1
|
Chua KP, Conti RM, Lagisetty P, Bohnert ASB, Nuliyalu U, Nguyen TD. Association Between Cost-Sharing and Buprenorphine Prescription Abandonment. J Gen Intern Med 2024; 39:2160-2168. [PMID: 38888865 PMCID: PMC11347500 DOI: 10.1007/s11606-024-08819-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 05/13/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Prior studies suggest cost-sharing decreases buprenorphine dispensing. However, these studies used databases that only report prescriptions filled by patients, not those that were "abandoned." Consequently, the studies could not calculate the probability of buprenorphine prescription abandonment or evaluate whether cost-sharing is associated with abandonment. OBJECTIVE To evaluate the association between cost-sharing and buprenorphine prescription abandonment. DESIGN Cross-sectional analysis of the IQVIA Formulary Impact Analyzer, a pharmacy transaction database representing 63% of U.S. retail pharmacies. The database includes transaction records ("claims") for prescriptions even if they are not filled. PARTICIPANTS Buprenorphine claims in 2022 among commercially insured and Medicare patients. MAIN MEASURES We evaluated the association between cost-sharing per 30-day supply and abandonment using logistic regression, controlling for patient characteristics, product type, and buprenorphine use in the prior 180 days. We assessed for effect modification by prior buprenorphine use. KEY RESULTS Analyses included 2,346,994 and 1,242,596 buprenorphine prescription claims for commercially insured and Medicare patients, respectively. Among these claims, mean (SD) cost-sharing per 30-day supply was $28.1 (46.4) and $8.4 (20.2), and 1.5% and 1.2% were abandoned. Each $10 increase in cost-sharing per 30-day supply was associated with a 0.09 (95% CI: 0.09, 0.10) and 0.09 (95% CI: 0.08, 0.10) percentage-point increase in abandonment among commercially insured and Medicare patients. Among commercially insured and Medicare patients without prior buprenorphine use, respectively, a $10 increase in cost-sharing per 30-day supply was associated with a 0.12 (95% CI: 0.11, 0.14) and 0.13 (95% CI: 0.07, 0.18) percentage-point higher increase in the probability of abandonment compared with patients with > 90 days of prior buprenorphine use. CONCLUSIONS Among commercially insured and Medicare patients, buprenorphine prescription abandonment is rare and only minimally associated with cost-sharing. Findings suggest elimination of buprenorphine cost-sharing should only be one component of a larger, multi-faceted campaign to increase buprenorphine dispensing.
Collapse
Affiliation(s)
- Kao-Ping Chua
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA.
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA.
| | - Rena M Conti
- Department of Markets, Public Policy, And Law, Questrom School of Business, Boston University, Boston, MA, USA
| | - Pooja Lagisetty
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Amy S B Bohnert
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Usha Nuliyalu
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Thuy D Nguyen
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| |
Collapse
|
2
|
Eddelbuettel JCP, Kennedy-Hendricks A, Meiselbach MK, Stuart EA, Huskamp HA, Busch AB, Hollander MAG, Schilling C, Barry CL, Eisenberg MD. Changes in Healthcare Spending Attributable to High Deductible Health Plan Offer Among Enrollees with Comorbid Substance Use Disorder and Cardiovascular Disease. J Gen Intern Med 2024; 39:1993-2000. [PMID: 38459412 PMCID: PMC11306437 DOI: 10.1007/s11606-024-08700-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/23/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND The rise in prevalence of high deductible health plans (HDHPs) in the United States may raise concerns for high-need, high-utilization populations such as those with comorbid chronic conditions. In this study, we examine changes in total and out-of-pocket (OOP) spending attributable to HDHPs for enrollees with comorbid substance use disorder (SUD) and cardiovascular disease (CVD). METHODS We used de-identified administrative claims data from 2007 to 2017. SUD and CVD were defined using algorithms of ICD 9 and 10 codes and HEDIS guidelines. The main outcome measures of interest were spending measure for all non-SUD/CVD-related services, SUD-specific services, and CVD-specific services, for all services and medications specifically. We assessed both total and OOP spending. We used an intent-to-treat two-part model approach to model spending and computed the marginal effect of HDHP offer as both the dollar change and percent change in spending attributable to HDHP offer. RESULTS Our sample included 33,684 enrollee-years and was predominantly white and male with a mean age of 53 years. The sample had high demonstrated substantial healthcare utilization with 94% using any non-SUD/CVD services, and 84% and 78% using SUD and CVD services, respectively. HDHP offer was associated with a 17.0% (95% CI = [0.07, 0.27] increase in OOP spending for all non-SUD/CVD services, a 21.1% (95% CI = [0.11, 0.31]) increase in OOP spending for all SUD-specific services, and a 13.1% (95% CI = [0.04, 0.23]) increase in OOP spending for all CVD-specific services. HDHP offer was also associated with a significant increase in OOP spending on non-SUD/CVD-specific medications and SUD-specific medications, but not CVD-specific medications. CONCLUSIONS This study suggests that while HDHPs do not change overall levels of annual spending among enrollees with comorbid CVD and SUD, they may increase the financial burden of healthcare services by raising OOP costs, which could negatively impact this high-need and high-utilization population.
Collapse
Affiliation(s)
| | | | - Mark K Meiselbach
- Department of Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth A Stuart
- Department of Biostatistics, Johns Hopkins University, Baltimore, MD, USA
| | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | | | - Mara A G Hollander
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, NC, USA
| | - Cameron Schilling
- Department of Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
| | - Colleen L Barry
- Brooks School of Public Policy, Cornell University, Ithaca, NY, USA
| | - Matthew D Eisenberg
- Department of Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
- Optum Labs, Boston, MA, USA
| |
Collapse
|
3
|
Africa RE, Shabani S, Coblens OM, McKinnon BJ. Trends and postoperative outcomes of thyroidectomy after expansion and rise of health insurance deductibles in the fiscal year. Am J Otolaryngol 2024; 45:104312. [PMID: 38657532 DOI: 10.1016/j.amjoto.2024.104312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND The purpose of this study is to evaluate a relationship between expansion of High Deductible Health Plans (HDHPs) and the number of thyroid surgery cases with associated postoperative outcomes in the fiscal year. METHODS Data from TriNetX was used to evaluate the trends in thyroid surgery from 2005 and 2021 between the end of the year (Quarter 4) and the beginning of the year (Quarter 1). Risk of postoperative outcomes were statistically interrogated. RESULTS The average rate of thyroid surgery in cases/year between Quarter 4 and Quarter 1 was similar after expansion of HDHPs (152; 146; p = 0.64). There was no increased risk of postoperative complications. The rate of surgery decreased significantly for patients with Medicare after implementation of the revised American Thyroid Association (ATA) guidelines (Quarter 4: p = 0.03; Quarter 1: p = 0.02). CONCLUSIONS Patients are less likely to delay thyroid surgery at the end of the year despite higher deductibles.
Collapse
Affiliation(s)
- Robert E Africa
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Sepehr Shabani
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Orly M Coblens
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Brian J McKinnon
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA
| |
Collapse
|
4
|
Garabedian LF, Zhang F, Costa R, Argetsinger S, Ross-Degnan D, Wharam JF. Association of State Insulin Out-of-Pocket Caps With Insulin Cost-Sharing and Use Among Commercially Insured Patients With Diabetes : A Pre-Post Study With a Control Group. Ann Intern Med 2024; 177:439-448. [PMID: 38527286 DOI: 10.7326/m23-1965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Twenty-five states have implemented insulin out-of-pocket (OOP) cost caps, but their effectiveness is uncertain. OBJECTIVE To examine the effect of state insulin OOP caps on insulin use and OOP costs among commercially insured persons with diabetes. DESIGN Pre-post study with control group. SETTING Eight states implementing insulin OOP caps of $25 to $30, $50, or $100 in January 2021, and 17 control states. PARTICIPANTS Commercially insured persons with diabetes and insulin users younger than 65 years. Subgroups of particular interest included members from states with insulin OOP caps of $25 to $30, enrollees with health savings accounts (HSAs) that require high insulin OOP payments, and lower-income members. MEASUREMENTS Mean monthly 30-day insulin fills and OOP costs. RESULTS State insulin caps were not associated with changes in insulin use in the overall population (relative change in fills per month, 1.8% [95% CI, -3.2% to 6.9%]). Insulin users in intervention states saw a 17.4% (CI, -23.9% to -10.9%) relative reduction in insulin OOP costs, largely driven by reductions among HSA enrollees; there was no difference in OOP costs among nonaccount plan members. More generous ($25 to $30) state insulin OOP caps were associated with insulin OOP cost reductions of 40.0% (CI, -62.5% to -17.6%), again primarily driven by a larger reduction in the subgroup with HSA plans. LIMITATIONS Single national insurer; 9-month follow-up. CONCLUSION Insulin OOP caps were associated with reduced insulin OOP costs but no overall increases in insulin use. A proposed national insulin cap of $35 for commercially insured persons might lead to meaningful insulin OOP savings but have a limited effect on insulin use. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention and National Institute of Diabetes and Digestive and Kidney Diseases.
Collapse
Affiliation(s)
- Laura F Garabedian
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (L.F.G., F.Z., R.C., S.A., D.R.)
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (L.F.G., F.Z., R.C., S.A., D.R.)
| | - Rebecca Costa
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (L.F.G., F.Z., R.C., S.A., D.R.)
| | - Stephanie Argetsinger
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (L.F.G., F.Z., R.C., S.A., D.R.)
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (L.F.G., F.Z., R.C., S.A., D.R.)
| | - J Frank Wharam
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, and Department of Medicine and Duke-Margolis Institute for Health Policy, Duke University, Durham, North Carolina (J.F.W.)
| |
Collapse
|
5
|
Cliff BQ, Eddelbuettel JCP, Meiselbach MK, Eisenberg MD. Deductible imputation in administrative medical claims datasets. Health Serv Res 2024; 59:e14278. [PMID: 38233373 PMCID: PMC11248712 DOI: 10.1111/1475-6773.14278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVE To validate imputation methods used to infer plan-level deductibles and determine which enrollees are in high-deductible health plans (HDHPs) in administrative claims datasets. DATA SOURCES AND STUDY SETTING 2017 medical and pharmaceutical claims from OptumLabs Data Warehouse for US individuals <65 continuously enrolled in an employer-sponsored plan. Data include enrollee and plan characteristics, deductible spending, plan spending, and actual plan-level deductibles. STUDY DESIGN We impute plan deductibles using four methods: (1) parametric prediction using individual-level spending; (2) parametric prediction with imputation and plan characteristics; (3) highest plan-specific mode of individual annual deductible spending; and (4) deductible spending at the 80th percentile among individuals meeting their deductible. We compare deductibles' levels and categories for imputed versus actual deductibles. DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS All methods had a positive predictive value (PPV) for determining high- versus low-deductible plans of ≥87%; negative predictive values (NPV) were lower. The method imputing plan-specific deductible spending modes was most accurate and least computationally intensive (PPV: 95%; NPV: 91%). This method also best correlated with actual deductible levels; 69% of imputed deductibles were within $250 of the true deductible. CONCLUSIONS In the absence of plan structure data, imputing plan-specific modes of individual annual deductible spending best correlates with true deductibles and best predicts enrollees in HDHPs.
Collapse
Affiliation(s)
- Betsy Q. Cliff
- Department of Public Health SciencesUniversity of ChicagoChicagoIllinoisUSA
| | | | - Mark K. Meiselbach
- Health Policy and ManagementJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Matthew D. Eisenberg
- Health Policy and ManagementJohns Hopkins UniversityBaltimoreMarylandUSA
- Johns Hopkins UniversityBaltimoreMarylandUSA
| |
Collapse
|
6
|
McCoy RG, Swarna KS, Jiang DH, Van Houten HK, Chen J, Davis EM, Herrin J. Enrollment in High-Deductible Health Plans and Incident Diabetes Complications. JAMA Netw Open 2024; 7:e243394. [PMID: 38517436 PMCID: PMC10960199 DOI: 10.1001/jamanetworkopen.2024.3394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 01/25/2024] [Indexed: 03/23/2024] Open
Abstract
Importance Preventing diabetes complications requires monitoring and control of hyperglycemia and cardiovascular risk factors. Switching to high-deductible health plans (HDHPs) has been shown to hinder aspects of diabetes care; however, the association of HDHP enrollment with microvascular and macrovascular diabetes complications is unknown. Objective To examine the association between an employer-required switch to an HDHP and incident complications of diabetes. Design, Setting, and Participants This retrospective cohort study used deidentified administrative claims data for US adults with diabetes enrolled in employer-sponsored health plans between January 1, 2010, and December 31, 2019. Data analysis was performed from May 26, 2022, to January 2, 2024. Exposures Adults with a baseline year of non-HDHP enrollment who had to switch to an HDHP because their employer offered no non-HDHP alternative in that year were compared with adults who were continuously enrolled in a non-HDHP. Main Outcomes and Measures Mixed-effects logistic regression models examined the association between switching to an HDHP and, individually, the odds of myocardial infarction, stroke, hospitalization for heart failure, lower-extremity complication, end-stage kidney disease, proliferative retinopathy, treatment for retinopathy, and blindness. Models were adjusted for demographics, comorbidities, and medications, with inverse propensity score weighting used to account for potential selection bias. Results The study included 42 326 adults who switched to an HDHP (mean [SD] age, 52 [10] years; 19 752 [46.7%] female) and 202 729 adults who did not switch (mean [SD] age, 53 [10] years; 89 828 [44.3%] female). Those who switched to an HDHP had greater odds of experiencing all diabetes complications (odds ratio [OR], 1.11; 95% CI, 1.06-1.16 for myocardial infarction; OR, 1.15; 95% CI, 1.09-1.21 for stroke; OR, 1.35; 95% CI, 1.30-1.41 for hospitalization for heart failure; OR, 2.53; 95% CI, 2.38-2.70 for end-stage kidney disease; OR, 2.23; 95% CI, 2.17-2.29 for lower-extremity complication; OR, 1.17; 95% CI, 1.13-1.21 for proliferative retinopathy; OR, 2.35; 95% CI, 2.18-2.54 for blindness; and OR, 2.28; 95% CI, 2.15-2.41 for retinopathy treatment). Conclusions and Relevance This study found that an employer-driven switch to an HDHP was associated with increased odds of experiencing all diabetes complications. These findings reinforce the potential harm associated with HDHPs for people with diabetes and the importance of affordable and accessible chronic disease management, which is hindered by high out-of-pocket costs incurred by HDHPs.
