Learning From What Has Been Done
Research in Action, Issue 9
This synthesis describes evidence-based research demonstrating what strategies reduce health care costs and what strategies have only mixed results.
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Introduction / Background / Policies That Made a Difference in Lowering Costs / Policies That Had Mixed Results / Ongoing Research / Conclusion / References
By Mark W. Stanton, M.A.
Introduction
During the latter half of the 1990s, health care cost inflation
slowed after several years of rapidly rising price increases.
Many hoped that the various policies and programs
implemented by government, employers, and insurers in the
'90s to control costs would continue to moderate these
increases for the foreseeable future. However, in the last
several years, rising health care costs have again become an
issue.
In 2000, the average annual health insurance
premium in the private sector rose to $2,655 for single
coverage and $6,772 for family coverage, an increase of
33.3 percent and 36.7 percent, respectively, since 1996,
according to new data from the Medical Expenditure Panel
Survey,1 conducted by the Agency for Healthcare Research
and Quality (AHRQ).
Dissatisfaction with the system is
also rising. According to a recent Harris Poll survey, 56
percent of the public, 46 percent of physicians, 48 percent
of employers, 50 percent of health plan managers, and 51
percent of hospital managers said that the health care
system requires "radical change."2 The survey report
predicted that dissatisfaction with the health care system
would increase over the next few years as a result of
increased out-of-pocket costs, concerns about prescription
drug prices, and a possible increase in the number of
uninsured Americans.
Today's policymakers are searching for ways to decrease
the current levels of growth without reducing access to
needed health care services or creating undue burdens for
providers. In some instances, they are revisiting past
strategies; in others, they are exploring new approaches that
seem to hold promise. Before making decisions, today's
policymakers could gain insights by studying the outcomes
of evidence-based research efforts.
This synthesis is intended to provide some of those insights
by examining strategies intended to affect costs and
investigating whether or not they save money. AHRQ-funded
research has found that some approaches (specific
employer contribution methods, competition among health
maintenance organizations [HMOs], and behavioral
managed care) save money, and others (cost sharing,
flexible spending accounts, and hospital mergers) have
mixed results. A unique contribution of AHRQ's research is
its focus on the dynamic or interactive effects of cost-containment
strategies; i.e., estimating the likely effects of
efforts in one sector on the rest of the system. The synthesis
also reviews some of the new research efforts underway.
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Background
In 2000, health care spending rose to $1.3 trillion dollars,
or an average of $4,637 per person. As a percentage of the
Gross Domestic Product (GDP), it grew from 13.1 percent
in 1999 to 13.2 percent in 2000.3 National health
expenditures are expected to reach $2.8 trillion in 2011,
with an average annual growth rate of 7.3 percent from
2001 to 2011. By growing 2.5 percent faster than the GDP,
expenditures will consume approximately 17 percent of the
GDP in 2011.4
In 2000, spending for health services increased at virtually
identical rates in the public (6.9 percent) and private (7.0
percent) sectors. Spending on Medicare, the largest single
public health care program, rose 5.6 percent in 2000,
following much lower growth rates of 0.6 percent in 1998
and 1.5 percent in 1999.3 For the private sector, the year
2000 marked the third straight year of significantly high
growth.5 During 2000, hospital spending growth was 5.1
percent, the first time since 1993 that hospital spending
increased more than 4.0 percent.3
Growth rates are driven by factors such as:6
- Increased use of health care, especially expensive new medical technologies, by all age groups.
- General price inflation.
- Inflation in the prices of medical services beyond general price inflation.
- Aging of the population.
Other factors related to the
organization and delivery of care have also played a role.
For example, the recent movement from tightly managed
care to looser versions of managed care has been a
significant factor in rising costs. In an unprecedented
decline, HMO enrollment fell from 29 percent to 23
percent of privately insured employees from 2000 to 2001
while the percentage of those employees enrolled in the
looser versions of managed care rose proportionately.5
In efforts to restrain rising costs, various strategies have
been used in recent years, including the formation of
physician hospital organizations, the use of different
provider capitation schemes, and negotiated discounts for
private insurers. Recent cost-sharing strategies include
various "tiered" copayment systems for prescription drug
benefits and for hospital use.
