Insurance deductibles may impact ED visits for chest pain, notably in lower-income areas
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Individuals whose employers switched to higher deductible health plans were less likely to visit the ED for chest pain after the switch, according to data published in Circulation.
After the switch to a higher deductible, there was a disproportionate increase in hospitalizations after ED diagnosis of nonspecific chest pain and subsequent acute MI diagnosis on hospital discharge among employees from lower-income neighborhoods, researchers reported.
“In this study, we found that members whose employers mandated [switches to higher-deductible health plans] had reduced index ED visits with a diagnosis of nonspecific chest pain,” Shih-Chuan Chou, MD, MPH, SM, instructor in emergency medicine at Brigham and Women’s Hospital, and colleagues wrote. “Subgroup analyses suggested that members with baseline year cardiovascular comorbidities and those with higher neighborhood poverty rates accounted for most of the observed reduction.”
For this analysis, researchers utilized a commercial and Medicare Advantage claims database to identify 557,501 people (mean age, 42 years) whose employers exclusively offered low-deductible health plans ( $500) one year and then mandated high-deductible health plans ( $1,000) for a subsequent year. This group was matched to a control group of 5,861,990 individuals whose employers only offered low-deductible plans.
The primary outcomes included rates of index ED visits with a principal diagnosis of nonspecific chest pain, admission during index ED visits and index ED visits followed by noninvasive cardiac testing within 3 and 30 days, coronary revascularization and hospitalization for acute MI within 30 days.
Decrease in ED visits
Researchers reported that switching to a high-deductible health plan was associated with a 4.3% decrease in ED visits for nonspecific chest pain (95% CI, –5.9 to –2.7; absolute change, –4.5 visits per 10,000 person-years; 95% CI, –6.3 to –2.8) and an 11.3% decrease in visits leading to hospitalization (95% CI, –14 to –8.6; absolute change, –1.7 visits per 10,000 person-years; 95% CI, –2.1 to –1.2).
Switching to a high-deductible health plan was not associated with any changes in stress testing at 3 or 30 days after the index nonspecific chest pain ED visit except for a 15.2% decrease in nuclear stress testing (95% CI, –21.5 to –8.9; absolute change, –0.8 per 10,000 person-years; 95% CI, –1.1 to –0.4).
Researchers observed a 15.9% increase (95% CI, –1 to 32.7) in 30-day admission for acute MI, but the findings were not statistically significant (absolute change, 0.3 per 10,000 person-years; 95% CI, –0.01 to 0.5).
However, in participants from higher-poverty neighborhoods, the switch to a high-deductible health plan was associated with a 29.4% increase (95% CI, 13.3-45.6) in acute MI hospitalization in the 30 days after ED visit for nonspecific chest pain (absolute change, 0.6 per 10,000 person-years; 95% CI, 0.3-0.9).
Shared decision-making
“These findings point to a growing need to incorporate cost-of-care information during shared decision-making between clinicians and patients, at a time when most employees have high-deductible health plans,” the researchers wrote. “Recent regulatory changes mandating price transparency are a promising change. With the increasing use of shared decision-making, particularly during ED evaluations for acute chest pain, it is also important for future research to examine how clinicians should best integrate cost-of-care information.”
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