A comparison of myhealthcare Cost Estimator users and nonusers: Effect on provider choices

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1 A comparison of myhealthcare Cost Estimator users and nonusers: Effect on provider choices Samira Kamrudin, MPH PhD Mona Shah, MS Marketing, Product and Innovation Strategic Insights Group Study Report: February 25, 2014

2 Abstract Research Objective: Over the years, consumers have been burdened with greater responsibility for a growing portion of their health care costs. This extra burden makes it more important for consumers to have meaningful information about treatment alternatives and their associated quality and costs. Internet-based transparency tools are one way to educate consumers on the variation in physicians quality and costs. However, research studies are limited in assessing the effects of transparency tools on provider choices and health care spending. UnitedHealthcare launched myhealthcare Cost Estimator (myhce) for consumers to obtain more accurate and personalized cost estimates based on their individual plan design characteristics and actual contracted rates, increasing the accuracy from what was previously available. The tool allows consumers to view specific pricing by episode of treatment alongside provider quality and cost information. It also assigns a designation to physicians, based on UnitedHealth Premium designation (UHPD) program s analysis of their quality and cost efficiency. UnitedHealth Premium aims to help members choose physicians who meet specific standards for quality and cost efficiency to ultimately lower costs and result in better outcomes for members. The goal of this study is to assess the effect of myhce usage on provider choices, and whether the tool encourages the use of quality and efficient (Q&E) physicians. Study Design: We conducted a cross-sectional analysis comparing myhce users and nonusers on demographic, plan design characteristics and provider choices, one year post-myhce. Measures were computed based on health plan administrative data, consisting of enrollment data, and medical claims with physician s specialty and UnitedHealth Premium s provider designation attached. Member characteristics were compared using t-tests for continuous variables and chi-square tests for categorical variables. Logistic regression analysis was used to model the use of Q&E physicians. Population Studied: Medical members who were registered to use UnitedHealthcare s website, resided in markets where the myhce tool was available, were between the ages 18 and 64, and were continuously enrolled for one year postmyhce roll-out were included in our study. MyHCE users were defined as those who used the myhce tool at least once during the study period and nonusers were randomly selected from the remaining population and did not log in to myhce during the study period. Principal Findings: MyHCE users tended to be younger, female and enrolled in consumer-driven health plans (CDHP). In comparing member characteristics between myhce users and nonusers, myhce users were younger in age with 50% aged 40 or younger compared to 40% of the nonusers. A higher proportion of myhce users were enrolled in a consumerdriven health plan (36.5% vs. 27.9%). A higher proportion of myhce users, compared to nonusers, also used the physician specialties that were included in the UHPD program (74.6% vs. 68.6%). Of those using these physician specialties, members that used myhce had higher odds of seeing a Q&E designated provider for all major specialty categories; myhce users had a 9% and 7% higher odds of using Q&E physicians for orthopedics and primary care, respectively. This steerage to Q&E physicians was observed for both CDH members and non-cdh members. Conclusion: Despite different types of members using myhce, the myhce tool is associated with greater usage of quality and efficient physicians. This effect is also seen among plans with and without higher cost-sharing. However, our study design does not account for any baseline differences in Q&E usage that may have existed between users and nonusers. Implications for Policy or Practice: Price and quality transparency tools delivered to consumers via the internet may be an effective way to engage consumers in seeking quality and cost-effective treatments. Future research should focus on examining changes in outcomes through a robust pre-post study design. 2 UnitedHealthcare

