Deductibles, Copayments, OOP Max Trends Indicate Cost-Sharing Growth

From 2013 to 2020, cost-sharing trends shifted: deductibles grew, copayments increased for certain services and depending on union employment, and out-of-pocket healthcare spending maximums rose, according to a study from Employee Benefit Research Institute (EBRI).

The EBRI Center for Research on Health Benefits Innovation (CRHBI) conducted this study using data from the Merative Market Scan Commercial Claims Database and Benefit Plan Design. The study analyzes the data for 5.6 to 8.4 million policyholders from 2013 to 2020.

“The biggest change in plan enrollment was the movement of enrollees from preferred provider organization (PPO)/point-of-service (POS) and comprehensive health plans to health maintenance organization (HMO)/exclusive provider organization (EPO) and health savings account (HSA) eligible health plans,” the study highlighted.

The study covered trends across four types of cost-sharing: deductibles, copayments, coinsurance, and out-of-pocket maximums. The study included both nominal values, which reflect the current dollar value, and real values, which reflect the inflation-adjusted value. This article covers only the real values.

Deductibles, on average, grew between 2013 and 2020. Employee-only coverage deductibles grew 13 percent over the seven-year study period from $1,227 to $1,412. Real deductibles for family coverage increased $2,096 to $2,313 — or 10 percent.

Health plans with HSAs had the highest deductibles, with an average real deductible for 2020 of $2,777 for employee-only coverage. Even though they had the highest deductible, these plan types and health reimbursement arrangements (HRAs) saw average employee-only deductibles decline. For HRAs, deductibles dropped by 4 percent. The plan type with the lowest deductible varied but tended to be HMOs and EPOs.

Meanwhile, family coverage deductibles rose significantly in comprehensive plans (13.4 percent) but dropped among PPO and POS plans by 0.4 percent.

A noticeable gap developed between men's and women’s deductibles during the seven-year study period. Men were more likely to plans with higher deductibles over time, but women’s selections of low-deductible plans remained the same. As a result, the deductible difference rose from four percent in 2013 to 20 percent by 2020.

Copayments increased in value for two of the services that the researchers observed: inpatient admission copayments grew by 4 percent and emergency department copayments grew by 2 percent. Inpatient admissions led the way with the highest copayments, hitting $254 in 2020, while primary care physician visits saw the lowest copayments of around $25 the same year.

Union and non-union employment made a significant difference in copayment costs. In 2020, inpatient admission copayments were 40 percent lower for union employees and specialist copayments were 17 percent lower in the same year.

Coinsurance did not see dramatic shifts between 2013 and 2022, which did not surprise the researchers.

“Costs can be shifted to enrollees without increasing coinsurance rates,” the researchers noted. “Rising medical costs lead to enrollees paying more automatically even if coinsurance rates are constant.”

Out-of-pocket maximums rose between 2013 and 2020—two percent on average annually for employee-only coverage and two percent on average annually for family coverage. In 2020, comprehensive plan enrollees had the highest out-of-pocket maximums. HMOs and EPOs had the lowest out-of-pocket maximums.

Average out-of-pocket spending maximum levels did not reach the statutory maximum. The 2020 employee-only statutory out-of-pocket maximum was $8,150 but the average out-of-pocket maximum was less than half of that ($3,473) and the 2020 family statutory out-of-pocket maximum was $16,300 but the average family out-of-pocket healthcare spending amounted to around slightly more than a third of that ($5,817).

Copayments and coinsurance can have an impact on member spending, separate studies showed.