High Deductibles Keeping Chest-Pain Patients Out of the ED?

Anna Goshua

June 29, 2021

Patients who switched to a high-deductible health plan (HDHP) were less likely to visit an emergency department (ED) for nonspecific chest pain than patients who stayed on a low-deductible plan, a new study shows.

An analysis of a national insurance claims database showed that enrolment in HDHPs was linked to a decrease in both ED visits for nonspecific chest pain and hospitalizations during these visits. Further, low-income patients with HDHPs were almost one-third more likely to have an acute myocardial infarction (AMI) 30 days after an initial ED visit for chest pain.

Shih-Chuan Chou

"Now that patients are seeing such high out-of-pocket costs, it's hard for them to decide if it's worth that money to come get all these expensive tests," said lead study author Shih-Chuan Chou, MD, Brigham and Women's Hospital, Boston, in an interview with Medscape Medical News.

The results were published online June 28 in Circulation.

The researchers used a commercial and Medicare Advantage insurance claims database to analyze enrollees who had at least 2 years of employer-sponsored insurance from 2003 to 2014 and were 19 to 63 years of age in their first year of enrolment.

They identified 557,501 enrollees whose employers offered only low-deductible health plans (≤$500) one year and then, at an index date, mandated enrolment in a HDHP (≥$1000) the following year. These individuals were matched to a control group of 5,861,990 enrollees who had been enrolled in low-deductible plans only during the same 2-year period.

The researchers examined whether ED usage changed after enrollees switched to a HDHP. They also compared differences between the HDHP group and the matched control subjects before and after the index date for the following outcomes: population rates of index ED visits for nonspecific chest pain, hospitalization during the visit, noninvasive cardiac testing performed at 3 and 30 days after the visit, coronary revascularization, and hospitalization due to AMI at 30 days after the visit.

The analysis was further stratified by factors such as baseline-year cardiovascular morbidities and neighborhood poverty rate.

Switching to a HDHP was linked to a 4.3% relative decrease in ED visits for nonspecific chest pain (95% CI, –5.9 to –2.7), and an 11.3% decrease in visits that resulted in hospitalization (95% CI, –14.0 to –8.6).

Enrollees with baseline-year cardiovascular morbidities and those from neighborhoods with higher rates of poverty accounted for most of the reduction. No significant change in noninvasive testing or revascularization was observed.

Low-income patients were 29.4% more likely to be hospitalized for AMI 30 days after their initial ED visit (95% CI, 13.3 - 45.6).

Nieca Goldberg

"We worry about lower-income patients in particular because they may not be able to afford regular medical care and evaluation of their cardiac risk factors," said Nieca Goldberg, MD, Joan H. Tisch Center for Women's Health, New York City, who was not involved in the study.

"From this study and others, it has become evident that HDHPs have disproportionate effects on lower-income populations, likely leading to avoidance of appropriate care and increased morbidity," write Neil Kalwani, MD, and Alexander Sandhu, MD, Stanford University, California, in an accompanying editorial.

Protecting this population in the face of increased cost-sharing could involve "deductibles tied to income levels, increased employer contributions to health savings accounts for low-income employees, and expansion of value-based insurance design, in which the degree of cost-sharing is reduced for high-value services," they add.

Moving forward, clinicians should make an effort to ask patients about their financial realities, Chou said. "We need to do it in a way that makes patients feel comfortable and also make sure that we maintain equity and not discriminate against patients who have fewer financial resources."

The study was independently funded. Chou, Goldberg, and Kalwani declare no relevant financial relationships. Sandhu receives research support from the National Heart, Lung, and Blood Institute and does health policy consulting for Acumen, LLC.

Circulation. Published online June 28, 2021. Abstract, Editorial

Anna Goshua is a reporting intern with Medscape. She is a dual medical and journalism student who has previously written for STAT, Scientific American, Slate, and other outlets. She can be reached at agoshua@webmd.net or @AnnaGoshua.

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