Consumer Directed Health Consumer Directed Health Plans and Patient ActivationPlans and Patient Activation

Judith HibbardJudith HibbardJessica GreeneJessica Greene

Martin TuslerMartin TuslerUniversity of OregonUniversity of Oregon

Funding Provided by the Robert Wood Funding Provided by the Robert Wood Johnson Foundation through the HCFO Johnson Foundation through the HCFO

InitiativeInitiative

A Key Assumption is that CDHPs will A Key Assumption is that CDHPs will activate consumers to become better activate consumers to become better managers of their health and health care.managers of their health and health care.

Emerging Evidence Suggests that Emerging Evidence Suggests that Consumers do change Behavior in a Consumers do change Behavior in a

CDHPCDHP

Seek out informationSeek out information

Increase use of preventive careIncrease use of preventive care

Reduce utilizationReduce utilization

Cease chronic disease medicationsCease chronic disease medications

Specific Research Questions:Specific Research Questions:

Do the more activated choose a CDHP?Do the more activated choose a CDHP?

Do those in a CDHP become more activated Do those in a CDHP become more activated over time?over time?

Are the more activated more likely to engage in Are the more activated more likely to engage in health promoting behaviors? More likely to adopt health promoting behaviors? More likely to adopt new health promoting behaviors?new health promoting behaviors?

Are the more activated less likely to engage in Are the more activated less likely to engage in unproductive behaviors? Less likely to adopt unproductive behaviors? Less likely to adopt new unproductive behaviors?new unproductive behaviors?

Measuring ActivationMeasuring Activation

Patient Activation Measure assesses Patient Activation Measure assesses knowledge, skills, and confidence for knowledge, skills, and confidence for managing health and health caremanaging health and health care

Developed using qualitative methods, Developed using qualitative methods, classical test theory, and Rasch analysis. classical test theory, and Rasch analysis. The resulting metric, is a unidimensional, The resulting metric, is a unidimensional, interval level, Guttman-style measure with interval level, Guttman-style measure with strong psychometric properties.strong psychometric properties.

DataData

Mixed mode survey (2004 and 2005) from Mixed mode survey (2004 and 2005) from employees offered CDHP and PPO plans in employees offered CDHP and PPO plans in 2004 (n=2104) response rate 79%; 2005 2004 (n=2104) response rate 79%; 2005 (n=1616) response rate 80% (n=1616) response rate 80%

Collapsed high deductible and low deductible Collapsed high deductible and low deductible CDHP in this analysisCDHP in this analysis

Analysis compares the PPO enrollees with those Analysis compares the PPO enrollees with those who opted into the CDHPwho opted into the CDHP

Favorable Selection into CDHPFavorable Selection into CDHP

Fewer Chronic ConditionsFewer Chronic Conditions

Lower Medical ClaimsLower Medical Claims

Lower Pharmacy ClaimsLower Pharmacy Claims

Better EducatedBetter Educated

Those who are More Activated More likely to Those who are More Activated More likely to Enroll in a CDHPEnroll in a CDHP

PAM score by plan type PAM score by plan type

60.5

61

61.5

62

62.5

63

63.5

64

64.5

2004***

PPO

CDHP

Key: *** p < .001

Activation Did Not Change Significantly for Activation Did Not Change Significantly for CDHP or PPO enrollees from 2004-05CDHP or PPO enrollees from 2004-05

6060.5

6161.5

6262.5

6363.5

6464.5

65

Activation Score

PPO CDHP

2004

2005

Key: Differences are not significant, Paired-Samples t-test

Information Seeking by Plan Type Information Seeking by Plan Type Plan type with higher likelihood of behaviorPlan type with higher likelihood of behavior

BehaviorBehavior 20042004 20052005

Used any health websiteUsed any health website CDHP***CDHP*** CDHP**CDHP**

Used a telephone advice nurseUsed a telephone advice nurse NSNS NSNS

Was persistent in asking doctor to Was persistent in asking doctor to explain questionsexplain questions

NSNS NSNS

Key: * p < .05, *** p < .001

Behaviors by Plan Type Behaviors by Plan Type Plan type with higher likelihood of behavior Plan type with higher likelihood of behavior

Risky Cost Saving BehaviorsRisky Cost Saving Behaviors 20042004 20052005

Didn't go to doctor to save money Didn't go to doctor to save money PPO*PPO* PPO*PPO*

Took lower dose to save money Took lower dose to save money NSNS NSNS

Did not fill prescription to save money Did not fill prescription to save money NSNS NSNS

Healthy BehaviorsHealthy Behaviors

Limited fat in diet Limited fat in diet CDHP***CDHP*** NSNS

ExercisedExercised CDHP***CDHP*** NSNS

Ate 5 daily servings of fruits or Ate 5 daily servings of fruits or vegetablesvegetables

NSNS NSNS

Key: * p < .05, *** p < .001

Multivariate Analysis: Information Seeking by PAM Multivariate Analysis: Information Seeking by PAM Score in 2004Score in 2004

Key: * p < .05, ** p < .01, *** p < .001, Controlling for Education, Income, Age, Health, job type, gender, and survey mode

