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.

Social Determinants of Poor Management of Type 2 Diabetes Among the Insured

“…In recent years, there has been growing enrollment in high-deductible health plans (HDHPs) among working age adults [ 16 ]. For vulnerable populations, especially low-income patients, HDHPs may present barriers to care and increases in adverse outcomes and costs [ 17 ]. Wharam et al showed that low-income people with diabetes and HDHPs had increased high severity emergency department visits and hospitalizations compared to the general population with diabetes on HDHPs [ 17 ].…”

Reduced Cost-sharing for Preventive Drugs Preferentially Benefits Low-income Patients With Diabetes in High Deductible Health Plans With Health Savings Accounts

“…SDC Section 1: Imputation of deductible amounts Our algorithm for imputing employer-mandated membership in high deductible health plans has been described in detail previously. [1][2][3] We summarize these methods briefly below.…”

“…Our dataset contains limited and incomplete individual-level socioeconomic variables; to derive proxy measures, 8 our data vendor converted members' most recent residential street addresses to geocodes which can be linked to publicly available geographically-derived socioeconomic measures. Geographic measures of socioeconomic status have been validated [9][10][11] and used in multiple studies by ourselves 3,12,13 and others 14,15 to examine the differential impact of changes in cost-sharing within population subgroups. We linked to census tract-level data from the 2008-2012 American Community Survey (ACS) 16 ,17 to create measures of neighborhood poverty, defined as <5%, 5.0-9.9%, 10.0-24.9%, ≥25.0% of households living below the US Department of Health and Human Services federal poverty threshold, 18 which we stratified for subgroup analysis as lower income (<10.0%) vs. higher income (≥10.0%).…”

“…2 Defined as lower income. 3 See manuscript for definition of race/ethnicity categories. * Lower standardized differences indicate greater similarity.…”

“…** An ACG Score of 1.0 represents the mean score of the reference population SDC Table 5b. Baseline characteristics of PDL and control patients living in neighborhoods with ≥10% below poverty (lower income), before and after the propensity score match 0 (0.0) 0 (0.0) 0 (0.0) (0.0) 5%-9.9% 1 0 (0.0) 0 (0.0) 0 (0.0) (0.0) 10%- 19 3 See manuscript for definition of race/ethnicity categories. * Lower standardized differences indicate greater similarity.…”