Expanding pre-deductible coverage in HSAs boosts adherence to certain medications

It is important to remember that when medication adherence fell as a result of the introduction of an HSA-eligible health plan.

Patients with certain chronic conditions increased medication adherence when enrolled in health savings accounts with pre-deductible coverage, a study reported in EBRI Issue Brief found.

IRS Notice 2019-45 allows HSA-eligible health plans the flexibility to cover 14 drug classes and other health services used to prevent exacerbation of chronic conditions before meeting the plan deductible. By 2022, there was evidence of a rebound in medication adherence.

“We found that the percentage of enrollees with diabetes using insulin increased 4 percentage points, and the percentage of enrollees with heart disease or diabetes using statins increased by 1 percentage point,” the report said. ”While the magnitude of the effect may seem small, it is important to remember that when medication adherence fell as a result of the introduction of an HSA-eligible health plan, the magnitude of the declines was relatively small as well. Furthermore, the implied out-of-pocket elasticities of demand are closely aligned with previously published estimates.”

The lack of a large increase in medication adherence also may be because adherence rates already were relatively high, averaging 77% to 89%, with the exception of inhaled corticosteroids. The way employers responded to the IRS notice also affected the results. Whether employers moved from deductibles to no cost sharing at all varied by medication. Statins were most likely to be covered in full, with 40% of employers reporting that they did not require any cost sharing as a result of the IRS notice. This may explain why statins were one of the two medications that experienced a rebound in adherence. By contrast, only one-quarter of employers exempted ACE inhibitors, SSRIs or inhaled corticosteroids from any cost sharing.

“Since 2021 was the first year that many employers expanded pre-deductible coverage, it may take time for enrollees to learn that their health plan has changed coverage for certain preventive services,” the report said. “They may not be aware that these medications are either free or subject to copayments or coinsurance instead of deductibles, despite employers’ best efforts to inform enrollees of a plan design change that is considered an improvement in benefits.

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”The fact that employers moved toward covering services on a pre-deductible basis after being allowed to do so comes at a critical time. When the Affordable Care Act passed in 2010, it included provisions requiring that employers and health plans cover certain preventive services in full. Plan sponsors have been prohibited from imposing any form of cost sharing on participants receiving these services.

“Employers and policymakers have an appetite for more-flexible plan designs or `smarter’ deductibles, because rising health care spending has created serious fiscal challenges,” researchers concluded. “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.”