Collapse
Affiliation(s)
- Rozalina G. McCoy
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore
- University of Maryland Institute for Health Computing, Bethesda
- Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park
- OptumLabs, Eden Prairie, Minnesota
| | - Kavya S. Swarna
- OptumLabs, Eden Prairie, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | - Holly K. Van Houten
- OptumLabs, Eden Prairie, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park
| | - Esa M. Davis
- University of Maryland Institute for Health Computing, Bethesda
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
7
|
Wharam JF, Argetsinger S, Lakoma M, Zhang F, Ross-Degnan D. Acute Diabetes Complications After Transition to a Value-Based Medication Benefit. JAMA HEALTH FORUM 2024; 5:e235309. [PMID: 38334992 PMCID: PMC10858396 DOI: 10.1001/jamahealthforum.2023.5309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/07/2023] [Indexed: 02/10/2024] Open
Abstract
Importance The association of value-based medication benefits with diabetes health outcomes is uncertain. Objective To assess the association of a preventive drug list (PDL) value-based medication benefit with acute, preventable diabetes complications. Design, Setting, and Participants This cohort study used a controlled interrupted time series design and analyzed data from a large, national, commercial health plan from January 1, 2004, through June 30, 2017, for patients with diabetes aged 12 to 64 years enrolled through employers that adopted PDLs (intervention group) and matched and weighted members with diabetes whose employers did not adopt PDLs (control group). All participants were continuously enrolled and analyzed for 1 year before and after the index date. Subgroup analysis assessed patients with diabetes living in lower-income and higher-income neighborhoods. Data analysis was performed between August 19, 2020, and December 1, 2023. Exposure At the index date, intervention group members experienced employer-mandated enrollment in a PDL benefit that was added to their follow-up year health plan. This benefit reduced out-of-pocket costs for common cardiometabolic drugs, including noninsulin antidiabetic agents and insulin. Matched control group members continued to have cardiometabolic medications subject to deductibles or co-payments at follow-up. Main Outcomes and Measures The primary outcome was acute, preventable diabetes complications (eg, bacterial infections, neurovascular events, acute coronary disease, and diabetic ketoacidosis) measured as complication days per 1000 members per year. Intermediate measures included the proportion of days covered by and higher use (mean of 1 or more 30-day fills per month) of antidiabetic agents. Results The study 10 588 patients in the intervention group (55.2% male; mean [SD] age, 51.1 [10.1] years) and 690 075 patients in the control group (55.2% male; mean [SD] age, 51.1 [10.1] years) after matching and weighting. From baseline to follow-up, the proportion of days covered by noninsulin antidiabetic agents increased by 4.7% (95% CI, 3.2%-6.2%) in the PDL group and by 7.3% (95% CI, 5.1%-9.5%) among PDL members from lower-income areas compared with controls. Higher use of noninsulin antidiabetic agents increased by 11.3% (95% CI, 8.2%-14.5%) in the PDL group and by 15.2% (95% CI, 10.6%-19.8%) among members of the PDL group from lower-income areas compared with controls. The PDL group experienced an 8.4% relative reduction in complication days (95% CI, -13.9% to -2.8%; absolute reduction, -20.2 [95% CI, -34.3 to -6.2] per 1000 members per year) compared with controls from baseline to follow-up, while PDL members residing in lower-income areas had a 10.2% relative reduction (95% CI, -17.4% to -3.0%; absolute, -26.1 [95% CI, -45.8 to -6.5] per 1000 members per year). Conclusions and Relevance In this cohort study, acute, preventable diabetes complication days decreased by 8.4% in the overall PDL group and by 10.2% among PDL members from lower-income areas compared with the control group. The results may support a strategy of incentivizing adoption of targeted cost-sharing reductions among commercially insured patients with diabetes and lower income to enhance health outcomes.
Collapse
Affiliation(s)
- J. Franklin Wharam
- Department of Medicine, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts
| | - Stephanie Argetsinger
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts
| | - Matthew Lakoma
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts
| | - Fang Zhang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
8
|
Jones KD, Lakatta AC, Haddock NT, Teotia SS. The Effects of High Deductible Health Plans on Breast Cancer Treatment and Reconstruction. Clin Breast Cancer 2023; 23:856-863. [PMID: 37709587 DOI: 10.1016/j.clbc.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/22/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND High-deductible health plans (HDHP) have expanded rapidly creating the potential for substantially increased out-of-pocket (OOP) costs. The associated financial strain has been associated with the decision to forego care, but the impact on patients undergoing breast cancer reconstruction is not known. We examined the impact of HDHPs vs. LDHPs and OOP maximums on breast reconstruction. METHODS Between January 2014 and 2020, patients who had breast reconstruction by the 2 senior authors were retrospectively evaluated. Information on patient's insurance contract was collected. Criteria for HDHP and LDHP were defined following section 223(c)(2)(A) of the Internal Revenue Code. All aspects of cancer diagnosis, cancer treatment, and surgical procedures were reviewed. RESULTS About 507 patients (262 in LDHPs and 245 in HDHPs) were reviewed. Patients treated with neoadjuvant chemotherapy were more likely to be enrolled in HDHPs (25.7% vs. 36.8%, P < .01). There was no significant difference in total operations, number of revisions, or length of reconstruction in days or calendar years. Additionally, no difference existed in the choice of autologous implant reconstruction. CONCLUSION The cost-sharing burden of HDHPs creates the potential for patients to forego care, and thus, effort should be directed toward increasing patient education concerning health plan benefits. Utilization of postdeductible spending, as well as resources of health savings accounts, may limit the adverse effects of HDHPs. This study also emphasizes the importance for providers to increase cost transparency.
Collapse
Affiliation(s)
- Kaitlin D Jones
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Alexis C Lakatta
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Nicholas T Haddock
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Sumeet S Teotia
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| |
Collapse
|
9
|
Wharam JF, Rosenthal MB. The Increasing Adoption of Out-of-Pocket Cost Caps: Benefits, Unintended Consequences, and Policy Opportunities. JAMA 2023; 330:591-592. [PMID: 37498619 DOI: 10.1001/jama.2023.9455] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
This Viewpoint discusses potential benefits and unintended consequences of out-of-pocket cost caps in Medicare and the employer-sponsored health insurance market and provides suggested policy opportunities to address shortcomings.
Collapse
Affiliation(s)
- J Frank Wharam
- Department of Medicine, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
| | | |
Collapse
|
10
|
Sinaiko AD, Ross-Degnan D, Wharam JF, LeCates RF, Wu AC, Zhang F, Galbraith AA. Utilization and Spending With Preventive Drug Lists for Asthma Medications in High-Deductible Health Plans. JAMA Netw Open 2023; 6:e2331259. [PMID: 37642963 PMCID: PMC10466161 DOI: 10.1001/jamanetworkopen.2023.31259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/23/2023] [Indexed: 08/31/2023] Open
Abstract
Importance High-deductible health plans with health savings accounts (HDHP-HSAs) incentivize patients to use less health care, including necessary care. Preventive drug lists (PDLs) exempt high-value medications from the deductible, reducing out-of-pocket cost sharing; the associations of PDLs with health outcomes among patients with asthma is unknown. Objective To evaluate the associations of a PDL for asthma medications on utilization, adverse outcomes, and patient spending for HDHP-HSA enrollees with asthma. Design, Setting, and Participants This case-control study used matched groups of patients with asthma before and after an insurance design change using a national commercial health insurance claims data set from 2004-2017. Participants included patients aged 4 to 64 years enrolled for 1 year in an HDHP-HSA without a PDL in which asthma medications were subject to the deductible who then transitioned to an HDHP-HSA with a PDL that included asthma medications; these patients were compared with a matched weighted sample of patients with 2 years of continuous enrollment in an HDHP-HSA without a PDL. Models controlled for patient demographics and asthma severity and were stratified by neighborhood income. Analyses were conducted from October 2020 to June 2023. Exposures Employer-mandated addition of a PDL that included asthma medications to an existing HDHP-HSA. Main Outcomes and Measures Outcomes of interest were utilization of asthma medications on the PDL (controllers and albuterol), asthma exacerbations (oral steroid bursts and asthma-related emergency department use), and out-of-pocket spending (all and asthma-specific). Results A total of 12 174 participants (mean [SD] age, 36.9 [16.9] years; 6848 [56.25%] female) were included in analyses. Compared with no PDL, PDLs were associated with increased rates of 30-day fills per enrollee for any controller medication (change, 0.10 [95% CI, 0.03 to 0.17] fills per enrollee; 12.9% increase) and for combination inhaled corticosteroid long-acting β2-agonist (ICS-LABA) medications (change, 0.06 [95% CI, 0.01 to 0.10] fills per enrollee; 25.4% increase), and increased proportion of days covered with ICS-LABA (6.0% [0.7% to 11.3%] of days; 15.6% increase). Gaining a PDL was associated with decreased out-of-pocket spending on asthma care (change, -$34 [95% CI, -$47 to -$21] per enrollee; 28.4% difference), but there was no significant change in asthma exacerbations and no difference in results by income. Conclusions and Relevance In this case-control study, reducing cost-sharing for asthma medications through a PDL was associated with increased adherence to controller medications, notably ICS-LABA medications used by patients with more severe asthma, but was not associated with improved clinical outcomes. These findings suggest that PDLs are a potential strategy to improve access and affordability of asthma care for patients in HDHP-HSAs.
Collapse
Affiliation(s)
- Anna D. Sinaiko
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - J. Frank Wharam
- Department of Medicine, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
| | - Robert F. LeCates
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Ann Chen Wu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Alison A. Galbraith
- Department of Pediatrics, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| |
Collapse
|
11
|
Benson NM, Price M, Weiss M, Vogeli C, Vienneau MM, Mendu ML, Flaster A, Balentine L, Jubelt L, Meyer GS, Hsu J. Tacking upwind: reducing spending among high-risk commercially insured patients. THE AMERICAN JOURNAL OF MANAGED CARE 2023; 29:220-226. [PMID: 37229781 PMCID: PMC11056950 DOI: 10.37765/ajmc.2023.89355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES The study examined a commercial accountable care organization (ACO) population and then assessed the impact of an integrated care management program on medical spending and clinical event rates. STUDY DESIGN Retrospective cohort study of high-risk individuals (n = 487) in a population of 365,413 individuals aged 18 to 64 years within the Mass General Brigham health system who were part of commercial ACO contracts with 3 large insurers between 2015 and 2019. METHODS Using medical spending claims and other enrollment data, the study assessed the demographic and clinical characteristics, medical spending, and clinical event rates of patients in the ACO and its high-risk care management program. The study then examined the impact of the program using a staggered difference-in-difference design with individual-level fixed effects and compared outcomes of those who had entered the program with those of similar patients who had not entered. RESULTS The commercially insured ACO population was healthy on average but included several hundred high-risk patients (n = 487). After adjustment, patients within the ACO's integrated care management program for high-risk patients had lower monthly medical spending (by $1361 per person per month) as well as lower emergency department visit and hospitalization rates compared with similar patients who had yet to start the program. Accounting for early ACO departure decreased the magnitude of the program effects as expected. CONCLUSIONS Commercial ACO populations may be healthy on average but still include some high-risk patients. Identifying which patients might benefit from more intensive care management could be critical for reaping the potential savings.
Collapse
Affiliation(s)
- Nicole M Benson
- McLean Hospital, Harvard Medical School, 115 Mill St, Belmont, MA 02478.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Africa RE, Westenhaver ZK, Zimmerer RE, McKinnon BJ. Analysis of Postoperative Outcomes and Economic Behavior Trends of Tympanoplasty and Mastoidectomy With Expansion of High Deductible Health Plans. Otol Neurotol 2023; 44:e160-e165. [PMID: 36728473 DOI: 10.1097/mao.0000000000003788] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
HYPOTHESIS With rising deductibles, patients will delay ear surgeries toward the end of the year, and there will be an increase in postoperative complications. BACKGROUND The Affordable Care Act (ACA), passed on March 23, 2010, expanded high deductible health plans. The deductible can provide support for patients with high medical costs, but high deductibles deter patients from seeking necessary preventive health care and having elective procedures. Patients may defer care toward the end of the year until the deductible is met. The purpose of this study is to evaluate the relationship between expanding high deductible health plans and the repeal of the ACA's individual mandate on December 22, 2017, with the economic behavior trends of tympanoplasty and mastoidectomy in the fiscal year and surgical outcomes. METHODS TriNetX was used to obtain summary statistics of patients who had tympanoplasty and/or mastoidectomy from 58 health care organizations. TriNetX is a global federated database that contains de-identified patient data from the electronic medical records of participating health care institutions. This study evaluated the trends in ear surgeries from 2005 to 2021 in the fiscal quarters 1 and 4. Relative risk of developing postoperative complications was statistically interrogated. RESULTS The average rate of ear surgeries measured in cases/year was higher in Quarter 4 than in Quarter 1 after the expansion of higher deductible health plans (180; 124; p < 0.0001). After the repeal of the ACA's individual mandate, the rate of ear surgeries in Quarter 4 significantly decreased compared to post-ACA (-3.7; 287; p = 0.0002). No statistically significant differences were notable in postoperative complications. CONCLUSIONS The expansion of high deductible health plans with a rise in deductibles is associated with an increase in ear surgeries toward the end of the year. The repeal of the ACA's individual mandate is associated with a decreased rate of ear surgeries compared to post-ACA implementation. Despite financial concern, there was no increase in postoperative complications toward the end of the year.
