Association Between Switching to a High-Deductible Health Plan and Major Cardiovascular Outcomes

Abstract

Importance: Most people with commercial health insurance in the US have high-deductible plans, but the association of such plans with major health outcomes is unknown.

Objective: To describe the association between enrollment in high-deductible health plans and the risk of major adverse cardiovascular outcomes.

Design, setting, and participants: This cohort study examined matched groups before and after an insurance design change. Data were from a large national commercial (and Medicare Advantage) health insurance claims data set that included members enrolled between January 1, 2003, and December 31, 2014. The study group included 156 962 individuals with risk factors for cardiovascular disease who were continuously enrolled in low-deductible (≤$500) health plans during a baseline year followed by up to 4 years in high-deductible (≥$1000) plans with typical value-based features after an employer-mandated switch. The matched control group included 1 467 758 individuals with the same risk factors who were contemporaneously enrolled in low-deductible plans. Data were analyzed from December 2017 to March 2020.

Exposures: Employer-mandated transition to a high-deductible health plan.

Main outcomes and measures: Time to first major adverse cardiovascular event defined as myocardial infarction or stroke.

Results: The study group included 156 962 individuals and the control group included 1 467 758 individuals; the mean age of members was 53 years (SD: high-deductible group, 6.7 years; control group, 6.9 years), 47% were female, and approximately 48% lived in low-income neighborhoods. First major adverse cardiovascular events among high-deductible health plan members did not differ relative to controls at follow-up vs baseline (adjusted hazard ratio, 1.00; 95% CI, 0.89-1.13). Findings were similar among subgroups with diabetes (adjusted hazard ratio, 0.93; 95% CI, 0.75-1.16) and with other cardiovascular risk factors (adjusted hazard ratio, 0.93; 95% CI, 0.81-1.07).

Conclusions and relevance: Mandated enrollment in high-deductible health plans with typical value-based features was not associated with increased risk of major adverse cardiovascular events.

Figure 1.. Total Out-of-Pocket Expenditures in the High-Deductible Health Plan (HDHP) Group and the Control Group

Figure 2.. Weighted and Adjusted Cumulative Rates of First Major Cardiovascular Events in the High-Deductible Health Plan (HDHP) Group and Control Group

First major cardiovascular events comprise myocardial infarction or stroke. A, Overall cohort includes patients with diabetes, cardiovascular disease, hypertension, or hyperlipidemia diagnosed before the index date (adjusted hazard ratio [aHR] for follow-up vs baseline year, 1.00; 95% CI, 0.89-1.13). B, Diabetes cohort defined using Johns Hopkins ACG software and diagnosed before the index date (aHR for follow-up vs baseline year, 0.93; 95% CI, 0.75-1.16). C, Other cardiovascular risk factor cohort comprises patients with cardiovascular disease, hypertension, or hyperlipidemia based on Johns Hopkins ACG software and diagnosed before the index date (aHR for follow-up vs baseline year, 0.93; 95% CI, 0.81-1.07). Outcome measures could occur more than once per person. We measured first events per person in both the baseline and follow-up periods, thus “resetting” each person to zero events at the beginning of the follow-up period.

Figure 3.. Weighted and Adjusted Cumulative Rates of First Myocardial Infarction, Stroke, and Amputation in the Overall High-Deductible Health Plan (HDHP) Cohort and Control Cohort

A, Myocardial infarction defined as 3 or more days of hospitalization with a myocardial infarction diagnosis at hospital discharge (adjusted hazard ratio [aHR] for follow-up vs baseline year, 1.02; 95% CI, 0.88-1.17). B, Stroke defined as 3 or more days of hospitalization with stroke diagnosis at hospital discharge (aHR for follow-up vs baseline year, 0.99; 95% CI, 0.81-1.23). C, Amputation defined as based on the presence of billing codes for amputation procedures (aHR for follow-up vs baseline year, 0.95; 95% CI, 0.71-1.27); see Methods section for details. Outcome measures could occur more than once per person. We measured first events per person in both the baseline and follow-up periods, thus “resetting” each person to zero events at the beginning of the follow-up period.