3 A comparison of myhealthcare Cost Estimator users and nonusers: Effect on provider choices Background, Research Objectives The United States Government Accountability Office report on health care price transparency established that meaningful price information is difficult for consumers to obtain prior to receiving care 1.Over the years, consumers have been burdened with greater responsibility for a growing proportion of the costs of their health care. Advancement in the health care system is crucial at this time; health care price information that is transparent or presented before consumers receive care may help consumers predict these costs and feel more confident in obtaining health care. Figure 1 represents the value of transparency, revealing significant price variation in a single market 2. Considerable price variation was found for specific treatment Value procedures; of Value Price of Transparency: the Price average Transparency: cost of vaginal childbirth varied by 60% ($7,000 to $11,000) within a market and the average Significant price of Significant lab Price tissue Variation Price tests Variation varied in a Single by 200% a Market Single ($60 Market to $200). Figure 1. Value of transparency, price variation in a single market Dallas Dallas Georgia Georgia Vaginal Child Birth: Vaginal Child Birth: Large Intestine Large Colonoscopy: Intestine Colonoscopy: Vaginal Child Birth: Vaginal Child Birth: Large Intestine Large Colonoscopy: Intestine Colonoscopy: Average price Average can vary price by can vary Average by price Average can vary price by can vary Average by price Average can vary price by 66% can vary Average by 66% price Average can vary price by 100% can vary by 100% 60% ($7,000 to 60% $11,000) ($7,000 to $11,000) 150% ($800 to 150% $2,000) ($800 to $2,000) ($6,000 to $10,000) ($6,000 to $10,000) ($1,000 to $2,000) ($1,000 to $2,000) $12,000 $12,000 $2,000 $2,000 $12,000 $12,000 $3,000 $3,000 $2,500 $2,500 $8,000 $8,000 $1,500 $1,500 $8,000 $8,000 $2,000 $2,000 $1,000 $1,000 $1,500 $1,500 $4,000 $4,000 $500 $500 $4,000 $4,000 $1,000 $1,000 $500 $500 Knee Arthroscopy: Knee Arthroscopy: Lab Tissue Test: Lab Tissue Test: Knee Arthroscopy: Knee Arthroscopy: Hip Replacement: Hip Replacement: Average price Average can vary price by can vary Average by price Average can vary price by can vary Average by price Average can vary price by 100% can vary by Average 100% price Average can vary price by 84% can vary by 84% 66% ($6,000 to 66% $10,000) ($6,000 to $10,000) over 200% ($60 over to $200) 200% ($60 to $200) ($5,000 to $10,000) ($5,000 to $10,000) ($19,000 to $35,000) ($19,000 to $35,000) $12,000 $12,000 $14,000 $40,000 $250 $14,000 $40,000 $250 $30,000 $30,000 $10,000 $10,000 $8,000 $8,000 $150 $150 $20,000 $20,000 $6,000 $6,000 $4,000 $4,000 $50 $50 $10,000 $10,000 $2,000 $2,000 25th percentile 25th of Allowed percentile Amount of Allowed 75th Amount percentile 75th of Allowed percentile Amount of Allowed Amount *The average price *The variation average is calculated price variation using is the calculated 25th percentile using the and 25th 75th percentile and of Provider 75th percentile Allowed of Amounts Provider sourced Allowed from Amounts 2008 sourced claims. Average from 2008 episode claims. cost Average includes episode Inpatient, cost includes Inpatient, Outpatient, Price 1 Physician, Outpatient, transparency 1 Lab, Radiology Physician, and Lab, Pharmacy Radiology cost and Pharmacy cost tools that are well-developed will support more informed, financially intelligent health care decisions, Confidential Property Confidential of UnitedHealth Property Group. of UnitedHealth Do not distribute Group. or Do reproduce not distribute without or express reproduce permission without express of UnitedHealth permission Group. of UnitedHealth Group. combined with benefit plans that are designed to require more conscious health care choices by consumers, which will in turn help create engaged, informed, educated consumers and may save as much as $36 billion (3.5%) from annual health care expenditures 3. In March 2012, UnitedHealthcare launched myhealthcare Cost Estimator (myhce) in select markets to help consumers obtain more accurate, personalized estimates they can trust; consumers can also view provider quality information alongside price to gain a complete understanding of their treatment, what to expect and alternatives. Estimates for procedures are based on available fee schedules and actual contracted rates with care providers. The UnitedHealth Premium designation program was developed in 2005 to show members that choosing a physician who meets specific standards for quality and cost efficiency can help keep health care costs lower for everyone. The program uses evidence-based, medical society, and national industry