Collapse
Affiliation(s)
| | | | | | - Brian J McKinnon
- Department of Otolaryngology-Head and Neck Surgery University of Texas Medical Branch, Galveston, TX
| |
Collapse
|
13
|
Herman WH, Schillinger D, Bolen S, Boltri JM, Bullock A, Chong W, Conlin PR, Cook JW, Dokun A, Fukagawa N, Gonzalvo J, Greenlee MC, Hawkins M, Idzik S, Leake E, Linder B, Lopata AM, Schumacher P, Shell D, Strogatz D, Towne J, Tracer H, Wu S. The National Clinical Care Commission Report to Congress: Recommendations to Better Leverage Federal Policies and Programs to Prevent and Control Diabetes. Diabetes Care 2023; 46:255-261. [PMID: 36701592 PMCID: PMC9887614 DOI: 10.2337/dc22-1587] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023]
Abstract
The National Clinical Care Commission (NCCC) was established by Congress to make recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. The NCCC developed a guiding framework that incorporated elements of the Socioecological and Chronic Care Models. It surveyed federal agencies and conducted follow-up meetings with representatives from 10 health-related and 11 non-health-related federal agencies. It held 12 public meetings, solicited public comments, met with numerous interested parties and key informants, and performed comprehensive literature reviews. The final report, transmitted to Congress in January 2022, contained 39 specific recommendations, including 3 foundational recommendations that addressed the necessity of an all-of-government approach to diabetes, health equity, and access to health care. At the general population level, the NCCC recommended that the federal government adopt a health-in-all-policies approach so that the activities of non-health-related federal agencies that address agriculture, food, housing, transportation, commerce, and the environment be coordinated with those of health-related federal agencies to affirmatively address the social and environmental conditions that contribute to diabetes and its complications. For individuals at risk for type 2 diabetes, including those with prediabetes, the NCCC recommended that federal policies and programs be strengthened to increase awareness of prediabetes and the availability of, referral to, and insurance coverage for intensive lifestyle interventions for diabetes prevention and that data be assembled to seek approval of metformin for diabetes prevention. For people with diabetes and its complications, the NCCC recommended that barriers to proven effective treatments for diabetes and its complications be removed, the size and competence of the workforce to treat diabetes and its complications be increased, and new payment models be implemented to support access to lifesaving medications and proven effective treatments for diabetes and its complications. The NCCC also outlined an ambitious research agenda. The NCCC strongly encourages the public to support these recommendations and Congress to take swift action.
Collapse
Affiliation(s)
| | - Dean Schillinger
- University of California San Francisco and San Francisco General Hospital, San Francisco, CA
| | - Shari Bolen
- Case Western Reserve at The MetroHealth System, Cleveland, OH
| | - John M. Boltri
- Northeast Ohio Medical University College of Medicine, Rootstown, OH
| | - Ann Bullock
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | | | - Paul R. Conlin
- Department of Veterans Affairs Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Ayotunde Dokun
- Carver School of Medicine, University of Iowa, Iowa City, IA
| | - Naomi Fukagawa
- Beltsville Human Nutrition Research Center, U.S. Department of Agriculture Agricultural Research Service, Beltsville, MD
| | | | | | | | - Shannon Idzik
- School of Nursing, University of Maryland Baltimore, Baltimore, MD
| | - Ellen Leake
- International Board of Directors, Juvenile Diabetes Research Foundation, Jackson, MS
| | - Barbara Linder
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Aaron M. Lopata
- Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
| | - Pat Schumacher
- Centers for Disease Control and Prevention, Department of Health and Human Services, Atlanta, GA
| | | | | | - Jana Towne
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | - Howard Tracer
- Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD
| | - Samuel Wu
- Office of Minority Health, Department of Health and Human Service, Rockville, MD
| |
Collapse
|
14
|
Jiang DH, Herrin J, Van Houten HK, McCoy RG. Evaluation of High-Deductible Health Plans and Acute Glycemic Complications Among Adults With Diabetes. JAMA Netw Open 2023; 6:e2250602. [PMID: 36662531 PMCID: PMC9860518 DOI: 10.1001/jamanetworkopen.2022.50602] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 11/20/2022] [Indexed: 01/21/2023] Open
Abstract
Importance Optimal diabetes care requires regular monitoring and care to maintain glycemic control. How high-deductible health plans (HDHPs), which reduce overall spending but may impede care by increasing out-of-pocket expenses, are associated with risks of severe hypoglycemia and hyperglycemia is unknown. Objective To examine the association between an employer-forced switch to HDHP and severe hypoglycemia and hyperglycemia. Design, Setting, and Participants This retrospective cohort study used deidentified administrative claims data for privately insured adults with diabetes from a single insurance carrier with multiple plans across the US between January 1, 2010, and December 31, 2018. Analyses were conducted between May 15, 2020, and November 3, 2022. Exposures Patients with 1 baseline year of enrollment in a non-HDHP whose employers subsequently forced a switch to an HDHP were compared with patients who did not switch. Main Outcomes and Measures Mixed-effects logistic regression models were used to examine the association between switching to an HDHP and the odds of severe hypoglycemia and hyperglycemia (ascertained using diagnosis codes in emergency department [ED] visits and hospitalizations), adjusting for patient age, sex, race and ethnicity, region, income, comorbidities, glucose-lowering medications, baseline ED and hospital visits for hypoglycemia and hyperglycemia, and baseline deductible amount, and applying inverse propensity score weighting to account for potential treatment selection bias. Results The study population was composed of 42 326 patients who switched to an HDHP (mean [SD] age: 52 [10] years, 19 752 [46.7%] women, 7375 [17.4%] Black, 5740 [13.6%] Hispanic, 26 572 [62.8%] non-Hispanic White) and 202 729 patients who did not switch (mean [SD] age, 53 [10] years, 89 828 [44.3%] women, 29 551 [14.6%] Black, 26 689 [13.2%] Hispanic, 130 843 [64.5%] non-Hispanic White). When comparing all study years, switching to an HDHP was not associated with increased odds of experiencing at least 1 hypoglycemia-related ED visit or hospitalization (OR, 1.01 [95% CI, 0.95-1.06]; P = .85), but each year of HDHP enrollment did increase these odds by 2% (OR, 1.02 [95% CI, 1.00-1.04]; P = .04). In contrast, switching to an HDHP did significantly increase the odds of experiencing at least 1 hyperglycemia-related ED visit or hospitalization (OR, 1.25 [95% CI, 1.11-1.42]; P < .001), with each year of HDHP enrollment increasing the odds by 5% (OR, 1.05 [95% CI, 1.01-1.09]; P = .02). Conclusions and Relevance In this cohort study, employer-forced switching to an HDHP was associated with increased odds of potentially preventable acute diabetes complications, potentially because of delayed or deferred care. These findings suggest that employers should be more judicious in their health plan offerings, and health plans and policy makers should consider allowing preventive and high-value services to be exempt from deductible requirements.
Collapse
Affiliation(s)
- David H. Jiang
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Holly K. Van Houten
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Rozalina G. McCoy
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- OptumLabs, Eden Prairie, Minnesota
| |
Collapse
|
15
|
Doty ME, Gil LA, Cooper JN. Association between high deductible health plan coverage and age at pediatric umbilical hernia repair. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000526. [PMID: 36969906 PMCID: PMC10030914 DOI: 10.1136/wjps-2022-000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/20/2023] [Indexed: 03/29/2023] Open
Abstract
Background High deductible health plans (HDHPs) are associated with the avoidance of both necessary and unnecessary healthcare. Umbilical hernia repair (UHR) is a procedure that is frequently unnecessarily performed in young children, contrary to best practice guidelines. We hypothesized that children with HDHPs, as compared with other types of commercial health plans, are less likely to undergo UHR before 4 years of age but are also more likely to have UHR delayed beyond 5 years of age. Methods Children aged 0-18 years old residing in metropolitan statistical areas (MSAs) who underwent UHR in 2012-2019 were identified in the IBM Marketscan Commercial Claims and Encounters Database. A quasi-experimental study design using MSA/year-level HDHP prevalence among children as an instrumental variable was employed to account for selection bias in HDHP enrollment. Two-stage least squares regression modeling was used to evaluate the association between HDHP coverage and age at UHR. Results A total of 8601 children were included (median age 5 years, IQR 3-7). Univariable analysis revealed no differences between the HDHP and non-HDHP groups in the likelihood of UHR being performed before 4 years of age (27.7% vs 28.7%, p=0.37) or after 5 years of age (39.8% vs 38.9%, p=0.52). Geographical region, metropolitan area size, and year were associated with HDHP enrollment. Instrumental variable analysis demonstrated no association between HDHP coverage and undergoing UHR at <4 years of age (p=0.76) or >5 years of age (p=0.87). Conclusions HDHP coverage is not associated with age at pediatric UHR. Future studies should investigate other means by which UHRs in young children can be avoided.
Collapse
Affiliation(s)
- Morgan E Doty
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Lindsay A Gil
- Department of Surgery, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Jennifer N Cooper
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio, USA
| |
Collapse
|
16
|
Huguet N, Dinh D, Hwang J, Marino M, Larson AE, Suchocki A, DeVoe JE. The Impact of the Affordable Care Act Medicaid Expansion on Acute Diabetes Complications Among Community Health Center Patients. J Prim Care Community Health 2023; 14:21501319231171437. [PMID: 37139559 PMCID: PMC10161334 DOI: 10.1177/21501319231171437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 05/05/2023] Open
Abstract
OBJECTIVE This study evaluates whether patients residing in expansion states have a greater increase in outpatient diagnoses of acute diabetes complications than those living in non-expansion states following the implementation of the Affordable Care Act (ACA). METHODS This retrospective cohort study uses electronic health records (EHR) from 10,665 non-pregnant patients, aged 19 to 64 years old who were diagnosed with diabetes in 2012 or 2013 from 347 community health centers (CHCs) across 16 states (11 expansion and 5 non-expansion states). Patients included had ≥1 outpatient ambulatory visit in each of these periods: pre-ACA: 2012 to 2013, post-ACA: 2014 to 2016, and post-ACA: 2017 to 2019. Acute diabetes-related complications were identified using International Classification Diseases (ICD-9-CM and ICD-10-CM) codes classification and could occur on or after diagnosis of diabetes. We performed difference-in-differences (DID) analysis using a generalized estimating equation to compare the change in rates of acute diabetes complications by year and by Medicaid expansion status. RESULTS There was a greater increase after year 2015 in visits related to abnormal blood glucose among patient living in Medicaid expansion states than in non-expansion states (2017 DID = 0.041, 95% CI = 0.027-0.056). Although both visits due to any acute diabetes complications and infection-related diabetes complications were higher among patients living in Medicaid expansion states, there was no difference in the trend overtime between expansion and non-expansion states. CONCLUSION We found a significantly greater rate of visits for abnormal blood glucose in patients receiving care in expansion states relative to patients in CHCs in non-expansion states starting in 2015. Additional resources for these clinics, such as the ability to provide blood glucose monitoring devices or mailed/delivered medications, could substantially benefit patients with diabetes.
Collapse
Affiliation(s)
| | - Dang Dinh
- Oregon Health & Science University, Portland, OR, USA
| | - Jun Hwang
- Oregon Health & Science University, Portland, OR, USA
| | - Miguel Marino
- Oregon Health & Science University, Portland, OR, USA
- Oregon Health & Science University—Portland State University, Portland, OR, USA
| | | | | | | |
Collapse
|
17
|
Du W, Liu P, Xu W. Effects of decreasing the out-of-pocket expenses for outpatient care on health-seeking behaviors, health outcomes and medical expenses of people with diabetes: evidence from China. Int J Equity Health 2022; 21:162. [PMID: 36384591 PMCID: PMC9667616 DOI: 10.1186/s12939-022-01775-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 09/18/2022] [Accepted: 10/16/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND To improve access to outpatient services and provide financial support in outpatient expenses for the insured, China has been establishing its scheme of decreasing the out-of-pocket expenses for outpatient care in recent years. There are 156 million diabetes patients in China which almost accounts for a quarter of diabetes population worldwide. Outpatient services plays an important role in diabetes treatment. The study aims to clarify the effects of decreasing the out-of-pocket expenses for outpatient care on health-seeking behaviors, health outcomes and medical expenses of people with diabetes. METHODS This study constructed a two-way fixed effect model, utilized 5,996 diabetes patients' medical visits records from 2019 to 2021, to ascertain the influence of decreasing the out-of-pocket expenses for outpatient care on diabetes patients. The dependent variables were diabetes patients' health-seeking behaviors, health outcomes, medical expenses and expenditure of the basic medical insurance funds for them; the core explanatory variable was the out-of-pocket expenses for outpatient care expressed by the annual outpatient reimbursement ratio. RESULTS With each increase of 1% in the annual outpatient reimbursement ratio: (1) for health-seeking behaviors, a diabetes patient's annual number of outpatient visits and annual number of medical visits increased by 0.021 and 0.014, while the annual number of hospitalizations decreased by 0.006; (2) for health outcomes, a diabetes patient's annual length of hospital stays and average length of a hospital stay decreased by 1.2% and 1.1% respectively, and the number of diabetes complications and Diabetes Complications Severity Index (DCSI) score both decreased by 0.001; (3) for medical expenses, a diabetes patient's annual outpatient expenses, annual inpatient expenses, annual medical expenses and annual out-of-pocket expenses decreased by 2.2%, 4.6%, 2.6% and 4.0%; (4) for expenditure of the basic medical insurance funds for a diabetes patient, the annual expenditure on outpatient services increased by 1.1%, and on inpatient services decreased by 4.4%, but on healthcare services didn't change. CONCLUSION Decreasing the out-of-pocket expenses for outpatient care appropriately among people with diabetes could make patients have a more rational health-seeking behaviors, a better health status and a more reasonable medical expenses while the expenditure of the basic medical insurance funds is stable totally.
Collapse
Affiliation(s)
- Wenwen Du
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing,, 211198, Jiangsu, China
| | - Ping Liu
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing,, 211198, Jiangsu, China
| | - Wei Xu
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing,, 211198, Jiangsu, China.
| |
Collapse
|
18
|
Chamine I, Hwang J, Valenzuela S, Marino M, Larson AE, Georgescu J, Latkovic-Taber M, Angier H, DeVoe JE, Huguet N. Acute and Chronic Diabetes-Related Complications Among Patients With Diabetes Receiving Care in Community Health Centers. Diabetes Care 2022; 45:e141-e143. [PMID: 35972244 PMCID: PMC9643147 DOI: 10.2337/dc22-0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/08/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Irina Chamine
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Jun Hwang
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Steele Valenzuela
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
- Department of Biostatistics, School of Public Health, Oregon Health & Science University–Portland
| | | | | | | | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Jennifer E. DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| |
Collapse
|
19
|
Wharam JF, Wallace J, Argetsinger S, Zhang F, Lu CY, Stryjewski TP, Ross-Degnan D, Newhouse JP. Diabetes Microvascular Disease Diagnosis and Treatment After High-Deductible Health Plan Enrollment. Diabetes Care 2022; 45:1754-1761. [PMID: 34588211 PMCID: PMC9346988 DOI: 10.2337/dc21-0407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 09/01/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The Affordable Care Act mandates that primary preventive services have no out-of-pocket costs but does not exempt secondary prevention from out-of-pocket costs. Most commercially insured patients with diabetes have high-deductible health plans (HDHPs) that subject key microvascular disease-related services to high out-of-pocket costs. Brief treatment delays can significantly worsen microvascular disease outcomes. RESEARCH DESIGN AND METHODS This cohort study used a large national commercial (and Medicare Advantage) health insurance claims data set to examine matched groups before and after an insurance design change. The study group included 50,790 patients with diabetes who were continuously enrolled in low-deductible (≤$500) health plans during a baseline year, followed by up to 4 years in high-deductible (≥$1,000) plans after an employer-mandated switch. HDHPs had low out-of-pocket costs for nephropathy screening but not retinopathy screening. A matched control group included 335,178 patients with diabetes who were contemporaneously enrolled in low-deductible plans. Measures included time to first detected microvascular disease screening, severe microvascular disease diagnosis, vision loss diagnosis/treatment, and renal function loss diagnosis/treatment. RESULTS HDHP enrollment was associated with relative delays in retinopathy screening (0.7 months [95% CI 0.4, 1.0]), severe retinopathy diagnosis (2.9 months [0.5, 5.3]), and vision loss diagnosis/treatment (3.8 months [1.2, 6.3]). Nephropathy-associated measures did not change to a statistically significant degree among HDHP members relative to control subjects at follow-up. CONCLUSIONS People with diabetes in HDHPs experienced delayed retinopathy diagnosis and vision loss diagnosis/treatment of up to 3.8 months compared with low-deductible plan enrollees. Findings raise concerns about visual health among HDHP members and call attention to discrepancies in Affordable Care Act cost sharing exemptions.