Policymakers have
encouraged enrollment in managed care plans (Medicare +
Choice), launched fraud and abuse investigations of the
Medicare program, and allowed inpatient hospital
contracting under Medicaid. Other efforts have been made
to slow the rate of Medicare cost growth by slowing the
increase in payments to health plans, hospitals, home care
providers, and nursing home providers.
In the private
sector, employers have responded to rising cost pressures by
encouraging employees to enroll in managed care plans and
by restructuring their benefits packages and contribution
formulas. Hospitals, physicians, and other providers have
engaged in a variety of mergers and consolidations. And
further changes will be forthcoming in both the public and
private sectors as efforts to meet the conflicting needs to
contain costs and preserve access continue.
Summary
Strategies that reduce costs:
- Employer contribution methods. Employer premium costs were lowered by an average of $480 when employers offered
employees more than two plans and made a fixed dollar contribution regardless of the plan chosen, compared to making a
fixed dollar contribution and offering only two plans.
- HMOs and competition. HMOs reduced costs in highly competitive markets by substituting ambulatory care for hospital
visits.
- Managed care and a State mental health parity mandate. Three years after an insurer introduced a managed behavioral
health care plan, costs for mental health/substance abuse care dropped 39 percent. This step was a response to a State
mental health parity mandate that was expected to lead to higher health care costs. The study did not measure any effects
on the quality of care.
Strategies that have mixed results:
- Flexible spending accounts (FSAs). The tax exemption granted to individual users for these accounts saves money for
taxpayers and is conservatively estimated to reduce Federal revenues by at least $8 billion. FSAs currently encourage
participants to spend money at year's end on medical services with relatively minor value in order to avoid losing the funds
at the end of the year. Allowing a limited amount of the funds remaining in the accounts at year's end to be carried forward
into the following year might eliminate this cost inefficiency.
- Cost sharing. Higher deductibles and copayments save money for insurers and third-party payers but lead to higher out-of-pocket
consumer expenses. This burden falls most heavily on people with the lowest income, those with chronic health
conditions, and those Medicare beneficiaries without employer-subsidized supplemental coverage or Medicaid.
- Hospital mergers. Savings from hospital mergers may be less than anticipated. One study found an average price reduction
of 7 percent for consumers. However, a later study showed that the savings were considerably smaller, or even nonexistent,
when the merging hospital was compared to rival hospitals competing in the same market.
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Policies That Made a Difference in Lowering Costs
Fixed Dollar Contributions Lower Employer Health Care
Costs
Many economists and policymakers have argued that for
employers to lower their health insurance costs, they should
stimulate competition for enrollees among plans by
contributing a fixed dollar amount toward premiums and
offering employees multiple health plans. AHRQ
researchers examined the determinants of competition
among health plans in the context of a model where health
plans first compete to be selected by employers and then
compete to be chosen by employees.7
They show that
focusing competition on the price-sensitive buyer—either
the employer or the employee—leads to lower prices.
While the model suggests this can be achieved either by offering
very few plans or else by offering many plans, the
empirical evidence suggests that premiums are lower with
three or more plans and a fixed dollar contribution.
When employers made the same dollar contribution toward
all plans and offered employees more than two plans, their
premiums for single coverage were lowered by $480 and
their premiums for family coverage were lowered by $791
when compared with premiums for employers making a
fixed dollar contribution but offering only two plans.
However, increasing the number of plans led to higher
premiums if the employer paid the full premium cost.
Under the employer-pays-all scenario, single and family
premiums increased by $441 and $1,853, respectively, when
employers offered three or more plans compared with
offering two plans.7
These findings suggest that an employer's choice of
contribution methods affects the premiums charged by
health plans. Premium differences are one of many factors
employers need to consider when deciding on the number
of plans to offer employees and how to structure employer
contributions. The data analyzed for the study come from
the 1996 Medical Expenditure Panel Survey Insurance
Component.1
Competition Among HMOs Lowers Consumer Prices
The more HMO competitors that an HMO faces in a given
market, the more likely it is to engage in price competition.
