Awakening Consumer Stewardship of Health Benefits: Prevalence and Differentiation of New Health Plan Models
Authors: Rosenthal Meredith , Milstein Arnold 
Published: July 2004

Context. Despite widespread publicity of consumer‐directed health plans, little is known about their prevalence and the extent to which their designs adequately reflect and support consumerism.

Objective. We examined three types of consumer‐directed health plans: health reimbursement accounts (HRAs), premium‐tiered, and point‐of‐care tiered benefit plans. We sought to measure the extent to which these plans had diffused, as well as to provide a critical look at the ways in which these plans support consumerism. Consumerism in this context refers to efforts to enable informed consumer choice and consumers' involvement in managing their health. We also wished to determine whether mainstream health plans—health maintenance organization (HMO), point of service (POS), and preferred provider organization (PPO) models—were being influenced by consumerism.

Data Sources/Study Setting. Our study uses national survey data collected by Mercer Human Resource Consulting from 680 national and regional commercial health benefit plans on HMO, PPO, POS, and consumer‐directed products.

Study Design. We defined consumer‐directed products as health benefit plans that provided (1) consumer incentives to select more economical health care options, including self‐care and no care, and (2) information and support to inform such selections. We asked health plans that offered consumer‐directed products about 2003 enrollment, basic design features, and the availability of decision support. We also asked mainstream health plans about their activities that supported consumerism (e.g., proactive outreach to inform or influence enrollee behavior, such as self‐management or preventive care, reminders sent to patients with identified medical conditions.)

Data Collection/Extraction Methods. We analyzed survey responses for all four product lines in order to identify those plans that offer health reimbursement accounts (HRAs), premium‐tiered, or point‐of‐care tiered models as well as efforts of mainstream health plans to engage informed consumer decision making.

Principal Findings. The majority of enrollees in consumer‐directed health plans are in tiered models (primarily point‐of‐care tiered networks) rather than HRAs. Tiers are predominantly determined based on both cost and quality criteria. Enrollment in HRAs has grown substantially, in part because of the entry of mainstream managed care plans into the consumer‐directed market. Health reimbursement accounts, tiered networks, and traditional managed care plans vary in their capacity to support consumers in managing their health risks and selection of provider and treatment options, with HRAs providing the most and mainstream plans the least.

Conclusions. While enrollment in consumer‐directed health plans continues to grow steadily, it remains a tiny fraction of all employer‐sponsored coverage. Decision support in these plans, a critical link to help consumers make more informed choices, is also still limited. This lack may be of concern in light of the fact that only a minority of such plans report that they monitor claims to protect against underuse. Tiered benefit models appear to be more readily accepted by the market than HRAs. If they are to succeed in optimizing consumers' utility from health benefit spending, careful attention needs to be paid to how well these models inform consumers about the consequences of their selections.