Poor and Sicker With High Deductibles Delay Diabetes Care

Alicia Ault

January 16, 2017

People with diabetes enrolled in high-deductible healthcare plans — especially the poorer and sicker — are delaying physician visits for preventable complications, which leads to a greater number of expensive emergency-department visits, finds a newly published study.

The results of the controlled, interrupted-time-series study, conducted by J Frank Wharam, MB, associate professor of population medicine at Harvard Medical School, were first presented last June at the American Diabetes Association (ADA) 2016 Scientific Sessions, as reported by Medscape Medical News.

The study was published online January 9 in JAMA Internal Medicine.

It's not clear whether the observed trend is leading to poorer health, say Dr Wharam and coauthors in their report.

"Although we cannot directly determine whether delayed outpatient complication visits caused increased morbidity among vulnerable high-deductible health plan members, the large increases in emergency-department complication episode costs that were detected seem suggestive," write the researchers.

High-deductible health plans have become increasingly common in the United States, with an estimated 40% of Americans with private health insurance enrolled in such a plan, said A Mark Fendrick, MD, director of the Center for Value-Based Insurance Design at the University of Michigan, Ann Arbor, in an accompanying editorial.

The plans aim to make consumers more cost-conscious by requiring them to pay all costs — which can mean several thousand dollars — until the deductible is met.

Higher Deductibles Delayed Outpatient Visits

The Harvard study found that those with diabetes enrolled in a health plan with a deductible of more than $1000 did not skip regular primary-care visits with disease monitoring, such as HbA1c testing, as those services were usually not subject to the deductible.

However, they delayed outpatient visits for diabetes complications such as cellulitis, urinary tract infection, and hypo- or hyperglycemia.

Emergency-department visits for those preventable complications also increased for people with high deductibles compared with controls, who had a deductible of $500 or less.

High-deductible enrollees saw an overall 8% increase in annual emergency-department visits.

And for those who lived at or well below the poverty line, emergency department visits rose almost 22%.

Visits also increased for patients eligible for health savings accounts, said the authors. Like high-deductible plans, these accounts — which participants fund with pretax income — are supposed to act as incentives to be more cost-conscious. But they also have the highest out-of-pocket expenses and led to the greatest cost burdens, say the Harvard researchers.

High-Deductible Plans Not All Bad, But Not Good for the Vulnerable

The authors suggest that high deductibles might not be all bad, but that poorer and sicker patients are not good candidates for such plans.

These patients likely had greater concerns about out-of-pocket spending and "might therefore attempt to minimize health expenditures by forgoing expensive scheduled and acute visits or by shifting care to less expensive but potentially less appropriate settings," they write.

"Vulnerable groups may not have the savings available to pay for needed care," agreed Dr Fendrick in his editorial.

The Harvard study "adds to a large and growing body of evidence reporting that, while consumer cost-sharing may not have large deleterious health effects on the general population, low-income and very sick populations are particularly vulnerable to cost-related nonadherence," writes Dr Fendrick.

Deductibles are not the best way to create more value-conscious consumers, he added.

Dr Fendrick proposes what he calls "smarter" deductibles, where patients would shoulder more of the cost burden for services deemed low value and less costs for high-value services.

The study was supported by grants from the Centers for Disease Control and Prevention and National Institute of Diabetes and Digestive and Kidney Diseases. Dr Wharam and colleagues have reported no relevant financial relationships. Dr Fendrick reported receiving personal fees from Merck, AstraZeneca, TriZetto, Amgen, Lilly, AbbVie, Johnson & Johnson, and Sanofi; grants from the National Pharmaceutical Council, PhRMA, Gary and Mary West Health Foundation, states of New York and Michigan, Laura and John Arnold Foundation, Robert Wood Johnson Foundation, and Agency for Healthcare Research and Quality, and that he owned equity in Zansors, Sempre Health, Wellth, and V-BID Health.

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JAMA Intern Med. Published online January 9, 2017. Abstract, Editorial

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