This process means lower premiums for consumers.
To find out the effects of market structure on consumer
premiums and the utilization levels of inpatient and
outpatient care, AHRQ-funded researchers compared data
on premiums, hospital use, and ambulatory visits for over
3,000 group-model and independent practice association
(IPA) model HMOs during 1989-95.8
A group-model
HMO is a prepaid health care system that contracts
with one physician group to provide health services. It is a
more tightly managed form of HMO than the IPA model.
An IPA-model HMO is a prepaid health care system that
contracts with individual physicians in independent
practices and/or with associations of independent
physicians. Market structure is defined as a combination of
the penetration rate (the percentage of the population in a
given market enrolled in HMOs) and the number of HMOs
operating in that market.
AHRQ research found that market structure had the
following effects on premiums:
- Group-model HMOs in highly competitive markets (17
competitors and 45 percent HMO market penetration)
had premiums that were 11 percent lower than those in
the average HMO.
- Group-model HMOs in less competitive markets (5
competitors and 15 percent HMO market penetration)
had premiums that were 3 percent higher than average
premiums.
- The effects of market structure on premiums for IPA-model
HMOs were similar but not as pronounced.8
Market structure also had the following effects on
utilization levels of ambulatory visits and inpatient care:
- In markets with many competitors and with high HMO
enrollment, group-model HMOs substituted ambulatory
visits for hospital visits.
- As the number of HMO competitors increased, hospital
use declined for both IPAs and group-model HMOs.
- The average number of ambulatory visits made by
enrollees in IPA-model HMOs was not affected by
market structure.8
One implication is that although HMOs practice price
competition in high-competition markets, they seem to
engage in a more costly (to consumers) rivalry to offer
more benefits and services in low-competition markets.
The study also suggested that HMOs reduce costs by
substituting ambulatory care for hospital visits in more
competitive markets. The study did not examine the
potential effects on the quality of care.
A related AHRQ-funded study of 1,927 hospitals in 134
metropolitan areas shows that higher HMO market
penetration is associated with lower risk-adjusted mortality
rates for fee-for-service (FFS) Medicare enrollees. This
spill-over effect on the quality of care received by those
enrolled in FFS plans may be due to a positive effect of
HMOs on local practice styles or a preferential selection by
HMOs for areas with better hospital care.9
Managed Care Mental Health Carve-Out With Parity
Mandate Lowers Cost
Introduction of a State mental health parity mandate
for severe mental disorders was expected to lead to
significant increases in health care costs for a large
employer group and its insurers. One insurer responded to
this concern by introducing a managed behavioral health
care carve-out. In a carve-out, an organization separate
from the principal health insurer is selected to manage
health care needs in a specific area (e.g., behavioral health)
for the employees of the group.
To learn how the managed behavioral health care carve-out
affected use and costs of care, researchers from AHRQ and
the National Institute of Mental Health studied 75,000
enrollees over a 4-year period before and after the carve-out
went into effect.10
After the carve-out had been in effect for 3 years:
- Per-member plan costs for mental health/substance
abuse services declined by almost 40 percent.
- Per-member plan costs for children and adolescents
declined even more steeply—by 64 percent.
Almost the entire drop in mental health/substance abuse
costs was attributable to a decline in the number of
inpatient hospital days for children and adolescents. The
number of hospital admissions did not change significantly
over the 4-year study period. However, treatment
prevalence rose almost 50 percent because of the rise in the
number of persons receiving outpatient treatment. Although
more people were in treatment, the average number of
visits per patient did not decline (Table 1).
The researchers concluded that the parity mandate did not
lead to cost increases. The researchers also determined that
the impact of the parity mandate on access was ambiguous:
while treatment prevalence rose nearly 50 percent, groups
not subject to the mandate experienced similar increases.
The study was not able to determine whether the significant
drop in inpatient use among children and adolescents was
due to the carve-out's curbing of inappropriate use or from
restricting needed services.