Collapse
Affiliation(s)
- J. Frank Wharam
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Duke-Margolis Center for Health Policy, Duke University, Durham, NC
| | | | - Stephanie Argetsinger
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Fang Zhang
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Christine Y. Lu
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | | | - Dennis Ross-Degnan
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
- Harvard Kennedy School, Cambridge, MA
- National Bureau of Economic Research, Cambridge, MA
| |
Collapse
|
20
|
Siegel KR, Ali MK, Ackermann RT, Black B, Huguet N, Kho A, Mangione CM, Nauman E, Ross-Degnan D, Schillinger D, Shi L, Wharam JF, Duru OK. Evaluating Natural Experiments that Impact the Diabetes Epidemic: an Introduction to the NEXT-D3 Network. Curr Diab Rep 2022; 22:393-403. [PMID: 35864324 PMCID: PMC9303841 DOI: 10.1007/s11892-022-01480-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Diabetes is an ongoing public health issue in the USA, and, despite progress, recent reports suggest acute and chronic diabetes complications are increasing. RECENT FINDINGS The Natural Experiments for Translation in Diabetes 3.0 (NEXT-D3) Network is a 5-year research collaboration involving six academic centers (Harvard University, Northwestern University, Oregon Health & Science University, Tulane University, University of California Los Angeles, and University of California San Francisco) and two funding agencies (Centers for Disease Control and Prevention and National Institutes of Health) to address the gaps leading to persisting diabetes burdens. The network builds on previously funded networks, expanding to include type 2 diabetes (T2D) prevention and an emphasis on health equity. NEXT-D3 researchers use rigorous natural experiment study designs to evaluate impacts of naturally occurring programs and policies, with a focus on diabetes-related outcomes. NEXT-D3 projects address whether and to what extent federal or state legislative policies and health plan innovations affect T2D risk and diabetes treatment and outcomes in the USA; real-world effects of increased access to health insurance under the Affordable Care Act; and the effectiveness of interventions that reduce barriers to medication access (e.g., decreased or eliminated cost sharing for cardiometabolic medications and new medications such as SGLT-2 inhibitors for Medicaid patients). Overarching goals include (1) expanding generalizable knowledge about policies and programs to manage or prevent T2D and educate decision-makers and organizations and (2) generating evidence to guide the development of health equity goals to reduce disparities in T2D-related risk factors, treatment, and complications.
Collapse
Affiliation(s)
- Karen R Siegel
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Mohammed K Ali
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Ronald T Ackermann
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bernard Black
- Pritzker School of Law, Institute for Policy Research, and Kellogg School of Management, Northwestern University, Evanston, IL, USA
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Abel Kho
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Carol M Mangione
- David Geffen School of Medicine at UCLA and Fielding School of Public Health, UCLA, Los Angeles, CA, USA
| | | | - Dennis Ross-Degnan
- Duke University Department of Medicine and Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Dean Schillinger
- Division of General Internal Medicine and Center for Vulnerable Populations, San Francisco General Hospital and University of California San Francisco, San Francisco, CA, USA
| | - Lizheng Shi
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - J Frank Wharam
- Duke University Department of Medicine and Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - O Kenrik Duru
- David Geffen School of Medicine at UCLA and Fielding School of Public Health, UCLA, Los Angeles, CA, USA
| |
Collapse
|
21
|
Association Between High Deductible Health Plans and Cost-Related Non-adherence to Medications Among Americans with Diabetes: an Observational Study. J Gen Intern Med 2022; 37:1910-1916. [PMID: 34324130 PMCID: PMC9198142 DOI: 10.1007/s11606-021-06937-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND For people with diabetes, adherence to prescribed medications is essential. However, the rising prevalence of high-deductible health plans (HDHPs), and prices of diabetes medications such as insulin, could deter adherence. OBJECTIVE To assess the impact of HDHP on cost-related medication non-adherence (CRN) among non-elderly adults with diabetes in the US. DESIGN Repeated cross-sectional survey. SETTING National Health Interview Survey, 2011-2018. PARTICIPANTS A total of 7469 privately insured adults ages 18-64 with diabetes who were prescribed medications and enrolled in a HDHP or a traditional commercial health plan (TCP). MAIN MEASURES Self-reported measures of CRN were compared between enrollees in HDHPs and TCPs overall and among the subset using insulin. Analyses were adjusted for demographic and clinical characteristics using multivariable linear regression models. KEY RESULTS HDHP enrollees were more likely than TCP enrollees to not fill a prescription (13.4% vs 9.9%; adjusted percentage point difference (AD) 3.4 [95% CI 1.5 to 5.4]); skip medication doses (11.4% vs 8.5%; AD 2.8 [CI 1.0 to 4.7]); take less medication (11.1% vs 8.8%; AD 2.3 [CI 0.5 to 4.0]); delay filling a prescription to save money (14.4% vs 10.8%; AD 3.0 [CI 1.1 to 4.9]); and to have any form of CRN (20.4% vs 15.5%; AD 4.4 [CI 2.2 to 6.7]). Among those taking insulin, HDHP enrollees were more likely to have any CRN (25.1% vs 18.9%; AD 5.9 [CI 1.1 to 10.8]). CONCLUSION HDHPs are associated with greater CRN among people with diabetes, particularly those prescribed insulin. For people with diabetes, enrollment in non-HDHPs might reduce CRN to prescribed medications.
Collapse
|
22
|
Glied SA, Remler DK, Springsteen M. Health Savings Accounts No Longer Promote Consumer Cost-Consciousness. HEALTH AFFAIRS (PROJECT HOPE) 2022; 41:814-820. [PMID: 35666974 DOI: 10.1377/hlthaff.2021.01954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Two decades ago Congress enabled Americans to open tax-favored health savings accounts (HSAs) in conjunction with qualifying high-deductible health plans (HDHPs). This HSA tax break is regressive: Higher-income Americans are more likely to have HSAs and fund them at higher levels. Proponents, however, have argued that this regressivity is offset by reductions in wasteful health care spending because consumers with HDHPs are more cost-conscious in their use of care. Using published sources and our own analysis of National Health Interview Survey data, we argue that HSAs no longer appreciably achieve this cost-consciousness aim because cost sharing has increased so much in non-HSA-qualified plans. Indeed, people who have HDHPs with HSAs are becoming less likely than others with private insurance to report financial barriers to care. In sum, promised gains in efficiency from HSAs have not borne out, so it is difficult to justify maintaining this regressive tax break.
Collapse
Affiliation(s)
- Sherry A Glied
- Sherry A. Glied , New York University, New York, New York
| | - Dahlia K Remler
- Dahlia K. Remler, Baruch College, City University of New York, New York, New York
| | | |
Collapse
|
23
|
Wu YM, Huang J, Reed ME. Association Between High-Deductible Health Plans and Engagement in Routine Medical Care for Type 2 Diabetes in a Privately Insured Population: A Propensity Score-Matched Study. Diabetes Care 2022; 45:1193-1200. [PMID: 35290445 PMCID: PMC9375446 DOI: 10.2337/dc21-1885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 02/14/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE High-deductible health plans (HDHPs) are increasingly more common but can be challenging for patients to navigate and may negatively affect care engagement for chronic conditions such as type 2 diabetes. We sought to understand how higher out-of-pocket costs affect participation in provider visits, medication adherence, and routine monitoring by patients with type 2 diabetes with an HDHP. RESEARCH DESIGN AND METHODS In a retrospective cohort of 19,379 Kaiser Permanente Northern California patients with type 2 diabetes (age 18-64 years), 6,801 patients with an HDHP were compared with those with a no-deductible plan using propensity score matching. We evaluated the number of telephone and office visits with primary care, oral diabetic medication adherence, and rates of HbA1c testing, blood pressure monitoring, and retinopathy screening. RESULTS Patients with an HDHP had fewer primary care office visits compared with patients with no deductible (4.25 vs. 4.85 visits per person; P < 0.001), less retinopathy screening (49.9% vs. 53.3%; P < 0.001), and fewer A1c and blood pressure measurements (46.7% vs. 51.4%; P < 0.001 and 93.2% vs. 94.4%; P = 0.004, respectively) compared with the control group. Medication adherence was not significantly different between patients with an HDHP and those with no deductible (57.4% vs. 58.6%; P = 0.234). CONCLUSIONS HDHPs seem to be a barrier for patients with type 2 diabetes and reduce care participation in both visits with out-of-pocket costs and preventive care without out-of-pocket costs, possibly because of the increased complexity of cost sharing under an HDHP, potentially leading to decreased monitoring of important clinical measurements.
Collapse
Affiliation(s)
- You M Wu
- Department of Adult and Family Medicine, Kaiser Permanente, Santa Clara, CA
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, CA
| | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA
| |
Collapse
|
24
|
Shiau R, Holmen J, Chitnis AS. Public Health Expenditures and Clinical and Social Complexity of Tuberculosis Cases-Alameda County, California, July-December 2017. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2022; 28:188-198. [PMID: 33938488 DOI: 10.1097/phh.0000000000001356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Alameda County, California, is a high tuberculosis (TB) burden county that reported a TB incidence rate of 8.1 per 100 000 during 2017. It is the only high TB burden California county that does not have a public health-funded TB clinic. OBJECTIVE To describe TB public health expenditures and clinical and social complexities of TB case-patients. DESIGN, SETTING, AND PARTICIPANTS Public health surveillance of confirmed and possible TB case-patients reported to Alameda County Public Health Department during July 1, 2017, to December 31, 2017. Social complexity status was categorized for all case-patients using surveillance data; clinical complexity status, either by surveillance definition or by the Charlson Comorbidity Index (CCI), was categorized only for confirmed TB case-patients. MAIN OUTCOME MEASURES Total public health and per patient expenditures were stratified by insurance status. Cohen's kappa assessed concordance between clinical complexity definitions. All comparisons were conducted using Fisher's exact or Kruskal-Wallis tests. RESULTS Of 81 case-patients reported, 68 (84%) had confirmed TB, 29 (36%) were socially complex, and 15 (19%) were uninsured. Total public health expenditures were $487 194, and 18% of expenditures were in nonlabor domains, 57% of which were for TB treatment, diagnostics, and insurance, with insured patients also incurring such expenditures. Median per patient expenditures were significantly higher for uninsured and government-insured patients than for privately insured patients ($7007 and $5045 vs $3704; P = .03). Among confirmed TB case-patients, 72% were clinically complex by surveillance definition and 53% by the CCI; concordance between definitions was poor (κ = 0.25; 95% confidence interval, 0.03-0.46). CONCLUSIONS Total public health expenditures approached $500 000. Most case-patients were clinically complex, and about 20% were uninsured. While expenditures were higher for uninsured case-patients, insured case-patients still incurred TB treatment, diagnostic, and insurance-related expenditures. State and local health departments may be able to use our expenditure estimates by insurance status and description of clinically complex TB case-patients to inform efforts to allocate and secure adequate funding.
Collapse
Affiliation(s)
- Rita Shiau
- Tuberculosis Control Section, Division of Communicable Disease Control and Prevention, Alameda County Public Health Department, San Leandro, California (Ms Shiau and Dr Chitnis); and Division of Pediatric Infectious Diseases, University of California San Francisco Benioff Children's Hospital of Oakland, Oakland, California (Dr Holmen)
| | | | | |
Collapse
|
25
|
Cliff BQ. Do high-deductible health plans affect price paid for childbirth? Health Serv Res 2022; 57:27-36. [PMID: 34254295 PMCID: PMC8763287 DOI: 10.1111/1475-6773.13702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/07/2021] [Accepted: 06/11/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To test whether out-of-pocket costs and negotiated hospital prices for childbirth change after enrollment in high-deductible health plans (HDHPs) and whether price effects differ in markets with more hospitals. DATA SOURCES Administrative medical claims data from 2010 to 2014 from three large commercial insurers with plans in all U.S. states provided by the Health Care Cost Institute (HCCI). STUDY DESIGN I identify employer groups that switched from non-HDHPs in 1 year to HDHPs in a subsequent year. I estimate enrollees' change in out-of-pocket costs and negotiated hospital prices for childbirth after HDHP switch, relative to a comparison group of employers that do not switch plans. I use a triple-difference design to estimate price changes for enrollees in markets with more hospital choices. Finally, I re-estimate models with hospital-fixed effects. DATA COLLECTION From the HCCI sample, childbearing women enrolled in an employer-sponsored plan with at least 10 people. PRINCIPAL FINDINGS Switching to an HDHP increases out-of-pocket cost $227 (p < 0.001; comparison group base $790) and has no meaningful effect on hospital-negotiated prices (-$26, p = 0.756; comparison group base $5821). HDHP switch is associated with a marginally statistically significant price increase in markets with three or fewer hospitals ($343, p = 0.096; comparison group base $5806) and, relative to those markets, with a price decrease in markets with more than three hospitals (-$512; p = 0.028). Predicted prices decrease from $5702 to $5551 after HDHP switch in markets with more than three hospitals due primarily to lower prices conditional on using the same hospital. CONCLUSIONS Prices for childbirth in markets with more hospitals decrease after HDHP switch due to lower hospital prices for HDHPs relative to prices at those same hospitals for non-HDHPs. These results reinforce previous findings that HDHPs do not promote price shopping but suggest negotiated prices may be lower for HDHP enrollees.
