Evaluating the Impact of Changes in Telehealth Cost-Sharing: An Analysis of High-Deductible Health Plan Enrollees

• In Event: Lightning Session: Health Policy & Natural Resource, Energy, and Environmental Policy

Abstract

Background: A majority of privately-insured Americans are enrolled in high-deductible health plans (HDHPs), which are characterized by 100% cost sharing for most services until a high deductible is met.  Evidence indicates that as patient cost-sharing increases, patients reduce their use of both high-value and low-value health care.  This may be especially problematic for the 60% of Americans that are chronically ill and require regular access to medical care to manage their diseases. Using quasi-experimental techniques, we study what happens to care utilization when patient cost-sharing decreases and whether patients are responsive to selective declines in cost-sharing, in a national cohort of 1.4 million chronically-ill adults. 

Methods: Using difference-in-differences and event study models, we evaluate the effect of a 2020 policy change to $0 cost sharing for telehealth services, and whether utilization changed differently for HDHP enrollees compared to nonHDHP enrollees. Due to this policy shock, HDHP enrollees experienced substantial declines in cost-sharing for telehealth, while nonHDHP enrollees experienced small declines in cost-sharing.  Entropy balancing weights were used to address confounding from time-varying factors. Our outcomes included the following: 1) use of any outpatient care; 2) use of $0 telehealth; and 3) use of $0 telehealth as a proportion of outpatient care. To test whether any differences were due to preferences for care modality versus cost-sharing, we further evaluated: 4) use of non-$0 telehealth. Data were obtained from the 2019 and 2020 MarketScan commercial insurance claims data, a national dataset of over 25 million persons annually with employer-sponsored health insurance.  

Results: Difference-in-differences models show no hange in overall outpatient visits between groups (p = 0.84). However, HDHP enrollees increased their use of $0 telehealth by 0.08 visits more over an 8-month period than did nonHDHP enrollees (p < 0.001) and shifted  more of their care to $0 telehealth (b= 0.01, p < 0.001) following the policy change. HDHP enrollees also had lower uptake of  non-$0 telehealth compared to nonHDHP enrollees ((b= -0.01, p = 0.04).  Event study models allowing for monthly changes in behavior across different disease states revealed similar results.

 
Discussion: 

Results show that HDHP enrollees with chronic conditions responded to a sudden decrease in (selective) cost-sharing for telehealth by increasing their use of such services more so than enrollees in non-HDHPs. That HDHP enrollees had lower use of telehealth  services that retained cost-sharing provides support for the argument that the causal mechanism for their relative increase in $0 telehealth utilization was due to the larger decline in cost-sharing rather than a stronger preference for the telehealth modality.

 

Implications for Policy or Practice:

This is the first study to rely on a policy shock – the shift to $0 telehealth – to evaluate the effects of HDHPs on consumer behavior. Our results indicate that patients respond in economically rational – and selective – ways to changes in cost-sharing.  Our findings have implications for the Consolidated Appropriations Act of 2023, which allows HDHPs to offer first-dollar coverage for telehealth for 2023 and 2024, and indicate that extending such legislation beyond 2024 can help ensure receipt of outpatient care for chronically-ill patients.

 

 

Author

• Risha Gidwani, University of Colorado Denver
  Presenting Author