standards with robust methodologies and data sources to evaluate physicians across 25 specialties. Physicians who meet both the quality and cost-efficiency designation criteria will receive the quality and efficient (Q&E) designation. At the time of this study, Tier 1 physicians were defined as having a Quality and Cost Efficiency (Q&E) designation. The current Premium designation program, starting in 2014, defines Tier 1 as Quality & Cost Efficiency OR Cost Efficiency & Not Enough Data to Assess Quality. Research from the Premium program evaluation indicated that Tier 1 physicians were associated with lower episode costs, (an average reduction of 21%) and improved overall outcomes 4. We examined the effects of price transparency on members provider choices, after adjusting for differences in member characteristics. In particular, we compared two distinct groups of members: 1) users of myhce and 2) nonusers of myhce, and whether differences in the percentage using a quality and efficient (Q&E) physician were found. We also assessed differences in effect by plan design, age, gender and geographic region. 3

4 Methods Population Criteria All medical plan members enrolled continuously for one year following the roll-out of myhce from March 31, 2012 through March 30, 2013, were selected for inclusion in the present study. All members resided within 47 markets where myhce was available as of March 31, 2012, were registered users of and, as of March 31, 2012, were between the ages of 18 and 64. In addition, myhce users were defined as members logging into myhce at least once during the study period (N=182,864). Nonusers were selected by random sample selection among those members who did not log into myhce, but had a valid registered account (N=243,200). Key Measures For each member, we obtained: Provider Choices We extracted all medical claims data with service dates between March 31, 2012 and March 30, Designations from the UnitedHealth Premium designation program were obtained and attached to the claims via provider number. Designations were available for 13 individual specialties, which fell into the broad categories of: primary care physicians, cardiologyrelated, orthopedics-related and other specialties (Table 2). The UnitedHealth Premium program assigns a designation of Quality and Efficient, also known as two-star, for providers that meet certain criteria for both quality and cost. Flags were created to indicate whether the members had at least one claim with a specialty physician and if the physician was seen, then whether the physician was designated as Q&E. Demographic and plan design characteristics The following member characteristics were obtained: age, gender, UnitedHealthCare-assigned geographic region, type of coverage or household composition, whether they had pharmacy coverage, financial arrangement of employer (self-insured or ASO vs. fully insured), market segment (national accounts, public sector, major accounts, key accounts), and consumerdriven health plan (CDHP) design (health savings account, health reimbursement account). Statistical Analysis Member characteristics were compared using t-tests for continuous variables and chi-square tests for categorical variables. The objective of the adjusted analysis was to examine the effect of myhce usage on use of Q&E physician, after other factors possibly affecting Q&E selection were accounted for. These factors included age, gender, region, coverage type, relationship, financial arrangement, market segment, and CDHP. Logistic regression was used to model Q&E provider utilization by broad specialty categories that were: all specialties, cardiology, orthopedics, primary care, and other specialties. Our model estimates the odds of seeing a Q&E provider by specialty using a logit model. Statistical significance was determined at the p-value of 0.05 or less, for all statistical tests. Sensitivity Analysis The percentage of myhce users and nonusers that used broad categories of specialties was also assessed for select subgroups of members. Logistic regressions were computed by evaluating member subgroups: older than 40 years, gender, whether members resided in the Northeast region, and whether members were enrolled in a CDH plan. These analyses allow us to determine if the effects on provider choice were similar by these subgroups. Results Member characteristics A comparison of the myhce users and nonusers on select demographic and plan design characteristics revealed that users were younger in age, with nearly 50% of myhce users being age 40 or younger compared to almost 40% of nonusers (Table 1). MyHCE users were also more likely to be female and less likely to reside in the Northeast with a greater presence in the Central and West regions. There was also a significant difference between myhce users and nonusers in terms of their plan design. A higher proportion of myhce users were enrolled in CDH plans including HSAs and HRAs; nearly 40% of myhce users were enrolled in CDH plans compared to 30% of nonusers, with a greater difference seen among enrollment in HSA plans (Table 1). All differences in characteristics were statistically significant (p-value<0.05) except pharmacy coverage. 4 UnitedHealthcare