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Policies That Had Mixed Results
Minor Change to FSA Exemption Could Improve Cost
Efficiency
Flexible spending accounts (FSAs) for health care are a
way to lessen the impact of cost sharing on individuals and
families. Typically, employees with FSAs also have
employer-sponsored health insurance policies. FSAs allow
employees to pay for out-of-pocket health care expenses
with pre-tax dollars. In a health care FSA, employees agree
to payroll deductions to put pre-tax dollars into an account
and then use the funds during the year for reimbursement
of health care expenses. If the employee has not used the
money by the end of the year, it is lost (the use-it-or-lose-it
feature). FSAs allow employees to purchase qualified
benefits (defined in Section 125 of the Internal Revenue
Service Code), such as deductibles, copayments, and
medical or dental expenses, on a before-tax basis.
The Federal and payroll tax exemptions allowable by FSAs
may well cause an annual tax loss of at least $8 billion
since the tax exemption reduces the amount of taxes that
would otherwise be collected. Health care FSAs have
received little empirical or theoretical analysis thus far. As
of 1995, 79 percent of employers offer such accounts and
the number of employees taking advantage of these
accounts was growing rapidly.11
A new AHRQ-funded study finds that the use-it-or-lose-it
feature of FSAs encourages individuals to incur medical
expenses with minimal value in order to avoid forfeiting the
funds remaining in the account at the end of the year.11
Removing this feature would eliminate a cost inefficiency
that encourages participants to spend money at year's end
on medical services that might have little value but add to
increasing health care costs. For example, an employee
might decide to buy an extra set of eyeglasses rather than
losing funds remaining in the FSA account at year's end.
Indeed, data from the study show that eye care expenditures
spiked upward at year's end.
The researchers suggested that if the law allowed people to
carry forward any funds remaining in an FSA at year's end,
insurers might respond by dropping coverage for certain
types of relatively predictable health care expenses, such as
orthodontic care and eyewear. If insurers did not cover
these items, then insurance premiums could be lower.
AHRQ-funded researchers studied the actual use of FSAs
based on the records of a medium-sized insurer with 22,000
policyholders who were employees in 73 companies. In this
group, 2,700 policyholders, or 12 percent, used an FSA
account.11
Facts about Flexible Spending Accounts
- FSAs for health care provide a tax exemption by
allowing employees to avoid taxes on their out-of-pocket
health care expenses.
- The entire amount withheld for the account is
exempted from payroll, Federal, and State income
taxes.
- Total out-of-pocket expenditures for Americans were
estimated to be $187 billion in 1999. If only 15
percent of out-of-pocket health care expenses were
paid with money deposited in FSAs (assuming the
average individual faces a 15 percent Federal tax
rate plus a 15 percent payroll levy), the Federal and
payroll tax exemptions would cause tax revenues to
drop by over $8 billion.
Source: Cardon JH, Showalter MH. An examination of flexible spending accounts.
J Health Econ 2001;20:935-54.
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Cost Sharing Hits Vulnerable Groups Hardest
Cost sharing, having individuals pay a portion of their
health care costs out-of-pocket, may contribute to
controlling health care costs by making people more
sensitive to the price of health care. However, it may
impose disproportionate burdens on vulnerable groups
such as the poor and those with multiple chronic
conditions.
How much the individual consumer pays for his or her
care is determined by how third-party payers (employers,
insurers, and government) divide up payments for health
care between themselves and consumers. "Cost sharing"
refers to the split between what the individual consumer
pays and what the third-party payer pays for health care. It
includes deductibles, copayments, and cash outlays that
individuals make for items not covered by health
insurance.
A study by AHRQ-funded researchers shows the effects of
current cost-sharing patterns on the out-of-pocket health
care expenses of Medicare beneficiaries.12
Using data drawn from the 1995 Medicare Current Beneficiary
Survey (MCBS) of 8,000 seniors, the researchers found
that out-of-pocket spending for health care averaged 19
percent of income for Medicare beneficiaries. The type of
supplemental insurance coverage held by beneficiaries had
a significant effect on the percentage of income paid out
of pocket. This percentage ranged from 8.4 percent for
those with both Medicare and Medicaid to 25.5 percent for
those with a self-purchased supplemental plan (Table 2).
