High-Deductible Insurance Plans Lead to Diabetes-Care Delays

Alicia Ault

June 12, 2016

NEW ORLEANS — Sicker and lower-income diabetes patients in the United States in private health plans with deductibles of $1000 or higher a year delay care for illnesses, which in turn leads to emergency-room visits and higher costs, according to a study presented here.

Almost half of all private insurance plans in the United States require a deductible of $1000 or higher, said James Frank Wharam, MB, BCh, BAO, MPH, an associate professor and general internist at Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.

Advocates of the high-deductible plans believe they increase quality and reduce costs, but critics say the opposite is possible, said Dr Wharam.

Some studies have shown the plans lead to care delays, but not much research has been conducted in chronically ill patients, who have a large potential for harm, he explained.

Dr Wharam and his colleagues at Harvard studied diabetic patients in high-deductible plans as part of the Natural Experiments for Translation in Diabetes (NEXT-D) study, which is funded by the Centers for Disease Control and Prevention (CDC) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Among other aspects of their project — the Impact of Emerging Health Insurance Designs on Diabetes Outcomes and Disparities — they looked specifically at diabetic patients who had three or more comorbidities or who were considered low income.

Those patients delayed outpatient visits for events such as cellulitis or angina, which led to higher-cost emergency-room visits when compared with a control group of equally matched patients in low-deductible plans, said Dr Wharam. The finding "might imply that more vulnerable high-deductible members with diabetes might be experiencing both adverse outcomes and increased financial burden," he said, in presenting his results here at the American Diabetes Association (ADA) 2016 Scientific Sessions on June 11.

Chair of the session, Sue Kirkman, MD, professor of medicine, division of endocrinology, at the University of North Carolina, Chapel Hill, said that anecdotally, it's been known that high-deductible plans lead to treatment delays, but hard evidence, especially in the chronically ill, has been lacking.

It's nice that he was actually able to show that people really do probably delay care for pretty serious things.

"We think it makes sense, but it's nice that he was actually able to show that people really do probably delay care for pretty serious things," Dr Kirkman told Medscape Medical News.

Emergency-Department Episode Costs Much Higher

Dr Wharam and colleagues took a retrospective look at private health plan enrollees from 2003 to 2012 whose data was included in the Optum insurance claims data set. The ages of the enrollees ranged from 12 to 64, and they predominantly had type 2 diabetes.

Each cohort of patients was followed for 3 years. The high-deductible cohort had 1 year of a deductible of less than $500 and then had a switch mandated by the insurer to a high-deductible plan, with lower premiums but deductibles of $1000 or more. The control patients had a deductible of $500 or less throughout the 3-year study period. The study included 12,084 patients with a high-deductible plan and a matched, equal number of low-deductible enrollees.

High-morbidity patients had an adjusted clinical group's score of three or more, while low-income patients were defined as those living in neighborhoods where at least 10% of households were below the federal poverty level.

To determine the effect of delayed care, the researchers created a new measure, which they called "acute preventable diabetes-complication visits."

It tracked outpatient and emergency-department visits for five illnesses, which were considered preventable with proper care: cellulitis, urinary-tract infection, angina/acute coronary syndrome, acute cerebrovascular disease, and pneumonia.

Overall, the researchers measured the time to first outpatient complication visit, the time to the first ER complication visit, the cost of the ER visit, and the cost of the ER episode, which included the total costs of care in the 7 days following the acute preventable visits to the ER.

When patients were forced to switch to a high-deductible plan, the actual increase in out-of-pocket costs was $409 on average, or a 27% relative increase, said Dr Wharam.

High-Deductible Patients Delay Time to Outpatient Visits, ER Costs Rise

Overall, high-deductible patients delayed the time to their first outpatient visit for a preventable complication, when compared with their baseline and the matched controls (hazard ratio [HR], 0.948; P = .049). The researchers did not observe a difference in any of the other measures for this group.

But the high-morbidity cohort had a statistically significant delay in time to first outpatient visit (HR 0.899, = .011).

The time to a first ER visit was unchanged, but the cost per visit was much higher — a $358 increase per member, or a 51% relative increase compared with controls. The cost per ER visit rose from about $10,000 at the time of the switch to a high-deductible plan to nearly $80,000 after 2 years of being on that plan. Costs per ER episode rose for controls, but not as steeply, topping out at just over $50,000.

Low-income patients also significantly delayed the first outpatient visit when compared with controls (HR, 0.914: P = .049) and experienced an increase in total ER-complication visits of 24 per 1000, or a 53% relative increase, said Dr Wharam. Total ER-episode costs rose by an absolute $322 per individual, or a 65% relative increase, he said.

The study's findings aren't generalizable to patients with very high deductibles, Medicaid enrollees, or those who have gotten insurance for the first time, said Dr Wharam.

The relationship between delays in outpatient visits and increased ER-complication visits and expenditures is currently "purely associational, though suggestive," he said.

Dr Wharam and coauthors and Dr Kirkman disclosed no relevant financial relationships.

American Diabetes Association (ADA) 2016 Scientific Sessions; June 11, 2016; New Orleans, Louisiana. Abstract 114-OR/114


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