Collapse
Affiliation(s)
- Betsy Q. Cliff
- Division of Health Policy & AdministrationUniversity of Illinois ChicagoChicagoIllinoisUSA
| |
Collapse
|
26
|
Kurani SS, Heien HC, Sangaralingham LR, Inselman JW, Shah ND, Golden SH, McCoy RG. Association of Area-Level Socioeconomic Deprivation With Hypoglycemic and Hyperglycemic Crises in US Adults With Diabetes. JAMA Netw Open 2022; 5:e2143597. [PMID: 35040969 PMCID: PMC8767428 DOI: 10.1001/jamanetworkopen.2021.43597] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Social determinants of health play a role in diabetes management and outcomes, including potentially life-threatening complications of severe hypoglycemia and diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS). Although several person-level socioeconomic factors have been associated with these complications, the implications of area-level socioeconomic deprivation are unknown. OBJECTIVE To examine the association between area-level deprivation and the risks of experiencing emergency department visits or hospitalizations for hypoglycemic and hyperglycemic crises (ie, DKA or HHS). DESIGN, SETTING, AND PARTICIPANTS This cohort study used deidentified administrative claims data for privately insured individuals and Medicare Advantage beneficiaries across the US. The analysis included adults with diabetes who met the claims criteria for diabetes between January 1, 2016, and December 31, 2017. Data analyses were performed from November 17, 2020, to November 11, 2021. EXPOSURES Area deprivation index (ADI) was derived for each county for 2016 and 2017 using 17 county-level indicators from the American Community Survey. ADI values were applied to patients who were living in each county based on their index dates and were categorized according to county-level ADI quintile (with quintile 1 having the least deprivation and quintile 5 having the most deprivation). MAIN OUTCOMES AND MEASURES The numbers of emergency department visits or hospitalizations related to the primary diagnoses of hypoglycemia and DKA or HHS (ascertained using validated diagnosis codes in the first or primary position of emergency department or hospital claims) between 2016 and 2019 were calculated for each ADI quintile using negative binomial regression models and adjusted for patient age, sex, health plan type, comorbidities, glucose-lowering medication type, and percentage of White residents in the county. RESULTS The study population included 1 116 361 individuals (563 943 women [50.5%]), with a mean (SD) age of 64.9 (13.2) years. Of these patients, 343 726 (30.8%) resided in counties with the least deprivation (quintile 1) and 121 810 (10.9%) lived in counties with the most deprivation (quintile 5). Adjusted rates of severe hypoglycemia increased from 13.54 (95% CI, 12.91-14.17) per 1000 person-years in quintile 1 counties to 19.13 (95% CI, 17.62-20.63) per 1000 person-years in quintile 5 counties, corresponding to an incidence rate ratio of 1.41 (95% CI, 1.29-1.54; P < .001). Adjusted rates of DKA or HHS increased from 7.49 (95% CI, 6.96-8.02) per 1000 person-years in quintile 1 counties to 8.37 (95% CI, 7.50-9.23) per 1000 person-years in quintile 5 counties, corresponding to an incidence rate ratio of 1.12 (95% CI, 1.00-1.25; P = .049). CONCLUSIONS AND RELEVANCE This study found that living in counties with a high area-level deprivation was associated with an increased risk of severe hypoglycemia and DKA or HHS. The concentration of these preventable events in areas of high deprivation signals the need for interventions that target the structural barriers to optimal diabetes management and health.
Collapse
Affiliation(s)
- Shaheen Shiraz Kurani
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Herbert C. Heien
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Lindsey R. Sangaralingham
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
- OptumLabs, Eden Prairie, Minnesota
| | - Jonathan W. Inselman
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Nilay D. Shah
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins Medicine, Baltimore, Maryland
- Office of Diversity, Inclusion, and Health Equity, Johns Hopkins Medicine, Baltimore, Maryland
| | - Rozalina G. McCoy
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
27
|
Khanijahani A, Akinci N, Iezadi S, Priore D. Impacts of high-deductible health plans on patients with diabetes: A systematic review of the literature. Prim Care Diabetes 2021; 15:948-957. [PMID: 34400113 DOI: 10.1016/j.pcd.2021.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVES High-deductible health plans (HDHPs) as a type of consumer-directed health insurance plan aim to control unnecessary service utilization and share the responsibility in payments and care with the patient. Our objective was to systematically pool the medical and non-medical impacts of HDHPs on patients with diabetes. METHODS We searched databases, including PubMed, Scopus, Embase, and Wiley, to identify relevant published studies. We outlined the eligibility criteria based on the study population, intervention, comparison, outcome, and types of studies (PICOT). We included peer-reviewed quantitative studies published in English, including quasi-experimental, observational, and cross-sectional studies in this review. We used the narrative data synthesis method to categorize and interpret the results. RESULTS Initial search yielded 149 results. After removing duplicates and screening for relevant titles and abstracts, and reviewing full texts, 11 studies met eligibility criteria. Overall, diabetic patients with HDHP were less likely to adhere to treatment and prescription refills, utilize fewer healthcare services and medications, and more likely to have acute emergency visits than their counterparts enrolled in low-deductible plans. However, the results on overall healthcare costs and the final health outcome were unclear. CONCLUSIONS It appears that HDHPs negatively impact low-income diabetic patients by leading them to forgo preventive and primary care services and experience excessive preventable emergency department visits. The socioeconomic characteristics of patients must be considered when developing HDHP policies, and adjustments should be made to HDHPs accordingly.
Collapse
Affiliation(s)
- Ahmad Khanijahani
- Department of Health Administration and Public Health, John G. Rangos School of Health Sciences, Duquesne University, Pittsburgh, PA, USA.
| | - Nesli Akinci
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Davie, FL, USA
| | - Shabnam Iezadi
- Hospital Management Research Center, Iran University of Medical Science, Tehran, Iran
| | - Dreux Priore
- Department of Health Administration and Public Health, John G. Rangos School of Health Sciences, Duquesne University, Pittsburgh, PA, USA
| |
Collapse
|
28
|
Larson K, Gottschlich EA, Cull WL, Olson LM. High-Deductible Health Plans for US Children: Trends, Health Service Use, and Financial Barriers to Care. Acad Pediatr 2021; 21:1345-1354. [PMID: 33713837 DOI: 10.1016/j.acap.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 02/08/2021] [Accepted: 03/04/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Few studies have examined children's enrollment in high-deductible health plans (HDHPs) and associations with health service use. We examine trends, health service use, and financial barriers to care for US children with high-deductible private insurance. METHODS Trend data on HDHP enrollment were available for 58,910 children ages 0 to 17 with private insurance from the 2007 to 2018 National Health Interview Survey. Health service indicators were examined in a cross-sectional sample of 23,959 children in the 2014-2018 datasets. High deductible was defined as a minimum of $2,700 for a family in 2018. Chi-square tests examined associations of HDHPs with health service indicators. Logistic regression models adjusted for sociodemographics and child health. RESULTS The percent of privately insured children with HDHPs increased from 18.4% to 48.6% from 2007 to 2018. In adjusted regression, those with HDHPs fared worse than those with traditional plans on 7 of 10 measures and those with HDHPs and no health savings account (HSA) fared worse on eight. While small differences were found for various child-focused measures, the most consistent differences were found for family-focused measures. Parents with HDHPs were more likely than parents with traditional private insurance to report they had delayed or forgone their medical care (10.2% vs 5.7%), had problems paying medical bills (15.7% vs 10.3%), and had family medical debt (34.1% vs 25.8%). CONCLUSIONS Privately insured families have seen substantial growth in high-deductible plans in the last decade. Families with HDHPs, especially those without HSAs, have more financial barriers to care.
Collapse
|
29
|
Garabedian LF, Zhang F, LeCates R, Wallace J, Ross-Degnan D, Wharam JF. Trends in high deductible health plan enrolment and spending among commercially insured members with and without chronic conditions: a Natural Experiment for Translation in Diabetes (NEXT-D2) Study. BMJ Open 2021; 11:e044198. [PMID: 34518242 PMCID: PMC8438755 DOI: 10.1136/bmjopen-2020-044198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES To examine trends in high deductible health plan (HDHP) enrolment among members with diabetes and cardiovascular disease (CVD) compared with healthy members and compare out-of-pocket (OOP) and total spending for members with chronic conditions in HDHPs versus low deductible plans. DESIGN Descriptive study with time trends. SETTING A large national commercial insurance database. PARTICIPANTS 1.2 million members with diabetes, 4.5 million members with CVD (without diabetes) and 18 million healthy members (defined by a low comorbidity score) under the age of 65 years and insured between 2005 and 2013. OUTCOME MEASURES Percentage of members in an HDHP (ie, annual deductible ≥$1000) by year, annual mean OOP and total spending, adjusted for member sociodemographic and employer characteristics. RESULTS Enrolment in HDHPs among members in all disease categories increased by 5 percentage points a year and was over 50% by 2013. On average, over the study period, HDHP enrolment among members with diabetes and CVD was 2.84 (95% CI: 2.78 to 2.90) and 2.02 (95% CI: 1.98 to 2.05) percentage points lower, respectively, than among healthy members. HDHP members with diabetes, CVD and low morbidity had higher annual OOP costs ($636 (95% CI: 630 to 642), $539 (95% CI: 537 to 542) and $113 (95% CI: 112 to 113)) and lower total costs (-$529 (95% CI: -597 to -461), -$364 (95% CI: -385 to -342) and -$79 (95% CI: -81 to -76)), respectively, than corresponding low deductible members when averaged over the study period. Members with chronic diseases had yearly OOP expenditures that were five to seven times higher than healthier members. CONCLUSION High HDHP enrolment coupled with the high OOP costs associated with HDHPs may be particularly detrimental to the financial well-being of people with diabetes and CVD, who have more healthcare needs than healthier populations.
Collapse
Affiliation(s)
- Laura F Garabedian
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Fang Zhang
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Robert LeCates
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Jamie Wallace
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Dennis Ross-Degnan
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - James F Wharam
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| |
Collapse
|
30
|
Sinaiko AD, Gaye M, Wu AC, Bambury E, Zhang F, Xu X, Wharam JF, Galbraith AA. Out-of-Pocket Spending for Asthma-Related Care Among Commercially Insured Patients, 2004-2016. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4324-4331.e7. [PMID: 34481128 DOI: 10.1016/j.jaip.2021.07.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Out-of-pocket (OOP) health care costs can cause financial burden and deferred care for many Americans. Little is known about OOP spending for asthma-related care among the commercially insured. OBJECTIVES To analyze OOP spending for asthma-related care overall, across types of care, and by income. METHODS Using enrollment, claims, and geocoded census tract data on income from a large US commercial health plan from 2004 to 2016, we measured inflation-adjusted OOP spending for individuals with asthma ages 4 to 64 years (n = 1,986,769). We estimated annual asthma-related OOP spending over time, and average total, asthma-related, asthma type of care, and asthma medication spending by income. We measured trends in median OOP cost per medication. Linear regression models were adjusted for patient covariates and deductible level. RESULTS Asthma-related OOP spending decreased over time both for patients enrolled in high-deductible health plans and for those in traditional plans. High-deductible plan enrollment increased from 7% to 54%. Compared with patients living in high-income areas, patients in the lowest-income areas had similar annual total and asthma-related OOP spending, but spent 30% less on controller medications and a higher proportion of their asthma-related OOP spending on inpatient and emergency care (10% vs 3%; P < .001). Asthma-related OOP spending represented a higher proportion of household income for patients in lower-income areas. CONCLUSIONS Patients with asthma living in the lowest-income areas have greater cost burden, lower spending on controller medications, and greater spending on high-acuity care than higher-income counterparts.
Collapse
Affiliation(s)
- Anna D Sinaiko
- Harvard T.H. Chan School of Public Health, Boston, Mass.