More than half of out-of-pocket spending was for
prescription drugs and dental services.
The researchers also reported that, despite Medicaid
coverage for some, the 20 percent of Medicare
beneficiaries with the lowest income spent almost a third
(31.5 percent) of their income on health care, compared
with 8.5 percent in the highest income category. Medicare
beneficiaries in another vulnerable group, those in poor
health, spent 28.5 percent of their income on health care,
compared with 14.9 percent for those in excellent health
(Table 3). (The MCBS asks respondents to assess their health status on a scale from poor to excellent.)
A second study, based on data from AHRQ's Medical
Expenditure Panel Survey, focused on out-of-pocket
spending (deductibles, copayments and cash outlays) by
people with and without chronic illnesses across the entire
population (not just Medicare enrollees).13
It found that the
burden of cost sharing falls most heavily on those with
multiple chronic health conditions and on Medicare
beneficiaries who do not have employer-subsidized
supplemental coverage or Medicaid.
The researchers analyzed spending by both individuals and
families. They found that:
- For people age 65 and over, the highest average out-of-pocket
spending category was prescription drugs ($397),
followed by dental services ($145).
- For people under age 65, the highest average out-of-pocket
spending category was for physician office visits
($104).
- For people with three or more chronic conditions,
average out-of-pocket spending on prescription drugs
was $667.
- Two-person families with an elderly head of household
spent an average of $812 out of pocket, compared with
$429 for their non-elderly counterparts.13
Cost Effect of Mergers Varies by Competitiveness of Market
Many hospital mergers have taken place in recent years.
One of the most frequently mentioned reasons for mergers
is eliminating the duplication of services. Mergers can lead
to lower prices and result in savings for consumers.
However, those concerned about antitrust implications
worry that mergers can decrease consumer welfare by
leading to higher prices and declining competition. Two
closely related AHRQ-funded studies have extensively
investigated the question of whether hospital mergers save
money for consumers.
The first study investigated 122 hospital mergers that took
place from 1986 to 1994.14
It examined the effects of
hospital mergers on price and costs in markets of varying
hospital concentration. While consumers realized an
average price reduction of 7 percent as a result of mergers,
the price reduction was considerably less in highly
concentrated markets. These findings suggest that a greater
emphasis should be placed on antitrust scrutiny of mergers
in areas where the market is dominated by a small number
of competing hospitals.
The second study included 204 hospitals involved in
mergers that took place from 1989 to 1997.15
It refined the
analysis of the first study by dividing nonmerger hospitals
into rival and nonrival groups. It then compared consumer
cost savings only between the merged hospitals and their
immediate rival hospitals. This study found that savings
were modest or nonexistent when merging hospitals were
compared with rival nonmerging hospitals in the same
markets.
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Ongoing Research
The studies cited above are only a part of a much broader
AHRQ research portfolio to inform policymakers on issues
related to cost. Two major initiatives—the Medical
Expenditure Panel Survey (MEPS) and the Healthcare Cost
and Utilization Project (HCUP)—provide essential data that
have been used across the country by researchers and
policymakers in tracking health care use and costs and
assessing trends over time.
Medical Expenditure Panel Survey
An ongoing survey, MEPS continually provides policymakers, health care
administrators, businesses, and others with timely
comprehensive information about health care use and costs
in the United States and improves the accuracy of their
economic projections.
MEPS collects data on the specific
health services that Americans use, how frequently they use
them, the cost of these services, and how they are paid for,
as well as data on the cost, scope, and breadth of private
health insurance held by and available to the U.S.
population. MEPS is unparalleled for the degree of detail in
its data, as well as its ability to link data on health services
spending and health insurance to the demographic,
employment, economic, health status, and other
characteristics of survey respondents. Moreover, MEPS is
the only national survey that provides a foundation for
estimating the impact of changes in sources of payment and
insurance coverage on different economic groups or special
populations of interest, such as the poor, elderly, families,
veterans, the uninsured, and racial and ethnic minorities.