5 A comparison of myhealthcare Cost Estimator users and nonusers: Effect on provider choices Table 1. Member characteristics by myhce user status Age Distribution Avg Age (years) Gender Region Coverage Type myhce Users N=182,864 Nonusers N=243,200 Difference in % % 13.5% % 24.4% % 27.5% % 34.6% -4.5 Mean (SD 2 ) 42.7 (11.5) 44.5 (11.3) -- Female 55.4% 49.5% 5.9 Male 44.6% 55.4% Central 43.6% 39.9% 3.7 Northeast 14.1% 21.7% -7.6 Southeast 22.7% 21.5% 1.2 West 19.6% 16.9% 2.7 Employee only 32.7% 34.1% -1.4 Family with spouse only 18.1% 16.1% 2.0 Family with children 49.3% 49.7% -0.4 Relationship Employee 90.6% 87.0% 3.6 Spouse 9.4% 13.0% -3.6 Financial Arrangement ASO 80.8% 78.0% 2.8 Fully Insured 19.2% 22.0% -2.8 Market Segment National Accounts 55.2% 53.9% 1.3 Public Sector 8.5% 10.5% -2.0 Major Accounts 11.4% 11.4% 0.0 Key Accounts 15.1% 14.1% 1.0 Small Business 8.4% 8.1% 0.3 Plan Coverage Pharmacy Coverage Yes 42.0% 42.0% 0.0 No 58.0% 58.0% 0.0 HSA Plan Yes 19.0% 13.3% 5.7 No 81.0% 86.7% -5.7 HRA Plan Yes 16.9% 14.1% 2.8 No 83.1% 85.9% -2.8 CDH Plan Yes 36.5% 27.9% 8.6 No 63.6% 72.1% Difference in percent is calculated by proportion of myhce users for each characteristic minus non-myhce members. Positive differences represent a greater representation of the characteristic among myhce users. All differences in characteristics were statistically significant (p-value<0.05) except pharmacy coverage. 2 SD=standard deviation 5

6 Provider specialty utilization Among all physician specialties designated by the Premium program, myhce users were more likely to see a specialty physician. Almost 75% of users saw a specialist, compared to 68.6% of nonusers. The greatest difference in use for broad categories was in primary care and orthopedics (Table 2). Table 2. Utilization of specialties designated by the UnitedHealth Premium designation program, by study group and by specialty category Provider Specialty myhce Users N=182,864 Nonusers N=243,200 Difference in % 1 All specialties 136,369 (74.6%) 166,723 (68.6%) 6.0 Any primary care provider 2 130,264 (71.2%) 157,933 (64.9%) 6.3 Cardiology 16,991 (10.1%) 20,710 (9.6%) 0.5 Orthopedics 3 23,212 (13.8%) 23,655 (11.0%) 2.8 Other specialty 4 23,212 (13.8%) 23,655 (11.0%) Difference in percent is calculated by percentage of myhce users that see specialty category minus non-myhce members that see specialty category. Positive differences represent greater usage of specialty among myhce users 2 Any primary care provider includes the following four specialties: family medicine, internal medicine, obstetrics and gynecology, and pediatrics 3 Orthopedics include neurosurgery and spine 4 Other specialties include: allergy, endocrinology, infectious disease, nephrology, neurology, pulmonology, and rheumatology Among users, the use of quality and efficient (Q&E) physicians Within all broad categories of specialties, we found a higher proportion of myhce users that saw a Q&E designated provider compared to nonusers. Except for cardiology, the differences in Q&E usage were statistically significant (Table 3). The adjusted logistic regression results were consistent with the unadjusted findings in that we saw that myhce users had higher odds of using Q&E designated physicians, among all physician specialties. This is driven by Q&E usage among primary care physicians and orthopedists, where odds were found to be 7% and 9% higher, respectively among myhce users compared to nonusers (p-value<0.05). The odds of seeing a Q&E physician are similar for cardiology-related physicians and other physician specialties (Table 4). Table 3. Percentage seeing a physician designated as quality and efficient (Q&E), by study group Provider Specialty myhce Users N=182,864 Nonusers N=243,200 Difference in % 1 All specialties: Of the users, % that see Q&E 61.2% 59.2% 2.0 Any Primary Care Provider: 2 Of the users, % that see Q&E 59.0% 56.8% 2.2 Cardiology: Of the users, % that see Q&E 80.0% 79.0% 1.0 Orthopedics: 3 Of the users, % that see Q&E 60.9% 59.0% 