PPO CDHP

Legend: Did not do the behavior

Did the behavior

50

55

60

65

70

Used any healthwebsite

Used a telephoneadvice nurse**

Was persistent inasking doctor to

explainquestions***

50

55

60

65

70

Used any healthwebsite*

Used a telephoneadvice nurse

Was persistent inasking doctor to

explainquestions***

Multivariate Analysis:Multivariate Analysis:Risky Cost-Saving Behaviors by PAM score in 2004Risky Cost-Saving Behaviors by PAM score in 2004

50

55

60

65

70

Didn't go to doctorto save money

Took lower dose tosave money

Did not fillprescription to save

money

50

55

60

65

70

Didn't go to doctorto save money

Took lower dose tosave money

Did not fillprescription to save

money

PPO CDHP

Legend: Did not do the behavior

Did the behaviorControlling for Education, Income, Age, Health, job type, gender, and survey mode

Multivariate Analysis: Multivariate Analysis: Healthy Behaviors by PAM score in 2004Healthy Behaviors by PAM score in 2004

Key: * p < .05, ** p < .01, *** p < .001 Controlling for Education, Income, Age, Health, job type, gender, and survey mode

PPO CDHP

Legend: Did not do the behavior

Did the behavior

50

55

60

65

70

Limited fat in diet** Exercised* Ate 5 daily servingsof fruits orvegetables

50

55

60

65

70

Limited fat in diet*** Exercised*** Ate 5 daily servingsof fruits or

vegetables***

45

50

55

60

65

70

75

Used any healthwebsite***

Used a telephoneadvice nurse***

Was persistent inasking doctor to

explain questions

45

50

55

60

65

70

75

Used any healthwebsite

Used a telephoneadvice nurse

Was persistent inasking doctor to

explainquestions**

Multivariate Analysis:Multivariate Analysis:New Information Seeking by PAM score in 2005New Information Seeking by PAM score in 2005

Key: * p < .05, ** p < .01, *** p < .001, Controlling for Education, Income, Age, Health, job type, gender, and survey mode

PPO CDHP

Legend: Did not adopt the behavior

Adopted the behavior

25 67295 983286 616

50

55

60

65

70

Didn't go to doctorto save money

Took lower dose tosave money

Did not fillprescription to save

money

50

55

60

65

70

Didn't go to doctorto save money

Took lower dose tosave money

Did not fillprescription to save

money

Multivariate Analysis:Multivariate Analysis:New Risky Cost-saving Behaviors by PAM score in 2005New Risky Cost-saving Behaviors by PAM score in 2005

PPO CDHP

Legend: Did not adopt the behavior

Adopted the behaviorControlling for Education, Income, Age, Health, job type, gender, and survey mode

327 1075340 1133322 1013

50

55

60

65

70

Limited fat in diet* Exercised** Ate 5 daily servingsof fruits orvegetables

50

55

60

65

70

Limited fat in diet** Exercised Ate 5 daily servingsof fruits or

vegetables*

Multivariate Analysis:Multivariate Analysis:New Healthy Behaviors by PAM score in 2005New Healthy Behaviors by PAM score in 2005

Key: * p < .05, ** p < .01 Controlling for Education, Income, Age, Health, job type, gender, and survey mode

PPO CDHP

Legend: Did not adopt the behavior

Adopted the behavior

235 737186 578193 586

Activation As a Predictor of Activation As a Predictor of Information Seeking BehaviorsInformation Seeking Behaviors

BehaviorBehavior 20042004 20052005

Used any health websiteUsed any health website ** ****Used a telephone advice nurseUsed a telephone advice nurse **** ****Was persistent in asking doctor to explain Was persistent in asking doctor to explain ****** ******

KEY: Based on Logistic Regressions controlling for Education, Income, Age, Self-reported Health, Gender, Hourly/Salaried, Plan Type, and Survey Mode

Activation as a Predictor of Behavioral Activation as a Predictor of Behavioral AdoptionAdoption

KEY: Based on Logistic Regressions controlling for Education, Income, Age, Self-reported Health, Gender, Hourly/Salaried, Plan Type, and Survey Mode

Risky Cost Saving BehaviorsRisky Cost Saving Behaviors 20042004 20052005

Didn't go to doctor to save money Didn't go to doctor to save money NSNS NSNS

Took lower dose to save money Took lower dose to save money NSNS NSNS

Did not fill prescription to save money Did not fill prescription to save money NSNS NSNS

Healthy BehaviorsHealthy Behaviors

Limited fat in diet Limited fat in diet ****** ******ExercisedExercised ****** ****Ate 5 daily servings of fruits or vegetablesAte 5 daily servings of fruits or vegetables ****** ****

SummarySummary

Those more activated more likely to enroll Those more activated more likely to enroll in a CDHPin a CDHPExperience in a CDHP does not appear to Experience in a CDHP does not appear to increase activationincrease activationActivation is related to many of the Activation is related to many of the behaviors encouraged by health plans, behaviors encouraged by health plans, this is true regardless of plan designthis is true regardless of plan designCDHP’s good choice for those already CDHP’s good choice for those already activatedactivated