High-Deductible Insurance and Delay in Care for the Macrovascular Complications of Diabetes

Abstract

Background: Little is known about the long-term effects of high-deductible insurance on care for chronic medical conditions.

Objective: To determine whether a transition from low-deductible to high-deductible insurance is associated with delayed medical care for macrovascular complications of diabetes.

Design: Observational longitudinal comparison of matched groups.

Setting: A large national health insurer during 2003 to 2012.

Participants: The intervention group comprised 33 957 persons with diabetes who were continuously enrolled in low-deductible (≤$500) insurance plans during a baseline year followed by up to 4 years in high-deductible (≥$1000) plans. The control group included 294 942 persons with diabetes who were enrolled in low-deductible plans contemporaneously with matched intervention group members.

Intervention: Employer-mandated transition to a high-deductible plan.

Measurements: The number of months it took for persons in each study group to seek care for their first major macrovascular symptom, have their first major diagnostic test for macrovascular disease, and have their first major procedure-based treatment was determined. Between-group differences in time to reach a midpoint event rate were then calculated.

Results: No baseline differences were found between groups. During follow-up, the delay for the high-deductible group was 1.5 months (95% CI, 0.8 to 2.3 months) for seeking care for the first major symptom, 1.9 months (CI, 1.4 to 2.3 months) for the first diagnostic test, and 3.1 months (CI, 0.5 to 5.8 months) for the first procedure-based treatment.

Limitation: Health outcomes were not examined.

Conclusion: Among persons with diabetes, mandated enrollment in a high-deductible insurance plan was associated with delays in seeking care for the first major symptoms of macrovascular disease, the first diagnostic test, and the first procedure-based treatment.

Primary funding source: National Institute of Diabetes and Digestive and Kidney Diseases.

Figure 1.

Study design showing example members (horizontal lines) of the high-deductible health plan group (above) and matched control group (below)

Figure 2.

Steps in estimating the delay for the high-deductible group to reach half of the final event rate of controls at follow up.

Figure 3.

Monthly mean out-of-pocket medical expenditures before and after the index date in the high-deductible health plan and control groups, indicating the extent of the actual cost sharing increase experienced by high-deductible health plan members. The HDHP group experiences peaks at the beginning each benefit year, which taper as members exceed their annual deductible. Abbreviation: HDHP, high-deductible health plan. Vertical blue line is centered at the index month when high-deductible health plan group members were switched into high-deductible health plans.

Figure 4.a-c.

Weighted and adjusted time-to-event plots¹ showing time to first major macrovascular disease symptom, diagnostic test, or treatment after a mandated high-deductible health plan switch, compared to contemporaneous control group members who remained in low-deductible plans. Abbreviation: HDHP, high-deductible health plan; aHR, adjusted hazard ratio. Vertical blue line is centered at the index month when high-deductible health plan members were switched into high-deductible health plans. Major macrovascular disease symptoms included intermittent claudication, peripheral artery disease related ischemic pain, cellulitis, abscess of upper and lower limb, embolism/thrombosis, ulcer of lower limb, acute osteomyelitis, transient ischemic attack, angina, and acute and sub-acute forms of ischemic heart disease (Appendix Table 4). Major macrovascular disease diagnostic testing included magnetic resonance angiogram, angiography, intravascular ultrasound, ambulatory cardiac monitoring, brain and neck vessel angiography, brain imaging, echocardiogram, exercise tolerance tests, stress echocardiogram, cardiac catheterization angiogram, computed tomography of coronary vessels, cardiac MRI, and perfusion imaging (Appendix Table 4). Major macrovascular disease procedure-based treatments included angioplasty/stenting, endarterectomy, peripheral artery bypass, peripheral artery thrombectomy/embolectomy, endarterectomy/stenting, percutaneous coronary intervention/angioplasty, and coronary artery bypass grafting (Appendix Table 4). ¹Plots derived from parametric regression survival-time models with a Weibull distribution and adjusted for age group, gender, race/ethnicity, diabetes patients per employer category, and US region; and using weights derived from the coarsened exact matching algorithm.