Health savings accounts have mixed effects on healthcare spending, use

Health savings account (HSA) plan enrollment did not impact overall healthcare spending but reduced the use of outpatient services, according to data from the Employee Benefit Research Institute (EBRI).

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) introduced high-deductible health plans (HDHPs) and created HSAs. Since the MMA, employers have generally offered HDHPs in conjunction with HSAs—commonly referred to as HSA-eligible health plans or HSA plans—or raised deductibles in other plans like preferred provider organizations (PPOs).

As PPO deductibles grow closer to HSA plan deductibles, stakeholders have questioned how big of a factor deductibles are when managing healthcare use by health plan type.

The study assesses the impact of plan type on healthcare use and spending and specifically looks at how HSAs influence these factors. The data reflects members in HSA plans and PPO members in health plans with deductibles large enough to be HSA eligible.

The findings indicated that HSA plans have mixed effects on healthcare use. There were 1.2 additional inpatient admissions per 1,000 enrollees in HSA plans compared to PPOs, and HSA members had 15.1 more hospital days per 1,000 enrollees than PPO members.

The increase in inpatient admissions did not stem from emergency department visits, as HSA plan members had 29.6 fewer emergency department visits per 1,000 enrollees than PPO members.

HSA plan members attended 25.6 fewer physician office visits per 1,000 enrollees compared to PPO members, shifting from specialist visits to primary care visits. Those enrolled in HSA plans saw specialists 47.8 fewer times per 1,000 enrollees but saw primary care physicians 22.2 more times.

HSA plan enrollees filled 135.4 fewer prescriptions per 1,000 enrollees compared to those in PPOs. Female HSA plan enrollees had nine fewer breast cancer screenings and 3.4 fewer cervical cancer screenings per 1,000. HSA enrollment did not impact colorectal cancer screenings.

The data revealed some key findings among subgroups. For example, women were the drivers of higher inpatient admissions and days among HSA plan members. Women reduced the use of emergency department visits, specialist visits, and prescription drug fills by a greater degree than men. Similarly, women increased their use of primary care visits more than men.

Enrollees with family coverage drove the increase in inpatient admissions, inpatient days, and primary care office visits compared to those with employee-only coverage. Family coverage members were also responsible for fewer specialist visits, lower use of prescription medications, and the decline in breast and cervical cancer screenings.

Spouses of policyholders experienced fewer inpatient admissions, accounted for a larger increase in hospital days, had fewer prescription drug fills, and had slightly fewer emergency department and specialist visits.

Among people with no health conditions, emergency department visits, specialist visits, and prescription drug fills were fewer in HSA plans compared to PPO plans, while primary care visits increased in HSA plans. Among people with two or more health conditions, inpatient admissions, inpatient days, and primary care office visits increased in HSA plans relative to PPO plans.

HSA enrollment’s effect on healthcare spending was similar to that on healthcare use. Spending on inpatient services was $61.30 (6 percent) per member per year (PMPY) higher among HSA plan members than PPO members. Spending on primary care visits was $4.20 (2 percent) higher PMPY for HSA plan members.

Spending on emergency department and specialist visits were 7 percent and 2 percent lower PMPY among HSA plan members. Prescription drug spending was not statistically different among HSA and PPO members. Overall, there was no statistically significant difference in overall spending between HSA plan and PPO enrollees.

Spending on inpatient services was $2,334 (21 percent) PMPY higher among HSA plan members with two or more health conditions relative to PPO members.

Total healthcare spending was $60.30 (2 percent) lower PMPY among HSA members with no health conditions compared to PPO members, but spending was $2,490 (6 percent) higher PMPY among HSA members with two or more health conditions.

The study findings suggest that HSAs may cause members to use fewer unnecessary and fewer necessary services as they balance saving for future healthcare expenses over spending for current needs.