1.9 Other specialty: 4 Of the users, % that see Q&E 63.6% 62.5% Difference in percent is calculated by percentage of myhce users that see Q&E designated physicians minus non-myhce members that see Q&E designated physician. Positive differences represent greater usage of Q&E designated physicians among myhce users 2 Any primary care provider includes the following four specialties: family medicine, internal medicine, obstetrics and gynecology, and pediatrics 3 Orthopedics include neurosurgery and spine 4 Other specialties include: allergy, endocrinology, infectious disease, nephrology, neurology, pulmonology, and rheumatology *The number of users in each category is presented in Table 2 Table 4. Logistic regression analysis, the odds of seeing a Q&E designated provider by broad provider specialty categories Provider Specialty Odds Ratio 1 95% Confidence Interval All specialties , 1.09 Any primary care provider , 1.08 Cardiology , 1.07 Orthopedics , 1.13 Other specialty , All odds ratios are adjusted for the following variables: age, gender, UnitedHealthcare region, coverage type, customer attributes, plan design characteristics (CDHP, HSA, HRA) 2 Any primary care provider includes the following four specialties: family medicine, internal medicine, obstetrics and gynecology, and pediatrics 3 Orthopedics include neurosurgery and spine 4 Other specialties include: allergy, endocrinology, infectious disease, nephrology, neurology, pulmonology, and rheumatology Bold type indicates statistically significant findings at the alpha=0.05 level 6 UnitedHealthcare

7 Sensitivity Analyses A higher percentage of myhce users were younger in age ( 40 years) and female while a greater percentage of nonusers resided in the Northeast region. In evaluating the logistic regressions for Q&E physician use, we found that younger age groups ( 40 years) had a greater magnitude in the association for myhce usage and Q&E physician selection (OR: 1.12, p-value<0.05) (Table 5). Although a positive association was also observed for older age groups (>40 years) the magnitude was not as strong compared to younger myhce users. Moreover, a difference in Q&E physician usage was not apparent when we compared males and females. MyHCE users that did not reside in the Northeast region were found to have higher odds in using Q&E physicians (Table 5). Table 5. Subgroup analysis, the odds of seeing a Q&E designated physician by age, gender, region, and plan design for all specialties myhce Users Nonusers Odds Ratio 95% Confidence Interval Age>40 Yes 75, , , 1.09 No 60,397 58, , 1.14 Gender Male 53,889 74, , 1.10 Female 82,477 91, , 1.08 Northeast Region Yes 18,672 37, , 1.05 No 117, , , 1.10 CDH Plan Yes 50,336 45, , 1.11 No 86, , , 1.09 Bold type indicates statistically significant findings at the alpha=0.05 level All specialties include: family medicine, internal medicine, obstetrics and gynecology, pediatrics, allergy, endocrinology, infectious disease, nephrology, neurology, pulmonology, rheumatology, neurosurgery, orthopedics and spine, and cardiology Members with consumer driven health plans Since a larger proportion of myhce users were enrolled in a CDH plan, it suggests that there could be a different effect on provider choices by plan design. Subgroup analyses were conducted to investigate the role of CDH plans in myhce use and seeing a Q&E provider, to see if the higher cost sharing structure of these plans would influence the shopping behavior of these individuals differently compared to non-cdh enrollees. In both CDH and non-cdh subgroups, using myhce was associated with greater odds of Q&E provider use but there were no major differences in this effect between groups (Table 5). For example, the odds of using a Q&E provider was 9% higher among CDH members, compared to 8% higher among non-cdh members. Both odds ratios were statistically significant (p-value<0.05). When looking within primary care specialties and orthopedic-related specialties, this finding held true. However, among cardiology-related specialties and other specialties, the difference in Q&E usage among myhce users versus nonusers, was greater among non-cdh members compared to CDH members (data not shown). These findings suggest that the myhce tool may be the factor in consumer engagement and use of Q&E providers and CDHP status may not be a strong contributor to the association. There were no differences detected when we assessed HSA and HRA plans in subgroup analysis (data not shown). 7