| | - Marema Gaye
- Harvard T.H. Chan School of Public Health, Boston, Mass
| | - Ann Chen Wu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | | | - Fang Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Xin Xu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - J Frank Wharam
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Alison A Galbraith
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| |
Collapse
|
31
|
McCoy RG, Galindo RJ, Swarna KS, Van Houten HK, O’Connor PJ, Umpierrez GE, Shah ND. Sociodemographic, Clinical, and Treatment-Related Factors Associated With Hyperglycemic Crises Among Adults With Type 1 or Type 2 Diabetes in the US From 2014 to 2020. JAMA Netw Open 2021; 4:e2123471. [PMID: 34468753 PMCID: PMC8411297 DOI: 10.1001/jamanetworkopen.2021.23471] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Hyperglycemic crises (ie, diabetic ketoacidosis [DKA] and hyperglycemic hyperosmolar state [HHS]) are life-threatening acute complications of diabetes. Efforts to prevent these events at the population level have been hindered by scarce granular data and difficulty in identifying individuals at highest risk. OBJECTIVE To assess sociodemographic, clinical, and treatment-related factors associated with hyperglycemic crises in adults with type 1 or type 2 diabetes in the US from 2014 to 2020. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study analyzed administrative claims and laboratory results for adults (aged ≥18 years) with type 1 or type 2 diabetes from the OptumLabs Data Warehouse from January 1, 2014, through December 31, 2020. MAIN OUTCOMES AND MEASURES Rates of emergency department or hospital visits with a primary diagnosis of DKA or HHS (adjusted for age, sex, race/ethnicity, and region, and for year when calculating annualized rates) were calculated separately for patients with type 1 diabetes and type 2 diabetes. The associations of sociodemographic factors (age, sex, race/ethnicity, region, and income), clinical factors (comorbidities), and treatment factors (glucose-lowering medications, hemoglobin A1c) with DKA or HHS in patients with type 1 or type 2 diabetes were assessed using negative binomial regression. RESULTS Among 20 156 adults with type 1 diabetes (mean [SD] age, 46.6 [16.5] years; 51.2% male; 72.6% White race/ethnicity) and 796 382 with type 2 diabetes (mean [SD] age, 65.6 [11.8] years; 50.3% female; 54.4% White race/ethnicity), adjusted rates of hyperglycemic crises were 52.69 per 1000 person-years (95% CI, 48.26-57.12 per 1000 person-years) for type 1 diabetes and 4.04 per 1000 person-years (95% CI, 3.88-4.21 per 1000 person-years) for type 2 diabetes. In both groups, factors associated with the greatest hyperglycemic crisis risk were low income (≥$200 000 vs <$40 000: type 1 diabetes incidence risk ratio [IRR], 0.61 [95% CI, 0.46-0.81]; type 2 diabetes IRR, 0.69 [95% CI, 0.56-0.86]), Black race/ethnicity (vs White race/ethnicity: type 1 diabetes IRR, 1.33 [95% CI, 1.01-1.74]; type 2 diabetes IRR, 1.18 [95% CI, 1.09-1.27]), high hemoglobin A1c level (≥10% vs 6.5%-6.9%: type 1 diabetes IRR, 7.81 [95% CI, 5.78-10.54]; type 2 diabetes IRR, 7.06 [95% CI, 6.26-7.96]), history of hyperglycemic crises (type 1 diabetes IRR, 7.88 [95% CI, 6.06-9.99]; type 2 diabetes IRR, 17.51 [95% CI, 15.07-20.34]), severe hypoglycemia (type 1 diabetes IRR, 2.77 [95% CI, 2.15-3.56]; type 2 diabetes IRR, 4.18 [95% CI, 3.58-4.87]), depression (type 1 diabetes IRR, 1.62 [95% CI, 1.37-1.92]; type 2 diabetes IRR, 1.46 [95% CI, 1.34-1.59]), neuropathy (type 1 diabetes IRR, 1.64 [95% CI, 1.39-1.93]; type 2 diabetes IRR, 1.25 [95% CI, 1.17-1.34]), and nephropathy (type 1 diabetes IRR, 1.22 [95% CI, 1.01-1.48]; type 2 diabetes IRR, 1.23 [95% CI, 1.14-1.33]). Age had a U-shaped association with hyperglycemic crisis risk in patients with type 1 diabetes (compared with patients aged 18-44 years: 45-64 years IRR, 0.72 [95% CI, 0.59-0.87]; 65-74 years IRR, 0.62 [95% CI, 0.47-0.80]; ≥75 years IRR, 0.96 [95% CI, 0.66-1.38]). In type 2 diabetes, risk of hyperglycemic crises decreased progressively with age (45-64 years IRR, 0.57 [95% CI, 0.51-0.63]; 65-74 years IRR, 0.44 [95% CI, .39-0.49]; ≥75 years IRR, 0.41 [95% CI, 0.36-0.47]). In patients with type 2 diabetes, higher risk was associated with sodium-glucose cotransporter 2 inhibitor therapy (IRR, 1.30; 95% CI, 1.14-1.49) and insulin dependency (compared with regimens with bolus insulin: regimens with basal insulin only, IRR, 0.69 [95% CI, 0.63-0.75]; and without any insulin, IRR, 0.36 [95% CI, 0.33-0.40]). CONCLUSIONS AND RELEVANCE In this cohort study, younger age, Black race/ethnicity, low income, and poor glycemic control were associated with an increased risk of hyperglycemic crises. The findings suggest that multidisciplinary interventions focusing on groups at high risk for hyperglycemic crises are needed to prevent these dangerous events.
Collapse
Affiliation(s)
- Rozalina G. McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Rodolfo J. Galindo
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Kavya Sindhu Swarna
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Holly K. Van Houten
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
- HealthPartners Institute Center for Chronic Care Innovation, Minneapolis, Minnesota
| | - Patrick J. O’Connor
- HealthPartners Institute Center for Chronic Care Innovation, Minneapolis, Minnesota
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Nilay D. Shah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
- OptumLabs, Eden Prairie, Minnesota
| |
Collapse
|
32
|
Lu CY, Busch AB, Zhang F, Madden JM, Callahan MX, LeCates RF, Wallace J, Foxworth P, Soumerai SB, Ross-Degnan D, Wharam JF. Impact of High-Deductible Health Plans on Medication Use Among Individuals With Bipolar Disorder. Psychiatr Serv 2021; 72:926-934. [PMID: 33971720 DOI: 10.1176/appi.ps.202000362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE High-deductible health plans (HDHPs) require substantial out-of-pocket spending for most services, although medications may be subject to traditional copayment arrangements. This study examined effects of HDHPs on medication out-of-pocket spending and use and quality of care among individuals with bipolar disorder. METHODS This quasi-experimental study used claims data (2003-2014) for a national sample of 3,532 members with bipolar disorder, ages 12-64, continuously enrolled for 1 year in a low-deductible plan (≤$500) and then for 1 year in an HDHP (≥$1,000) after an employer-mandated switch. HDHP members were matched to 18,923 contemporaneous individuals in low-deductible plans (control group). Outcome measures were out-of-pocket spending and use of bipolar disorder medications, psychotropics for other disorders, and all other medications and appropriate laboratory monitoring for psychotropics. RESULTS Relative to the control group, annual out-of-pocket spending per person for bipolar disorder medications increased 20.8% among HDHP members (95% confidence interval [CI]=14.9%-26.7%), and the absolute increase was $36 (95% CI=$25.9-$45.2). Specifically, out-of-pocket spending increased for antipsychotics (27.1%; 95% CI=17.4%-36.7%) and anticonvulsants (19.2%; 95% CI=11.9%-26.6%) but remained stable for lithium (-3.7%; 95% CI=-12.2% to 4.8%). No statistically significant changes were detected in use of bipolar disorder medications, other psychotropics, or all other medications or in appropriate laboratory monitoring for bipolar disorder medications. CONCLUSIONS HDHP members with bipolar disorder experienced a moderate increase in out-of-pocket spending for medications but preserved bipolar disorder medication use. Findings may reflect individuals' perceptions of the importance of these medications for their functioning and well-being.
Collapse
Affiliation(s)
- Christine Y Lu
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Lu, Zhang, Madden, Callahan, LeCates, Wallace, Soumerai, Ross-Degnan, Wharam); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch); Department of Pharmacy and Health Systems Sciences, Northeastern University Bouvé College of Health Sciences, Boston (Madden); Depression and Bipolar Support Alliance, Chicago (Foxworth)
| | - Alisa B Busch
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Lu, Zhang, Madden, Callahan, LeCates, Wallace, Soumerai, Ross-Degnan, Wharam); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch); Department of Pharmacy and Health Systems Sciences, Northeastern University Bouvé College of Health Sciences, Boston (Madden); Depression and Bipolar Support Alliance, Chicago (Foxworth)
| | - Fang Zhang
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Lu, Zhang, Madden, Callahan, LeCates, Wallace, Soumerai, Ross-Degnan, Wharam); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch); Department of Pharmacy and Health Systems Sciences, Northeastern University Bouvé College of Health Sciences, Boston (Madden); Depression and Bipolar Support Alliance, Chicago (Foxworth)
| | - Jeanne M Madden
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Lu, Zhang, Madden, Callahan, LeCates, Wallace, Soumerai, Ross-Degnan, Wharam); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch); Department of Pharmacy and Health Systems Sciences, Northeastern University Bouvé College of Health Sciences, Boston (Madden); Depression and Bipolar Support Alliance, Chicago (Foxworth)
| | - Matthew X Callahan
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Lu, Zhang, Madden, Callahan, LeCates, Wallace, Soumerai, Ross-Degnan, Wharam); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch); Department of Pharmacy and Health Systems Sciences, Northeastern University Bouvé College of Health Sciences, Boston (Madden); Depression and Bipolar Support Alliance, Chicago (Foxworth)
| | - Robert F LeCates
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Lu, Zhang, Madden, Callahan, LeCates, Wallace, Soumerai, Ross-Degnan, Wharam); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch); Department of Pharmacy and Health Systems Sciences, Northeastern University Bouvé College of Health Sciences, Boston (Madden); Depression and Bipolar Support Alliance, Chicago (Foxworth)
| | - Jamie Wallace
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Lu, Zhang, Madden, Callahan, LeCates, Wallace, Soumerai, Ross-Degnan, Wharam); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch); Department of Pharmacy and Health Systems Sciences, Northeastern University Bouvé College of Health Sciences, Boston (Madden); Depression and Bipolar Support Alliance, Chicago (Foxworth)
| | - Phyllis Foxworth
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Lu, Zhang, Madden, Callahan, LeCates, Wallace, Soumerai, Ross-Degnan, Wharam); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch); Department of Pharmacy and Health Systems Sciences, Northeastern University Bouvé College of Health Sciences, Boston (Madden); Depression and Bipolar Support Alliance, Chicago (Foxworth)
| | - Stephen B Soumerai
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Lu, Zhang, Madden, Callahan, LeCates, Wallace, Soumerai, Ross-Degnan, Wharam); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch); Department of Pharmacy and Health Systems Sciences, Northeastern University Bouvé College of Health Sciences, Boston (Madden); Depression and Bipolar Support Alliance, Chicago (Foxworth)
| | - Dennis Ross-Degnan
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Lu, Zhang, Madden, Callahan, LeCates, Wallace, Soumerai, Ross-Degnan, Wharam); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch); Department of Pharmacy and Health Systems Sciences, Northeastern University Bouvé College of Health Sciences, Boston (Madden); Depression and Bipolar Support Alliance, Chicago (Foxworth)
| | - J Frank Wharam
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Lu, Zhang, Madden, Callahan, LeCates, Wallace, Soumerai, Ross-Degnan, Wharam); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch); Department of Pharmacy and Health Systems Sciences, Northeastern University Bouvé College of Health Sciences, Boston (Madden); Depression and Bipolar Support Alliance, Chicago (Foxworth)
| |
Collapse
|
33
|
Galbraith AA, Ross-Degnan D, Zhang F, Wu AC, Sinaiko A, Peltz A, Xu X, Wallace J, Wharam JF. Controller Medication Use and Exacerbations for Children and Adults With Asthma in High-Deductible Health Plans. JAMA Pediatr 2021; 175:807-816. [PMID: 33970186 PMCID: PMC8111559 DOI: 10.1001/jamapediatrics.2021.0747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE High-deductible health plans (HDHPs) are increasingly common and associated with decreased medication use in some adult populations. How children are affected is less certain. OBJECTIVE To examine the association between HDHP enrollment and asthma controller medication use and exacerbations. DESIGN, SETTING, AND PARTICIPANTS For this longitudinal cohort study with a difference-in-differences design, data were obtained from a large, national, commercial (and Medicare Advantage) administrative claims database between January 1, 2002, and December 31, 2014. Children aged 4 to 17 years and adults aged 18 to 64 years with persistent asthma who switched from traditional plans to HDHPs or remained in traditional plans (control group) by employer choice during a 24-month period were identified. A coarsened exact matching technique was used to balance the groups on characteristics including employer and enrollee propensity to have HDHPs. In most HDHPs, asthma medications were exempt from the deductible and subject to copayments. Statistical analyses were conducted from August 13, 2019, to January 19, 2021. EXPOSURE Employer-mandated HDHP transition. MAIN OUTCOMES AND MEASURES Thirty-day fill rates and adherence (based on proportion of days covered [PDC]) were measured for asthma controller medications (inhaled corticosteroid [ICS], leukotriene inhibitors, and ICS long-acting β-agonists [ICS-LABAs]). Asthma exacerbations were measured by rates of oral corticosteroid bursts and asthma-related emergency department visits among controller medication users. RESULTS The HDHP group included 7275 children (mean [SD] age, 10.8 [3.3] years; 4402 boys [60.5%]; and 5172 non-Hispanic White children [71.1%]) and 17 614 adults (mean [SD] age, 41.1 [13.4] years; 10 464 women [59.4%]; and 12 548 non-Hispanic White adults [71.2%]). The matched control group included 45 549 children and 114 141 adults. Compared with controls, children switching to HDHPs experienced significant absolute decreases in annual 30-day fills only for ICS-LABA medications (absolute change, -0.04; 95% CI, -0.07 to -0.01). Adults switching to HDHPs did not have significant reductions in 30-day fills for any controllers. There were no statistically significant differences in PDC, oral steroid bursts, or asthma-related emergency department visits for children or adults. For the 9.9% of HDHP enrollees with health savings account-eligible HDHPs that subjected medications to the deductible, there was a significant absolute decrease in PDC for ICS-LABA compared with controls (-4.8%; 95% CI, -7.7% to -1.9%). CONCLUSIONS AND RELEVANCE This cohort study found that in a population where medications were exempt from the deductible for most enrollees, HDHP enrollment was associated with minimal or no reductions in controller medication use for children and adults and no change in asthma exacerbations. These findings suggest a potential benefit from exempting asthma medications from the deductible in HDHPs.
Collapse
Affiliation(s)
- Alison A. Galbraith
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts,Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts,Associate Editor, JAMA Pediatrics
| | - Dennis Ross-Degnan
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | - Fang Zhang
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | - Ann Chen Wu
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts,Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Anna Sinaiko
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Alon Peltz
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts,Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Xin Xu
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts,Now with Takeda Pharmaceutical Company, Lexington, Massachusetts
| | - Jamie Wallace
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts,Now with University of Washington School of Public Health, Seattle, Washington
| | - J. Frank Wharam
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
34
|
Murray Horwitz ME, Pace LE, Schwarz EB, Ross-Degnan D. Use of contraception before and after a diabetes diagnosis: An observational matched cohort study. Prim Care Diabetes 2021; 15:719-725. [PMID: 33744164 DOI: 10.1016/j.pcd.2021.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 09/28/2020] [Accepted: 02/25/2021] [Indexed: 01/02/2023]
Abstract
AIMS To determine how a diabetes diagnosis affects contraception use. METHODS This retrospective cohort study used private insurance data from non-pregnant women aged 15-49 years, 2000-2014. We identified women with a new diabetes diagnosis and a control group without diabetes, matched on important potential confounders. We compared rates of prescription or procedural contraception use in the two groups before and after an index date (diabetes diagnosis and outpatient visit, respectively), yielding difference-in-differences estimates of the effect of a diabetes diagnosis on contraception use. RESULTS We identified 75,355 women with a new diabetes diagnosis and 7.5 million women without a diabetes diagnosis. Overall rates of contraception use did not increase in the year after diagnosis (absolute difference-in-difference: 0.4% [99.9% CI, -2.1% to 2.9%]; p < 0.001). In method-specific analyses, there was a decline in estrogen-containing and injectable contraceptives in the year after diagnosis (absolute difference-in-difference: -2.2% [-4.0% to -0.4%] and -0.8% [-1.5% to -0.1%], respectively; p < 0.001); no corresponding increase was noted for intrauterine contraception or subdermal implants. CONCLUSIONS Women with diabetes are less likely to use contraception after their diabetes diagnosis. Efforts are needed to ensure that women with diabetes receive the counseling and clinical services needed to carefully plan their pregnancies.
