Mixed HSA Results Show Need for Education

News Updates


Fall-off in preventative visits, some screenings, indicate confusion over coverage


With a growing number of workers covered by health savings account (HSA)-eligible high-deductible health plans, how does the use of health care services by HSA participants compare with traditional health plans?

New research from the nonprofit Employee Benefit Research Institute (EBRI) finds a mixed bag: Depending on the health care service, HSA plans could result in higher or lower use, and in some cases no change whatsoever.

The report, Quality of Health Care After Adopting a Full-Replacement, High-Deductible Health Plan with a Health Savings Account: A Five-Year Study, was published in the September EBRI Issue Brief. Data for the study came from a large employer that replaced all of its health insurance options with an HSA-eligible health plan. Use of health care services was examined over five years—of which four years followed the adoption of the HSA-eligible health plan.

“This study represents one of the longest observation periods reported with a full-replacement, HSA-eligible health plan, and is one of the few studies with a control group,” noted study co-author Paul Fronstin, director of EBRI’s health research and education program, in a statement accompanying the report.

Preventative Care Use and Coverage

By several measures, HSA plans appeared to result in less use of preventive health care. For instance, adoption of an HSA-eligible health plan was associated with:

• A slight decline in annual physicals, well-child pediatrician visits and other preventive visits relative to the comparison group after four years. Since preventive services must be covered on a first-dollar basis by nongrandfathered plans under the Affordable Care Act (ACA), the fall-off in preventative visits may indicate a lack of understanding among HSA participants regarding what is and isn’t covered outside their deductible.

• A reduction in breast cancer, cervical cancer and colorectal cancer screenings in year one, although screenings for breast cancer and cervical cancer rebounded in year two. By year four, breast cancer screening was higher among enrollees in the HSA-eligible health plan than in the comparison group. In contrast, throughout all of the study years, colorectal cancer screening was lower among HSA-eligible health plan enrollees than in the comparison group.

As with preventative services, cancer screenings that follow standard guidelines must be covered outside the deductible by nongrandfathered plans under the ACA, a point about which HSA participants may be unaware. (This doesn’t mean employees showing no symptoms of colorectal cancer are entitled to a colonoscopy every year covered on a first-dollar basis. Instead, nonsymptomatic employees over the age of 50 might receive a colonoscopy covered by the plan once every five years, in keeping with widely accepted diagnostic standards.)

• Use of antibiotics went up among the HSA-eligible plan enrollees for adults with acute bronchitis, as did X-rays for lower back pain—both services that are often considered unnecessary but are often routinely recommended by health care providers, according to EBRI.

Increased promotion of nurse hotlines or other health coaching services can provide participants with a better understanding of what is likely to be an effective use of their health care dollars.​

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