Do High Out-of-Pocket Costs Delay Diabetes Patients From Care?

Pam Harrison

November 20, 2018

Mandated enrollment into a high-deductible insurance plan delays the time it takes patients with diabetes to seek care for cardiovascular (macrovascular) disease-related symptoms, tests, and procedures, compared with those who remain on a low-deductible insurance plan, an observational, longitudinal study suggests.

"High-deductible plans, which require potential out-of-pocket spending of approximately $1000 to $7000 per person per year for most nonpreventive care, have become an increasingly common feature of US commercial health insurance," Frank Wharam, MD, MPH, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, and colleagues observe in their article, published online November 19 in the Annals of Internal Medicine.

"[And we found that] patients with diabetes whose employers switched to high-deductible insurance plans had delays in seeking care for the first major symptoms of the macrovascular complications of diabetes, having their first major diagnostic test for such complications, and having their first procedure-based treatment compared with persons in the control group," the investigators add.

"These results suggest that patients with diabetes who are switched to high-deductible health plans are affected by the increased out-of-pocket costs they face for medical services," the authors stress.

But in an accompanying editorial, Mark Pauly, PhD, The Wharton School, University of Pennsylvania, Philadelphia, argues that delays in seeking care among patients forced into a high-deductible insurance plan do not necessarily suggest harm.

For example, high-deductible plans might motivate patients to adopt a healthier lifestyle in an effort to avoid the need for costly healthcare, he argues.

Modest, Nonsignificant Differences in Care-Seeking Behavior

Most participants in the study by Wharam and colleagues were included in the large Optum database and covered by employer-sponsored insurance only.

"We considered an insurance plan to have a low deductible if the annual amount was $500 or less and a high deductible if the annual amount was $1000 or more," the researchers note.  

The intervention group consisted of 33,957 patients who were in a low-deductible insurance plan for at least 1 year and were switched to a high-deductible plan.

The control group was made up of 294,942 patients who remained on a low-deductible plan throughout the study. The mean age of both groups was approximately 50 years.

During a 4-year follow-up, investigators found that patients in the intervention group delayed seeking care for their first major macrovascular disease symptom by 1.5 months compared with controls. They also put off going for their first major diagnostic test by 1.9 months, again compared with controls. Both of these results were significantly different compared with controls.

Delays in time to the first procedure-based treatment were longer, at 3.1 months, relative to controls, although the difference between the two groups for this outcome did not achieve significance (P = .074), the authors point out.

Differences in care-seeking behavior between the two groups overall were, in fact, modest, as the adjusted hazard ratios (HR) indicate.

For example, the delay in seeking care for the first major macrovascular disease symptom was only 6% longer for patients in the intervention group compared with controls, at an HR of 0.94.

And delays in the time it took intervention patients to either their first diagnostic test or procedure-based treatment was only 9% longer compared with controls, at an HR of 0.91 for both endpoints.

As the authors observe, patients who were forced to enroll in a high-deductible insurance plan had between 43% and 53% higher out-of-pocket medical costs in each year of follow-up compared with baseline and relative to patients who remained in a low-deductible insurance plan.

"We recommend that clinicians and care management teams monitor the type of insurance that patients with diabetes have and consider further outreach and education for those with high-deductible plans," they suggest.

"[And] until the effects of high-deductible plans on long-term macrovascular complications of diabetes are better understood, policymakers and employers should remain cautious in encouraging uptake of such plans among vulnerable patients with diabetes, especially given recent evidence of adverse short-term health outcomes," the investigators conclude.

Do Delays Have Any Effect on Health Outcomes?

The authors themselves acknowledge that a major limitation of the study was that they could not assess whether or not the observed delays in time to seeking care had any effect on health outcomes.

In his editorial, Pauly notes firstly that the authors could not account for other factors that might have differed between those who did and did not switch insurance plans, and which therefore might explain the observed delays in care seeking among high-deductible insurance employees.  

"In particular, the researchers could not determine whether switching to a high-deductible plan was associated with subsequent changes in the volume or costs of encounters, tests, and procedures that might have affected patient outcomes," he adds.

The authors were also unable to determine if there had been any change in patients' health status before they even made their first claims.

So one reason behind the longer lag times in care-seeking behavior among those in the intervention group might be that these patients had adopted a healthier lifestyle — because of the higher cost of care — and didn't need to seek help as much as those who remained on a low-deductible plan, he suggests.

"The fundamental problem in trying to draw inferences about gains and losses from insurance claims data is that despite their 'big data' appeal, they lack crucial clinical information, such as health status," Pauly writes.

"Unfortunately, although these data are interesting, they cannot provide a definitive answer about the value of high-deductible plans for persons with diabetes," he concludes.

Wharam and Pauly have reported no relevant financial relationships. Disclosures for the other authors are listed in the article.

Ann Intern Med. Published online November 19, 2018. Abstract, Editorial

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