The GAO has released a report recently. This one is better than the EBRI report. It includes a literature review of 31 other studies, including most of the vendor reports I have used in the past.
Oddly, this review also excludes the American Academy of Actuaries study. Then it digs deeper into the experience of two large employers, one public and one private, that adopted HRA programs in 2003.
It compares the experience of the populations that chose the HRA with those that stayed in a PPO plan. It finds that the HRA choosers had substantially lower utilization in the two years before the HRA became available.
But it also found -
"For the public and private employers we reviewed, health care spending and utilization of health care services for the HRA groups generally increased by a smaller amount or decreased compared with the PPO groups, from the period before to the period after switching. Additionally, the majority of the studies we reviewed that examined total or medical spending and controlled for differences in health status or other characteristics of enrollees reported lower spending among enrollees in HRAs and other CDHPs relative to traditional plans."
Health care utilization started low for the HRA group, and got even lower after the switch.
Still, the GAO study is frustrating because it doesn't look at a lot of issues that are worth pursuing.
In the employers examined, the selection effect is very strong, much more so than most of the other experience I have seen.
The HRA choosers were substantially healthier than the PPO choosers, but why? Other than some very simple demographics (age, income, gender) GAO doesn't really explore the reasons.
We have long maintained that "early adopters" of any product or service are likely to be younger and better educated than the rest of the population, but very few studies bother to control for educational level.
It is impossible to draw conclusions without such a control. It would be very worth knowing if people with college degrees who choose an HRA are healthier than people with college degrees who do not.
But we cannot tell here who the HRA choosers are being compared to. If one group is made up of college graduates and the other is all high school drop-outs, the comparative health status would be completely unremarkable.
It would also be worth knowing how committed these two employers were to educating workers about the new program. We have seen over and over again that employers who take the time to educate employees about the new program have better results than those who do not.
GAO doesn't even reveal what proportion of the work force chose the new HRA program. Was it 50% or 5%? They don't say.
Finally, although GAO lists the financial structure of the PPO and HRA programs for the two employers, it doesn't discuss the differences, or flesh out related information such as whether unused HRA balances roll over from year to year. These design features are critical.
For instance, for the private employer, HRA enrollees pay $312 in premium and are exposed to a $2,500 deductible, of which the employer pays $750, leaving the worker exposed to $2,062 in annual costs.
The PPO enrollees pay $624 in premium and have a $300 deductible, leaving them exposed to only $924 in annual costs. That is a big difference. I'm not sure why anybody would sign up for a program like this.
So, once again we have a whole lot of numbers thrown around, but absolutely no increase in understanding. Sad.