the report concluded.