Diabetes Outpatient Care and Acute Complications Before and After High-Deductible Insurance Enrollment: A Natural Experiment for Translation in Diabetes (NEXT-D) Study

Abstract

Importance: High-deductible health plans (HDHPs) have expanded under the Affordable Care Act and are expected to play a major role in the future of US health policy. The effects of modern HDHPs on chronically ill patients and adverse outcomes are unknown.

Objective: To determine the association of HDHP with high-priority diabetes outpatient care and preventable acute complications.

Design, setting, and participants: Controlled interrupted-time-series study using a large national health insurer database from January 1, 2003, to December 31, 2012. A total of 12 084 HDHP members with diabetes, aged 12 to 64 years, who were enrolled for 1 year in a low-deductible (≤$500) plan followed by 2 years in an HDHP (≥$1000) after an employer-mandated switch were included. Patients transitioning to HDHPs were propensity-score matched with contemporaneous patients whose employers offered only low-deductible coverage. Low-income (n = 4121) and health savings account (HSA)-eligible (n = 1899) patients with diabetes were subgroups of interest. Data analysis was performed from February 23, 2015, to September 11, 2016.

Exposures: Employer-mandated HDHP transition.

Main outcomes and measures: High-priority outpatient visits, disease monitoring tests, and outpatient and emergency department visits for preventable acute diabetes complications.

Results: In the 12 084 HDHP members included after the propensity score match, the mean (SD) age was 50.4 (10.0) years; 5410 of the group (44.8%) were women. The overall, low-income, and HSA-eligible diabetes HDHP groups experienced increases in out-of-pocket medical expenditures of 49.4% (95% CI, 40.3% to 58.4%), 51.7% (95% CI, 38.6% to 64.7%), and 67.8% (95% CI, 47.9% to 87.8%), respectively, compared with controls in the year after transitioning to HDHPs. High-priority primary care visits and disease monitoring tests did not change significantly in the overall HDHP cohort; however, high-priority specialist visits declined by 5.5% (95% CI, -9.6% to -1.5%) in follow-up year 1 and 7.1% (95% CI, -11.5% to -2.7%) in follow-up year 2 vs baseline. Outpatient acute diabetes complication visits were delayed in the overall and low-income HDHP cohorts at follow-up (adjusted hazard ratios, 0.94 [95% CI, 0.88 to 0.99] for the overall cohort and 0.89 [95% CI, 0.81 to 0.98] for the low-income cohort). Annual emergency department acute complication visits among HDHP members increased by 8.0% (95% CI, 4.6% to 11.4%) in the overall group, 21.7% (95% CI, 14.5% to 28.9%) in the low-income group, and 15.5% (95% CI, 10.5% to 20.6%) in the HSA-eligible group.

Conclusions and relevance: Patients with diabetes experienced minimal changes in outpatient visits and disease monitoring after an HDHP switch, but low-income and HSA-eligible HDHP members experienced major increases in emergency department visits for preventable acute diabetes complications.

Figure 1

Unadjusted plots of preventable acute diabetes complication measures and tables (below each plot) showing adjusted effect estimates, stratified by morbidity group. Abbreviations: HDHP, high-deductible health plan; aHR, adjusted hazard ratio; CI, confidence interval. Note: “Total expenditures during acute complication episodes” is a proxy indicating overall utilization in the 7 days following emergency department visits for preventab le acute diabetes complications (as defined in the manuscript). Vertical blue lines are centered at the index date when HDHP members were switched into HDHPs. ^aAdjusted Clinical Groups score less than 2.0; ^bAdjusted Clinical Groups score greater than or equal to 3.0.

Figure 2

Unadjusted plots of preventable acute diabetes complication measures and tables (below each plot) showing adjusted effect estimates, stratified by income group. Abbreviations: HDHP, high-deductible health plan; aHR, adjusted hazard ratio; CI, confidence interval. Note: “Total expenditures during acute complication episodes” is a proxy indicating overall utilization in the 7 days following emergency department visits for preventable acute diabetes complications (as defined in the manuscript). Vertical blue lines are centered at the index date when HDHP members were switched into HDHPs. ^aLiving in neighborhoods with below-poverty levels of less than 5%. ^bLiving in neighborhoods with below-poverty levels of 10% or greater.