High-deductible insurance linked to delays in care for diabetes complications
medwireNews: Compulsory enrollment in a high-deductible health insurance plan is associated with significant delays in seeking care for macrovascular complications among people with diabetes, US research shows.
“These results suggest that patients with diabetes who are switched to high-deductible health plans are affected by the increased out-of-pocket costs they face for medical services,” J Frank Wharam and colleagues from Harvard Medical School in Boston, Massachusetts, write in the Annals of Internal Medicine.
However, the authors accept that their methods did not enable them to determine whether the changes they detected “represent delays or ultimate reductions” in the outcomes they evaluated.
The study included 33,957 people with diabetes registered with a large US national health insurer between 2003 and 2012 who were continuously enrolled in low-deductible (≤US $500 [€ 438] out-of-pocket spend) insurance plans during a baseline year, and then mandated by their employer to move to a high-deductible (≥$ 1000 [€ 876] out-of-pocket spend) plan.
During the following 4 years, the individuals on high-deductible plans had a significant 1.5-month adjusted delay in the median time to seeking care for a first major symptom of macrovascular complications when compared with 294,942 matched individuals with diabetes who were enrolled in low-deductible plans for the duration of follow-up. Major symptoms included angina, ischemic heart disease, transient ischemic attack, resting ischemic pain, thrombosis, and cellulitis, among others.
There was also a significant 1.9-month delay to the first diagnostic test and a significant 3.1-month delay to the first procedure-based treatment for coronary heart disease, cerebrovascular disease, or peripheral artery disease among the individuals in the high-deductible group.
Of note, the delay to first procedure-based treatment was entirely driven by significant delays in coronary heart disease treatment (3.9 months). There were no significant delays in treatment for cerebrovascular or peripheral artery disease between the groups.
After adjustment for age, sex, race/ethnicity, number of patients with diabetes per employer, and US region, the researchers found that patients with high-deductible plans were 6% less likely to seek care for a first major symptom at any given timepoint and 9% less likely to have a first diagnostic test or procedure-based treatment than those with low deductible plans.
By contrast, there were no significant differences in time to any of the outcomes between the high- and low-deductible groups during the baseline period.
Wharam et al conclude: “We recommend that clinicians and care management teams monitor the type of insurance that patients with diabetes have and consider further outreach and education for those with high-deductible plans.”
“Employers with high-deductible plans might also consider reduced cost sharing for patients with diabetes,” they add.
In an accompanying editorial, Mark Pauly, from the University of Pennsylvania in Philadelphia, USA, says that it is unclear whether the delays reported led to harm in the patients “because the study was unable to account for other factors that might differ between persons who switched and those who did not.”
“In particular, the researchers could not determine whether switching to a high-deductible plan was associated with subsequent changes in the volume or costs of encounters, tests, and procedures that might have affected patient outcomes; they could only say that the time to selected claims differed,” Pauly writes.
He concludes: “Unfortunately, although these data are interesting, they cannot provide a definitive answer about the value of high-deductible plans for persons with diabetes.”
By Laura Cowen
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