Collapse
Affiliation(s)
- Mara E Murray Horwitz
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | - Lydia E Pace
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Division of Women's Health, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Eleanor Bimla Schwarz
- Division of General Internal Medicine, University of California, Davis, 4150 V Street, Suite 3100, Sacramento, CA 95817, USA.
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| |
Collapse
|
35
|
Impact of High Deductible Health Plans on Diabetes Care Quality and Outcomes: Systematic Review. Endocr Pract 2021; 27:1156-1164. [PMID: 34245911 DOI: 10.1016/j.eprac.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/18/2021] [Accepted: 07/01/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To provide a review of the impact of high deductible health plans (HDHPs) on the utilizations of services required for optimal management of diabetes and subsequent health outcomes. METHODS Systematic literature review of studies published between January 1, 2000, and May 7, 2021, was conducted that examined the impact of HDHP on diabetes monitoring (eg, recommended laboratory and surveillance testing), routine care (eg, ambulatory appointments), medication management (eg, medication initiation, adherence), and acute health care utilization (eg, emergency department visits, hospitalizations, incident complications). RESULTS Of the 303 reviewed articles, 8 were relevant. These studies demonstrated that HDHPs lower spending at the expense of reduced high-value diabetes monitoring, routine care, and medication adherence, potentially contributing to the observed increases in acute health care utilization. Additionally, patient out-of-pocket costs for recommended screenings doubled, and total health care expenditures increased by 49.4% for HDHP enrollees compared with enrollees in traditional health plans. Reductions in disease monitoring and routine care and increases in acute health care utilization were greatest in lower-income patients. None of the studies examined the impact of HDHPs on access to diabetes self-management education, technology use, or glycemic control. CONCLUSION Although HDHPs reduce some health care utilization and costs, they appear to do so at the expense of limiting high-value care and medication adherence. Policymakers, providers, and payers should be more cognizant of the potential for negative consequences of HDHPs on patients' health.
Collapse
|
36
|
Association of Controller Use and Exacerbations for High-Deductible Plan Enrollees with and without Family Members with Asthma. Ann Am Thorac Soc 2021; 18:1255-1260. [PMID: 33529568 DOI: 10.1513/annalsats.202008-1084rl] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
37
|
Chou SC, Hong AS, Weiner SG, Wharam JF. Impact of High-Deductible Health Plans on Emergency Department Patients With Nonspecific Chest Pain and Their Subsequent Care. Circulation 2021; 144:336-349. [PMID: 34176279 PMCID: PMC8323713 DOI: 10.1161/circulationaha.120.052501] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Supplemental Digital Content is available in the text. Timely evaluation of acute chest pain is necessary, although most evaluations will not find significant coronary disease. With employers increasingly adopting high-deductible health plans (HDHP), how HDHPs impact subsequent care after an emergency department (ED) diagnosis of nonspecific chest pain is unclear.
Collapse
Affiliation(s)
- Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA (S.-C.C., S.G.W.)
| | - Arthur S Hong
- Departments of Internal Medicine and Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas (A.S.H.)
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA (S.-C.C., S.G.W.)
| | - J Frank Wharam
- Department of Population Medicine, Harvard Medical School, Boston, MA (J.F.W.).,Harvard Pilgrim Health Care Institute, Boston, MA (J.F.W.)
| |
Collapse
|
38
|
Rabideau B, Eisenberg MD, Reid R, Sood N. Effects of employer-offered high-deductible plans on low-value spending in the privately insured population. JOURNAL OF HEALTH ECONOMICS 2021; 76:102424. [PMID: 33493781 PMCID: PMC7968441 DOI: 10.1016/j.jhealeco.2021.102424] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 12/09/2020] [Accepted: 12/30/2020] [Indexed: 06/12/2023]
Abstract
Enrollment in plans with high deductibles has increased more than seven-fold in the last decade. Proponents of these plans argue that high deductibles could reduce wasteful spending by providing patients with incentives to limit use of low-value services that offer little or no clinical benefit. Others are concerned that patients may respond to these incentives by reducing their use of medical services indiscriminately and regardless of clinical benefit, which may negatively impact health outcomes. This study uses individual-level insurance claims data (2008-2013) and plausibly exogenous changes in plan offerings within firms over time to estimate the intent-to-treat and local-average treatment effects of high-deductible plan offerings on spending on 24 low-value services received in the outpatient setting. We find that firm offer of a high-deductible plan leads to a 13.7% ($5.23) reduction in average enrollee spending on low-value outpatient services and a 5.2% ($105.77) reduction in overall outpatient spending. We also find reductions in spending on measures of low-value imaging and laboratory services. We find some evidence that offering high-deductible plans disproportionately reduces low-value spending relative to overall spending, indicating that deductibles may be a way to incentivize value-based decision making.
Collapse
Affiliation(s)
- Brendan Rabideau
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Matthew D Eisenberg
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States; Hopkins Business of Health Initiative, Johns Hopkins University, Baltimore, MD, United States
| | - Rachel Reid
- RAND Corporation, Boston, MA, United States; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Neeraj Sood
- Price School of Public Policy, University of Southern California, Los Angeles, CA, United States; NBER, United States; Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, United States.
| |
Collapse
|
39
|
Madden JM, Foxworth PM, Ross-Degnan D, Allen KG, Busch AB, Callahan MX, Lu CY, Wharam JF. Integrating Stakeholder Engagement With Claims-Based Research on Health Insurance Design and Bipolar Disorder. Psychiatr Serv 2021; 72:186-194. [PMID: 33167814 DOI: 10.1176/appi.ps.202000177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Researchers increasingly recognize that stakeholder involvement enhances research relevance and validity. However, reports of patient engagement in research that relies on administrative records data are rare. The authors' collaborative project combined quantitative and qualitative studies of costs and access to care among U.S. adults with employer-sponsored insurance. The authors analyzed insurance claims to estimate the impacts on enrollee costs and utilization after patients with bipolar disorder were switched from traditional coverage to high-deductible health plans. In parallel, in-depth interviews explored people's experiences accessing treatment for bipolar disorder. Academic investigators on the research team partnered with the Depression and Bipolar Support Alliance (DBSA), a national advocacy organization for people with mood disorders. Detailed personal stories from DBSA-recruited volunteers informed and complemented the claims analyses. Several DBSA audience forums and a stakeholder advisor panel contributed regular feedback on study issues. These multiple engagement modes drew inputs of varying intensity from diverse community segments. Efforts to include new voices must acknowledge individuals' distinct interests and barriers to research participation. Strong engagement leadership roles ensure productive communication between researchers and stakeholders. The involvement of people with direct experience of care is especially necessary in research that uses secondary data. Longitudinal, adaptable partnerships enable colearning and higher-quality research that captures the manifold dimensions of patient experiences.
Collapse
Affiliation(s)
- Jeanne M Madden
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston (Madden); Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Madden, Ross-Degnan, Callahan, Lu, Wharam); Depression and Bipolar Support Alliance, Chicago (Foxworth, Allen); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch)
| | - Phyllis M Foxworth
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston (Madden); Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Madden, Ross-Degnan, Callahan, Lu, Wharam); Depression and Bipolar Support Alliance, Chicago (Foxworth, Allen); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch)
| | - Dennis Ross-Degnan
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston (Madden); Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Madden, Ross-Degnan, Callahan, Lu, Wharam); Depression and Bipolar Support Alliance, Chicago (Foxworth, Allen); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch)
| | - Kimberly G Allen
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston (Madden); Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Madden, Ross-Degnan, Callahan, Lu, Wharam); Depression and Bipolar Support Alliance, Chicago (Foxworth, Allen); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch)
| | - Alisa B Busch
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston (Madden); Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Madden, Ross-Degnan, Callahan, Lu, Wharam); Depression and Bipolar Support Alliance, Chicago (Foxworth, Allen); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch)
| | - Matthew X Callahan
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston (Madden); Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Madden, Ross-Degnan, Callahan, Lu, Wharam); Depression and Bipolar Support Alliance, Chicago (Foxworth, Allen); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch)
| | - Christine Y Lu
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston (Madden); Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Madden, Ross-Degnan, Callahan, Lu, Wharam); Depression and Bipolar Support Alliance, Chicago (Foxworth, Allen); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch)
| | - James F Wharam
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston (Madden); Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston (Madden, Ross-Degnan, Callahan, Lu, Wharam); Depression and Bipolar Support Alliance, Chicago (Foxworth, Allen); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Boston (Busch)
| |
Collapse
|
40
|
High-Deductible Health Plans and Healthcare Access, Use, and Financial Strain in Those with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2021; 17:49-56. [PMID: 31599647 DOI: 10.1513/annalsats.201905-400oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Rationale: Medical treatment can improve quality of life and avert exacerbations for those with chronic obstructive pulmonary disease (COPD). High-deductible health plans (HDHPs) can increase exposure to medical costs, and might compromise healthcare access and financial well-being for patients with COPD.Objectives: To examine the association of HDHPs with healthcare access, utilization, and financial strain among individuals with COPD.Methods: We analyzed privately insured adults aged 40-64 years with COPD in the 2011-2017 National Health Interview Survey, which uses Internal Revenue Service-specified thresholds to classify health plans as "high" or "traditional" deductible coverage. We assessed the association between enrollment in an HDHP and indicators of cost-related impediments to care, financial strain, and healthcare utilization, adjusting for potential confounders.Results: Our sample included 803 individuals with an HDHP and 1,334 with a traditional plan. The two groups' demographic and health characteristics were similar. Individuals enrolled in an HDHP more frequently reported delayed or foregone care, cost-related medication nonadherence, medical bill problems, and financial strain. They also more frequently reported out-of-pocket healthcare spending in excess of $5,000 a year. Although the two groups' office visit rates were similar, those enrolled in an HDHP were more likely to report a hospitalization or emergency room visit in the past year.Conclusions: For patients with COPD, enrollment in an HDHP was associated with cost-related barriers to care, financial strain, and more frequent emergency room visits and hospitalizations.
Collapse
|
41
|
Varadarajan A, Walker RJ, Williams JS, Bishu K, Nagavally S, Egede LE. Relationship between insurance and access and cost of care in patients with diabetes before and after the affordable care act. INTERNATIONAL JOURNAL OF HEALTH GOVERNANCE 2020. [DOI: 10.1108/ijhg-02-2020-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe purpose of this paper is to examine the influence of insurance coverage changes over time for patients with diabetes on expenditures and access to care before and after the Affordable Care Act (ACA).Design/methodology/approachThe Medical Expenditure Panel Survey (MEPS) from 2002–2017 was used. Access included having a usual source of care, having delay in care or having delay in obtaining prescription medicine. Expenditures included inpatient, outpatient, office-based, prescription and emergency costs. Panels were broken into four time categories: 2002–2005 (pre-ACA), 2006–2009 (pre-ACA), 2010–2013 (post-ACA) and 2014–2017 (post-ACA). Logistic models for access and two-part regression models for cost were used to understand differences by insurance type over time.FindingsType of insurance changed significantly over time, with an increase for public insurance from 30.7% in 2002–2005 to 36.5% in 2014–2017 and a decrease in private insurance from 62.4% in 2002–2005 to 58.2% in 2014–2017. Compared to those with private insurance, those who were uninsured had lower inpatient ($2,147 less), outpatient ($431 less), office-based ($1,555 less), prescription ($1,869 less) and emergency cost ($92 less). Uninsured were also more likely to have delay in getting medical care (OR = 2.22; 95% CI 1.86, 3.06) and prescription medicine (OR = 1.85; 95% CI 1.53, 2.24) compared with privately insured groups.Originality/valueThough insurance coverage among patients with diabetes did not increase significantly, the type of insurance changed overtime and fewer individuals reported having a usual source of care. Uninsured individuals spent less across all cost types and were more likely to report delay in care despite the passage of the ACA.
Collapse
|
42
|
McCoy RG, Lipska KJ, Van Houten HK, Shah ND. Development and evaluation of a patient-centered quality indicator for the appropriateness of type 2 diabetes management. BMJ Open Diabetes Res Care 2020; 8:8/2/e001878. [PMID: 33234510 PMCID: PMC7689069 DOI: 10.1136/bmjdrc-2020-001878] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/07/2020] [Accepted: 11/04/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Current diabetes quality measures are agnostic to patient clinical complexity and type of treatment required to achieve it. Our objective was to introduce a patient-centered indicator of appropriate diabetes therapy indicator (ADTI), designed for patients with type 2 diabetes, which is based on hemoglobin A1c (HbA1c) but is also contextualized by patient complexity and treatment intensity. RESEARCH DESIGN AND METHODS A draft indicator was iteratively refined by a multidisciplinary Delphi panel using existing quality measures, guidelines, and published literature. ADTI performance was then assessed using OptumLabs Data Warehouse data for 2015. Included adults (n=206 279) with type 2 diabetes were categorized as clinically complex based on comorbidities, then categorized as treated appropriately, overtreated, or undertreated based on a matrix of clinical complexity, HbA1c level, and medications used. Associations between ADTI and emergency department/hospital visits for hypoglycemia and hyperglycemia were assessed by calculating event rates for each treatment intensity subset. RESULTS Overall, 7.4% of patients with type 2 diabetes were overtreated and 21.1% were undertreated. Patients with high complexity were more likely to be overtreated (OR 5.60, 95% CI 5.37 to 5.83) and less likely to be undertreated (OR 0.65, 95% CI 0.62 to 0.68) than patients with low complexity. Overtreated patients had higher rates of hypoglycemia than appropriately treated patients (22.0 vs 6.2 per 1000 people/year), whereas undertreated patients had higher rates of hyperglycemia (8.4 vs 1.9 per 1000 people/year). CONCLUSIONS The ADTI may facilitate timely, patient-centered treatment intensification/deintensification with the goal of achieving safer evidence-based care.
