Switching to high-deductible health plan increases odds for diabetes-related complications
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Key takeaways:
- Adults with diabetes are more likely to have complications if they switch to a high-deductible health plan.
- The risk for complications rises with each additional year of high-deductible health plan enrollment.
Adults with diabetes who are forced to switch to a high-deductible health insurance plan have higher risk for diabetes-related complications than those who remain on a regular health plan, according to study data.
“High-deductible health plans, which are increasingly common — both because their lower monthly premiums make them appealing and because employers increasingly offer no other options to their employees for health coverage — are not appropriate for people living with diabetes,” Rozalina G. McCoy, MD, MS, associate professor of medicine at University of Maryland School of Medicine and director of precision medicine and population health at the University of Maryland Institute for Health Computing, told Healio. “Our study, which looked at the implications of people with diabetes being forced to switch from a regular health plan to a high-deductible health plan because their employer offered no other option, found that people who are forced to switch experience significantly higher rates of all diabetes complications compared to other similar people with diabetes who were not forced to switch.”
McCoy and colleagues conducted a retrospective cohort study with data from 245,055 adults with diabetes who were enrolled in an employer-sponsored health plan that did not have a high deductible for at least 1 year from 2010 to 2018. Adults were considered to have been forced to switch to a high-deductible health plan if the only health plans available to them had an in-network deductible that exceeded the minimum individual deductible qualifying them for a health savings account. Participants who switched to a high-deductible health plan were compared with a group of adults who were not forced to switch. Data on macrovascular complications, microvascular complications, lower-extremity complications, retinopathy diagnosis and treatment, and blindness were collected. Data were obtained from the OptumLabs Data Warehouse.
High-deductible plans increase complications odds
Of the study group, 42,326 adults switched to a high-deductible health plan (mean age, 52 years; 46.7% women) and 202,729 remained in a non-high-deductible health plan (mean age, 53 years; 44.3% women). Adults who switched were more likely to have myocardial infarction (OR = 1.11; 95% CI, 1.06-1.16), stroke (OR = 1.15; 95% CI, 1.09-1.21), hospitalization for heart failure (OR = 1.35; 95% CI, 1.3-1.41), end-stage kidney disease (OR = 2.53; 95% CI, 2.38-2.7), a lower-extremity complication (OR = 2.23; 95% CI, 2.17-2.29), proliferative retinopathy (OR = 1.17; 95% CI, 1.13-1.21), blindness (OR = 2.35; 95% CI, 2.18-2.54) and retinopathy treatment (OR = 2.28; 95% CI, 2.15-2.41) than adults who did not switch.
Each year that participants were enrolled in a high-deductible health plan increased the odds for MI (OR = 1.07; 95% CI, 1.06-1.09), stroke (OR = 1.08; 95% CI, 1.06-1.1), hospitalization for heart failure (OR = 1.14; 95% CI, 1.12-1.15), end-stage kidney disease (OR = 1.34; 95% CI, 1.32-1.37), a lower-extremity complication (OR = 1.33; 95% CI, 1.32-1.34), proliferative retinopathy (OR = 1.05; 95% CI, 1.04-1.07), blindness (OR = 1.31; 95% CI, 1.28-1.34) and retinopathy treatment (OR = 1.29; 95% CI, 1.26-1.31).
Speak with patients about coverage
McCoy said the findings were concerning because an increasing number of people in the U.S. have high-deductible health plans.
“Patients with high-deductible health plans — consciously and subconsciously — ration their health care utilization, and we know that they do not preferentially restrict care that we believe to be low value; instead, they often limit care that is clinically important,” McCoy said. “We need to speak with our patients about their health insurance coverage and financial barriers to care so that we can work with them to address these barriers and make sure our patients get the care and treatments they need to be healthy. We also need to advocate to reform high-deductible health plans, if not eliminate them altogether, which I personally think is the most appropriate way forward. Diabetes complications can and should be prevented, but high-deductible plans force patients to ration their care, and so they develop these serious and irreversible diabetes complications that result in morbidity, disability and ultimately death.”
McCoy said future studies need to investigate how people with diabetes make decisions with health care services when they are enrolled in a high-deductible health plan.
“We need more research about how health policies impact care delivery and health,” McCoy said. “Unfortunately, there are not many agencies and organizations that fund such research, with most funding focused on biomedical and not policy or econometric analyses, but I hope that this changes and more work can be done to improve how care is delivered, paid for and accessed.”
For more information:
Rozalina G. McCoy, MD, MS, can be reached at rozalina.mccoy@som.umaryland.edu.
Perspective
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Osagie Ebekozien, MD, MPH, CPHQ
I congratulate McCoy and colleagues for their well-designed and adequately powered study examining the impact of high-deductible insurance plan on people with diabetes. They found that people that switched to a high-deductible plan had a staggering (more than 200% in some conditions) increased odds for complications as compared to those that didn’t switch plans. The study had limitations as addressed in their paper.
Overall, the study results remain shocking, press-worthy, unfortunate but sadly, not surprising. I had some reflections from reading the study, which I share below. My reflections are inspired from my leadership role as the chief medical officer of T1D Exchange and as a diabetes equity and population health researcher.
- Insurance plays such a key role in health outcomes. Our recent T1D Exchange study found that insurance is an independent contributor to clinical outcomes for people with type 1 diabetes. (Ebekozien O, et al. Diabetes Technol Ther. 2023;doi:10.1089/dia.2023.0320). Furthermore, T1D Exchange has previously published collaborative papers showing better diabetes outcomes in countries with more favorable insurance coverage as compared with the U.S. Is it time for us to consider a paradigm shift in insurance cost and access?
- Diabetes is expensive to manage. A recent American Diabetes Association study reported that one out of four health care dollars is spent on diabetes. Can we systemically bring down the overall cost of providing high-value diabetes care without the major price tag? More importantly, can we prevent more people from experiencing the burden of diabetes?
- Money and economic status are undisputed determinants of health outcomes. It is a sad reality whenever people with diabetes must make a choice between whether to pick up their diabetes medications vs, paying for rent or food on their table. Can we do better?
- Innovative therapies like the GLP-1 receptor agonists are showing remarkable benefit to improve diabetes outcomes and potentially reduce complications. Can we make these therapies more accessible without making people make major cost decisions?
I applaud several nonprofit organizations, including mine, industry partners, funders and philanthropic organizations that are acutely aware of the need to tackle these issues and working to implement different collaborative solutions. I am optimistic for the future of diabetes management.
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