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High deductibles may lead to increased diabetes complications

Patients with diabetes who have low-incomes and health savings account–eligible high-deductible health plans experienced significant increases in ED visits for preventable acute diabetes complications, according to research findings published in JAMA Internal Medicine. Therefore, vulnerable patients with diabetes may need protection under improved health insurance designs.

“High-deductible health plans (HDHPs) have recently become the predominant commercial health insurance arrangement in the United States,” J. Frank Wharam, MB, BCh, BAO, MPH, from the Harvard Medical School and Harvard Pilgrim Health Care Institute, and colleagues wrote. “These plans have expanded under the Affordable Care Act and are expected to play a major role in the future of U.S. health policy.”

“Diabetes is a major cause of morbidity and premature death in the United States,” they added. “High cost-sharing might especially affect chronically ill patients who require frequent and expensive services. However, the effects of HDHPs on outpatient care patterns and adverse outcomes among chronically ill patients are unknown.”

Between Feb. 23, 2015 and Sept. 11, 2016, Wharam and colleagues evaluated how high-deductible insurance enrollment affected diabetes outpatient care and acute complications. They assessed data from Jan. 1, 2003, to Dec. 31, 2012, from a large national health insurer database that included 12,084 HDHP members with diabetes aged 12 to 64 years (mean age, 50.4 years; 44.8% women). Participants had been enrolled in a low-deductible ( $500) plan for 1 year followed by an HDHP ( $1,000) for 2 years after an employer-mandated transition. Patients were categorized into two subgroups: low-income (n = 4,121) and health savings account (HSA)–eligible (n = 1,899). Patients who switched to HDHPs were propensity-score matched with patients who could only receive low-deductible coverage.

Results showed that in the year after switching to HDHPs, out-of-pocket medical expenditures increased by 49.4% (95% CI, 40.3-58.4) in the overall group, 51.7% (95% CI, 38.6-64.7) in the low-income group and 67.8% (95% CI, 47.9-87.8) in the HSA-eligible diabetes HDHP group, compared with controls. In the overall HDHP group, there was no significant change in high-priority primary care visits and disease monitoring tests; however, compared to baseline, there was a decline in high-priority specialist visits by 5.5% (95% CI, –9.6 to –1.5) in the first year of follow-up and 7.1% (95% CI, 11.5 to 2.7) in the second year of follow-up.

At follow-up, the overall (adjusted HR = 0.94; 95% CI, 0.88-0.99) and low-income HDHP (adjusted HR = 0.89; 95% CI, 0.81-0.98) groups had delayed outpatient acute diabetes complication visits. HDHP members in the overall, low-income and HSA-eligible groups experienced increases in annual ED acute complication visits by 8% (95% CI, 4.6-11.4), 21.7% (95% CI, 14.5-28.9) and 15.5% (95% CI, 10.5-20.6), respectively.

“This study found that patients with diabetes experienced minimal changes in outpatient visits and disease monitoring after an HDHP switch, but low-income, high-morbidity, and HSA HDHP subgroups experienced major increases in ED visits or expenditures for preventable acute diabetes complications,” Wharam and colleagues concluded. “These subgroups might be especially at risk in the increasingly HDHP-centric private U.S. health system, and our results support a strategy of minimizing the enrollment of vulnerable diabetes subpopulations in HDHPs or targeting cost-sharing reductions, such as HSA contributions, to such patients.”

In an accompanying editorial, A. Mark Fendrick, MD, from the Center for Value-Based Insurance Design at the University of Michigan, Ann Arbor, and Michael E. Chernew, PhD, from the department of health care policy at Harvard Medical School, wrote that this study builds upon evidence that shows that low-income individuals with severe illnesses are particularly susceptible to cost-related nonadherence.

“Rising health care spending has created serious fiscal challenges that emphasize the need to better engage consumers in their health care decisions,” Fendrick and Chernew concluded. “Interventions that improve patient-centered outcomes while maintaining affordability are needed. The alignment of clinically nuanced health care provider-facing and consumer engagement initiatives is a necessary and critical step to improve quality of care, enhance patient experience, and contain cost growth.” – by Alaina Tedesco

Disclosure: Wharam and colleagues report receiving support grants from the Centers for Disease Control and Prevention/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), as well as the NIDDK Health Delivery Systems Center for Diabetes Translational Research. Please see full editorial for complete list of Fendrick and Chernew’s relevant financial disclosures.