Collapse
Affiliation(s)
- Rozalina G McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Kasia J Lipska
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Holly K Van Houten
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Nilay D Shah
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
- OptumLabs, Cambridge, Massachusetts, USA
| |
Collapse
|
43
|
Chou SC, Hong AS, Weiner SG, Wharam JF. High-deductible health plans and low-value imaging in the emergency department. Health Serv Res 2020; 56:709-720. [PMID: 33025604 DOI: 10.1111/1475-6773.13569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To examine the effect of an employer-mandated switch to high-deductible health plans (HDHP) on emergency department (ED) low-value imaging. DATA SOURCES Claims data of a large national insurer between 2003 and 2014. STUDY DESIGN Difference-in-differences analysis with matched control groups. DATA COLLECTION/EXTRACTION METHODS The primary outcome is low-value imaging during ED visits for syncope, headache, or low back pain. We included members aged 19-63 years whose employers offered only low-deductible (≤$500) plans for one (baseline) year and, in the next (follow-up) year, offered only HDHPs (≥$1000). Contemporaneous members whose employers offered only low-deductible plans for two consecutive years served as controls. The groups were matched by person and employer propensity for HDHP switch, employer size, baseline calendar year, and baseline year quarterly number of total and imaged ED visits for each condition. We modeled the visit-level probability of low-value imaging using multivariable logistic regression with member-clustered standard errors. We also calculated population level monthly cumulative ED visit rates and modeled their trends using generalized linear regression adjusting for serial autocorrelation. PRINCIPAL FINDINGS After matching, we included 524 998 members in the HDHP group and 5 448 803 in the control group with a mean age of approximately 42 years and 48% female in both groups. On visit-level analyses, there were no significant differential changes in the probability of low-value imaging use in the HDHP and control groups. In population-level analyses, compared with control group members, members who switched to HDHPs experienced a relative decrease of 5.9% (95% CI - 10.3, -1.6) in ED visits for the study conditions and a relative decrease of 5.1% (95%CI -9.6, -0.6) in the subset of ED visits with low-value imaging. CONCLUSION Though HDHP switches decreased ED utilization, they had no significant effect on low-value imaging use after patients have decided to seek ED care.
Collapse
Affiliation(s)
- Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Arthur S Hong
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - J Frank Wharam
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| |
Collapse
|
44
|
Does the Encounter Type Matter When Defining Diabetes Complications in Electronic Health Records? Med Care 2020; 58 Suppl 6 Suppl 1:S53-S59. [PMID: 32011424 DOI: 10.1097/mlr.0000000000001297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Electronic health records (EHRs) and claims records are widely used in defining type 2 diabetes mellitus (T2DM) complications across different types of health care encounters. OBJECTIVE This study investigates whether using different EHR encounter types to define diabetes complications may lead to different results when examining associations between diabetes complications and their risk factors in patients with T2DM. RESEARCH DESIGN The study cohort of 64,855 adult patients with T2DM was created from EHR data from the Research Action for Health Network (REACHnet), using the Surveillance Prevention, and Management of Diabetes Mellitus (SUPREME-DM) definitions. Incidence of coronary heart disease (CHD) and stroke events were identified using International Classification of Diseases (ICD)-9/10 codes and grouped by encounter types: (1) inpatient (IP) or emergency department (ED) type, or (2) any health care encounter type. Cox proportional hazards regression was used to estimate associations between diabetes complications (ie, CHD and stroke) and risk factors (ie, low-density lipoprotein cholesterol and hemoglobin A1c). RESULTS The incidence rates of CHD and stroke in all health care settings were more than twice the incidence rates of CHD and stroke in IP/ED settings. The age-adjusted and multivariable-adjusted hazard ratios for incident CHD and stroke across different levels of low-density lipoprotein cholesterol and hemoglobin A1c were similar between IP/ED and all settings. CONCLUSION While there are large variations in incidence rates of CHD and stroke as absolute risks, the associations between both CHD and stroke and their respective risk factors measured by hazard ratios as relative risks are similar, regardless of alternative definitions.
Collapse
|
45
|
Reduced Cost-sharing for Preventive Drugs Preferentially Benefits Low-income Patients With Diabetes in High Deductible Health Plans With Health Savings Accounts. Med Care 2020; 58 Suppl 6 Suppl 1:S4-S13. [PMID: 32412948 DOI: 10.1097/mlr.0000000000001295] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND High deductible health plans linked to Health Savings Accounts (HSA-HDHPs) must include all care under the deductible except for select preventive services. Some employers and insurers have adopted Preventive Drug Lists (PDLs) that exempt specific classes of medications from deductibles. OBJECTIVE The objective of this study was to examine the association between shifts to PDL coverage and medication utilization among patients with diabetes in HSA-HDHPs. RESEARCH DESIGN A natural experiment comparing pre-post changes in monthly and annual outcomes in matched study groups. SUBJECTS The intervention group included 1744 commercially-insured HSA-HDHP patients with diabetes age 12-64 years switched by employers to PDL coverage; the control group included 3349 propensity-matched HSA-HDHP patients whose employers offered no PDL. MEASURES Outcomes were out-of-pocket (OOP) costs for medications and the number of pharmacy fills converted to 30-day equivalents. RESULTS Transition to the PDL was associated with a relative pre-post decrease of $612 (-35%, P<0.001) per member OOP medication expenditures; OOP reductions were higher for key classes of antidiabetic and cardiovascular medicines listed on the PDL; the policy did not affect unlisted classes. The PDL group experienced relative increases in medication use of 6.0 30-day fills per person during the year (+11.2%, P<0.001); the increase was more than twice as large for lower-income (+6.6 fills, +12.6%, P<0.001) than higher-income (+3.0 fills, +5.1%, P=0.024) patients. CONCLUSION Transition to a PDL which covers important classes of medication to manage diabetes and cardiovascular conditions is associated with substantial annual OOP cost savings for patients with diabetes and increased utilization of important classes of medications, especially for lower-income patients.
Collapse
|
46
|
Wharam JF, Wallace J, Zhang F, Xu X, Lu CY, Hernandez A, Ross-Degnan D, Newhouse JP. Association Between Switching to a High-Deductible Health Plan and Major Cardiovascular Outcomes. JAMA Netw Open 2020; 3:e208939. [PMID: 32706381 PMCID: PMC7382004 DOI: 10.1001/jamanetworkopen.2020.8939] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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.
Collapse
Affiliation(s)
- J. Frank Wharam
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Jamie Wallace
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Fang Zhang
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Xin Xu
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Christine Y. Lu
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Adrian Hernandez
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Dennis Ross-Degnan
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
| |
Collapse
|
47
|
Scheckel KA. The Rising Cost of Sugar. PHYSICIAN ASSISTANT CLINICS 2020. [DOI: 10.1016/j.cpha.2019.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
48
|
Hawks L, Himmelstein DU, Woolhandler S, Bor DH, Gaffney A, McCormick D. Trends in Unmet Need for Physician and Preventive Services in the United States, 1998-2017. JAMA Intern Med 2020; 180:439-448. [PMID: 31985751 PMCID: PMC6990729 DOI: 10.1001/jamainternmed.2019.6538] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Improvements in insurance coverage and access to care have resulted from the Affordable Care Act (ACA). However, a focus on short-term pre- to post-ACA changes may distract attention from longer-term trends in unmet health needs, and the problems that persist. OBJECTIVE To identify changes from 1998 to 2017 in unmet need for physician services among insured and uninsured adults aged 18 to 64 years in the United States. DESIGN, SETTING, AND PARTICIPANTS Survey study using 20 years of data, from January 1, 1998, to December 31, 2017, from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System to identify trends in unmet need for physician and preventive services. MAIN OUTCOMES AND MEASURES The proportion of persons unable to see a physician when needed owing to cost (in the past year), having no routine checkup for those in whom a routine checkup was likely indicated (within 2 years), or failing to receive clinically indicated preventive services (in the recommended timeframe), overall and among subgroups defined by the presence of chronic illnesses and by self-reported health status. We estimated changes over time using logistic regression controlling for age, sex, race, Census region, employment status, and income. RESULTS Among the adults aged 18 to 64 years in 1998 (n = 117 392) and in 2017 (n = 282 378) who responded to the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System (mean age was 39.2 [95% CI, 39.0-39.3]; 50.3% were female; 65.9% were white), uninsurance decreased by 2.1 (95% CI, 1.6-2.5) percentage points (from 16.9% to 14.8%). However, the adjusted proportion unable to see a physician owing to cost increased by 2.7 (95% CI, 2.2-3.8) percentage points overall (from 11.4% to 15.7%, unadjusted); by 5.9 (95% CI, 4.1-7.8) percentage points among the uninsured (32.9% to 39.6%, unadjusted) and 3.6 (95% CI, 3.2-4.0) percentage points among the insured (from 7.1% to 11.5%, unadjusted). The adjusted proportion of persons with chronic medical conditions who were unable to see a physician because of cost also increased for most conditions. For example, an increase in the inability to see a physician because of cost for patients with cardiovascular disease was 5.9% (95% CI, 1.7%-10.1%), for patients with elevated cholesterol was 3.5% (95% CI, 2.5%-4.5%), and for patients with binge drinking was 3.1% (95% CI, 2.3%-3.3%). The adjusted proportion of chronically ill adults receiving checkups did not change. While the adjusted share of people receiving guideline-recommended cholesterol tests (16.8% [95% CI, 16.1%-17.4%]) and flu shots (13.2% [95% CI, 12.7%-13.8%]) increased, the proportion of women receiving mammograms decreased (-6.7% [95% CI, -7.8 to -5.5]). CONCLUSIONS AND RELEVANCE Despite coverage gains since 1998, most measures of unmet need for physician services have shown no improvement, and financial access to physician services has decreased.
Collapse
Affiliation(s)
- Laura Hawks
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - David U Himmelstein
- Harvard Medical School, Boston, Massachusetts.,Hunter College, City University of New York, New York, New York
| | - Steffie Woolhandler
- Harvard Medical School, Boston, Massachusetts.,Hunter College, City University of New York, New York, New York
| | - David H Bor
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Adam Gaffney
- Harvard Medical School, Boston, Massachusetts.,Division of Pulmonary and Critical Care, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
49
|
Fendrick AM, Buxbaum JD, Tang Y, Vlahiotis A, McMorrow D, Rajpathak S, Chernew ME. Association Between Switching to a High-Deductible Health Plan and Discontinuation of Type 2 Diabetes Treatment. JAMA Netw Open 2019; 2:e1914372. [PMID: 31675081 PMCID: PMC6826641 DOI: 10.1001/jamanetworkopen.2019.14372] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE High-deductible health plans (HDHPs) are a common cost-savings option for employers but may lead to underuse of necessary treatments because beneficiaries bear the full cost of health care, including medications, until a deductible is met. OBJECTIVES To evaluate the association between switching from a non-HDHP to an HDHP and discontinuation of antihyperglycemic medication and to assess whether the association differs in patients using branded vs generic antihyperglycemic medications. DESIGN, SETTING, AND PARTICIPANTS This retrospective matched cohort study used administrative claims from MarketScan databases to identify commercially insured adult patients with type 2 diabetes who used at least 1 antihyperglycemic medication in 2013. Patients in the HDHP cohort (n = 1490) were matched by propensity scores to a non-HDPH control cohort (n = 1490). Data were collected and analyzed from January 1, 2013, through December 31, 2014. EXPOSURES Switching from a non-HDHP in 2013 to a full replacement HDHP in 2014 (no non-HDHP option offered) vs staying on a non-HDHP. MAIN OUTCOMES AND MEASURES Difference-in-differences models estimated discontinuation of branded and generic antihyperglycemic medications. RESULTS Among the 2980 patients included in the analysis (1932 men [64.8%]; mean [SD] age, HDHP cohort: 52.6 [6.9] years; non-HDHP cohort: 52.7 [7.3] years), no difference between the HDHP and non-HDHP cohorts was found in unadjusted follow-up discontinuation rates for all antihyperglycemic medications (255 [22.7%] vs 255 [23.3%]; P = .72); however, among patients using branded medication, a significantly greater proportion of patients in the HDHP group did not refill branded medications (81 of 396 [20.5%] vs 61 of 437 [14.0%]; P = .009). Difference-in-differences models were not statistically significant. CONCLUSIONS AND RELEVANCE These findings suggest switching to an HDHP is associated with discontinuation specifically of branded medications. Unintended health consequences may result and should be considered by employers making health care benefit decisions.
Collapse
Affiliation(s)
- A. Mark Fendrick
- Center for Value-Based Insurance Design, University of Michigan, Ann Arbor
| | - Jason D. Buxbaum
- Center for Value-Based Insurance Design, University of Michigan, Ann Arbor
| | - Yuexin Tang
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey
| | | | | | - Swapnil Rajpathak
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey
| | | |
Collapse
|
50
|
Zheng Z, Jemal A, Banegas MP, Han X, Yabroff KR. High-Deductible Health Plans and Cancer Survivorship: What Is the Association With Access to Care and Hospital Emergency Department Use? J Oncol Pract 2019; 15:e957-e968. [DOI: 10.1200/jop.18.00699] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: To examine the associations among high-deductible health plan (HDHP) enrollment, cancer survivorship, and access to care and utilization. MATERIALS AND METHODS: The 2010 to 2017 National Health Interview Survey was used to identify privately insured adults ages 18 to 64 years (cancer survivors, n = 4,321; individuals without a cancer history, n = 95,316). We used multivariable logistic regressions to evaluate the associations among HDHP/health savings account (HSA) status, delayed/forgone care for financial reasons, and hospital emergency department (ED) visits among cancer survivors compared with individuals without a cancer history. RESULTS: Among cancer survivors, HDHPs with or without HSA (8.9% and 13.9%, respectively; both P < .05) were associated with more delayed/forgone care compared with low-deductible health plans (LDHPs) (7.9%). HSA enrollment was associated with less delayed/forgone care among HDHP cancer survivors ( P < .05). ED visits were similar by insurance type. Among individuals without a cancer history, HDHP with or without HSA (9.5% and 10.8%, respectively; both P < .05) were both associated with more delayed/forgone care compared with LDHPs (5.9%). HSA enrollment also was associated with less delayed/forgone care among HDHP enrollees without a cancer history. A small difference in ED visits was observed between HDHPs without HSA (15.3%) and LDHPs (14.1%; P < .05) or HDHPs with HSA (13.4%; P < .05) among individuals without a cancer history. CONCLUSION: HDHP enrollment and HSA status affect access to care and hospital ED visits similarly by cancer history. HDHP enrollment may serve as a barrier to access to care among cancer survivors, although HSA enrollment coupled with an HDHP may mitigate the impact on access. HDHPs and HSA status were not associated with ED visits among cancer survivors. Improvement to care coordination efforts may be needed to reduce ED visits among privately insured cancer survivors.
Collapse
Affiliation(s)
- Zhiyuan Zheng
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA
| | - Ahmedin Jemal
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA
| | | | - Xuesong Han
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA
| | - K. Robin Yabroff
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA
| |
Collapse
|