AHRQ, which conducts MEPS in conjunction with the
National Center for Health Statistics, began fielding MEPS
in March 1996.
Healthcare Cost and Utilization Project
HCUP provides information on inpatient hospital charges at the national
and State levels, including all inpatient records with charge
data, clinical data, and demographic information from 80
percent of all hospital discharges in the United States.
HCUP is a Federal-State-industry partnership that provides
a geographically representative sample of hospital
discharges across the United States.
HCUP data help
researchers, policymakers, and health care administrators
answer questions about conditions treated and procedures
performed in U.S. hospitals and ambulatory surgery centers
for the population as a whole and for population subsets,
such as children and the elderly. HCUP data provide
information on reasons for hospitalization, how long people
stay in the hospital, the procedures they undergo while
hospitalized, and how specific conditions are treated in the
hospital.
Other Cost-Related Subjects
AHRQ is also currently funding research into a number of
other areas:
The costs of medical errors and complications—internal
AHRQ study. This study will examine how much more
employers and patients pay for care when medical errors or
complications are involved.
Impact of payment policies on the cost, content, and
quality of care—University of Minnesota, Division of
Health Services Research and Policy, Contract No. 290-00-
0017. This study combines data from health plans to
examine how economic incentives inherent in the
relationship between health plans and health care providers
(physicians and hospitals) influence the cost, quality, and
type of services received by patients.
Examination of potential cost-savings resulting from
volume-outcome effects—internal AHRQ study. This study
will compare the costs in hospitals that perform a high
number of coronary artery bypass grafts (CABGs) each
year with the costs in hospitals that perform a low number
of CABGs. It will also examine how the costs associated
with hospital volume affect cost savings for employers and
Medicare.
Costs of care for very low birthweight babies—RAND
Corporation, R03 HS13429-01. This research will provide
better information on the costs and cost-effectiveness of
neonatal intensive care for infants with low birthweights.
Very low birthweight infants (defined as infants with a
birthweight of 1,500 grams or less) are a vulnerable patient
population. Infant mortality in the United States is
concentrated among this population, who also are subject to
high rates of disability and morbidity.
Incidence of reduced use of prescribed medications by
Medicare beneficiaries in response to out-of-pocket
costs—Center for Health Care Policy and Evaluation,
Contract No. 290-00-0012. This study, using data from
MEPS and the Medicare Current Beneficiary Survey, will
examine the impact of out-of-pocket costs on the
prescription-medication-taking behavior of Medicare +
Choice beneficiaries.
Out-of-pocket prescribed drug costs among elderly
Medicare enrollees—Rutgers University Institute for
Health, Healthcare, and Aging Research, R03 HS13005-01.
This study, using data from MEPS and the Medicare
Current Beneficiary Survey, will examine the out-of-pocket
burden of prescribed medication costs for the elderly
enrolled in the Medicare program.
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Conclusion
Many strategies to contain costs have been tried in recent
years. Some, such as competition among HMOs, managed
care as a way to handle the cost implications of parity
mandates, and certain employer contribution methods, have
been at least partly successful. Others (FSAs, cost sharing,
and hospital mergers) have had mixed results. In some
cases, shifting economic conditions may have been
responsible for the success or failure of different strategies.
As newer strategies are brought into play, research will
continue to evaluate their impact on costs, as well as
outcomes and other aspects of care.
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References
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*14 Connor RA, Feldman RD, Dowd BE, Radcliff TA.
Which types of hospital mergers save consumers
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*15 Spang HR, Bazzoli GJ, Arnould RJ. Hospital mergers
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* AHRQ-funded/sponsored research
Return to Contents
AHRQ Publication No. 02-0046
Current as of September 2002
Internet Citation:
Reducing Costs in the Health Care System: Learning From What Has Been Done. Research in Action, Issue 9. AHRQ Publication No. 02-0046. September 2002. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/costsria/
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