8 Discussion Regardless of differences in member characteristics, we found that the myhce tool engages all consumers and is associated with greater usage of quality and efficient physicians. This effect was evident among members despite whether or not they had higher cost-sharing medical plans. In the past five years, public and private price transparency initiatives have become more prevalent 1 ; however published studies suggest that consumers may not use price transparency information even if they have access to it in making health care decisions 5 because of a lack of sensitivity to prices. Even though consumers may have concerns, research studies suggest that consumers want access to price information prior to receiving health care services 1. However, the research is limited in assessing the actual effects of transparency tools on provider choices and health care spending. The present study aimed to assess the effect of myhce usage on provider choices, and whether the tool encourages the use of quality and efficient (Q&E) physicians. We found that myhce users tended to be younger in age, with 50% of users aged 40 or younger compared to 40% of nonusers. This may be an indication of overall comfort in using online tools being higher among persons of younger ages 6. A higher proportion of myhce users were more likely to be female. In accord with our findings around age, myhce users were less likely to have families with children and more likely to be single or married without children. Moreover, myhce users were less likely to reside in the Northeast region. In terms of plan design characteristics, we found a higher proportion of myhce users to be enrolled in consumerdriven health plans. We considered that the higher cost-sharing attribute of the CDH plans may be an incentive to shop for Q&E physicians. Previous research in assessing users and nonusers of UnitedHealthcare s website showed similar differences in member characteristics overall 6. A higher proportion of myhce users, compared to nonusers, also used the physician specialties that were included in the UnitedHealth Premium program, possibly indicating higher health care needs among myhce users. Of those using these physician specialties, members that used myhce had higher odds of seeing a Q&E designated provider for all major specialty categories; myhce users had 9% and 7% higher odds of using Q&E providers for orthopedics and primary care, respectively. This steerage to Q&E physicians was observed for CDH members and non-cdh members, males and females, and younger and older members. The UnitedHealth Premium program evaluation indicated that Tier 1 physicians were associated with 21% lower episode costs. The episode-based costs of premium orthopedic surgeons were 26% lower than for other orthopedic surgeons 4. Based on this previous research, we can hypothesize that myhce members who use Q&E providers may save more money overall. There are several limitations in our study. This is a cross-sectional analysis based on one year of data post-myhce; we did not have baseline data available and therefore, we could not evaluate changes in provider choices over time. In addition, our data is limited in that we could not account for differences in health status or socioeconomic variables, which may play a role in the need to use the myhce tool and provider choices. Future research should focus on establishing a stronger cause-and-effect relationship by taking into account pre- and post- data. Our study shows that myhce has strong potential to engage consumers in seeking quality and cost-effective providers. Therefore, more effort is needed to reach groups of members who are not using the tool. Future research is needed to focus on health care spending and utilization, with an emphasis on conditions where there is high variation in care. References 1. United States. Government Accountability Office. Health care price transparency meaningful price information is difficult for consumers to obtain prior to receiving care : report to congressional requesters. Washington, D.C.: U.S. Govt. Accountability Office,; Available from: 2. UnitedHealthcare. Value of Price Transparency Coluni B. Save $36 billion in U.S. healthcare spending through price transparency: Thomson Reuters UnitedHealthcare UnitedHealthcare internal claims analysis Ginsburg PB. Shopping for price in medical care. Health affairs Mar-Apr;26(2):w Chen S, Karaca-Mandic P, Levin R. Who values information from a health plan Internet-based decision tool and why: a demographic and utilization analysis. Health services research Feb;47(1 Pt 1): Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. 9/ United HealthCare Services, Inc. UHCEW

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