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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.
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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
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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.
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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.)
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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.
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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
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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.
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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
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Gupta R, Yang L, Lewey J, Navathe AS, Groeneveld PW, Khatana SAM. Association of High-Deductible Health Plans With Health Care Use and Costs for Patients With Cardiovascular Disease. J Am Heart Assoc 2023; 12:e030730. [PMID: 37750565 PMCID: PMC10727247 DOI: 10.1161/jaha.123.030730] [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: 04/23/2023] [Accepted: 08/23/2023] [Indexed: 09/27/2023]
Abstract
Background By increasing cost sharing, high-deductible health plans (HDHPs) aim to reduce low-value health care use. The association of HDHPs with health care use and costs in patients with chronic cardiovascular disease is unknown. Methods and Results This longitudinal cohort study analyzed 57 690 privately insured patients, aged 18 to 64 years, from a large commercial claims database with chronic cardiovascular disease from 2011 to 2019. Health care entities in which all or most beneficiaries switched from being in a traditional plan to an HDHP were identified. A difference-in-differences design was used to account for differences between individuals who remained in traditional plans and those who switched to HDHPs and to assess changes in health care use and costs. Among the 934 individuals in the HDHP group and the 56 756 in the traditional plan group, switching to an HDHP was not associated with statistically significant changes in annual outpatient visits, hospitalizations, or emergency department visits (-8.3% [95% CI, -16.8 to 1.1], -28.5% [95% CI, -62.1 to 34.6], and 11.2% [95% CI, -20.9 to 56.5], respectively). Switching to an HDHP was associated with an increase of $921 (95% CI, $743-$1099) in out-of-pocket costs but no statistically significant difference in total health care costs. Conclusions Among commercially insured patients with chronic cardiovascular disease, switching to an HDHP was not associated with a change in health care use but was associated with an increase in out-of-pocket costs. Although health care use by individuals with chronic cardiovascular disease may not be sensitive to higher cost sharing associated with HDHP enrollment, there may be a significant increase in patients' financial burden.
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Affiliation(s)
- Ravi Gupta
- Division of General Internal MedicineJohns Hopkins University School of MedicineBaltimoreMD
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
- Hopkins Business of Health Initiative, Johns Hopkins UniversityBaltimoreMD
| | - Lin Yang
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
| | - Jennifer Lewey
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Amol S. Navathe
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Division of General Internal Medicine, Perelman School of MedicineUniversity of PennsylvaniaPAPhiladelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Peter W. Groeneveld
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of General Internal Medicine, Perelman School of MedicineUniversity of PennsylvaniaPAPhiladelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
| | - Sameed Ahmed M. Khatana
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
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Siegel KR, Gregg EW, Duru OK, Shi L, Mangione CM, Thornton PL, Clauser S, Ali MK. Time to start addressing (and not just describing) the social determinants of diabetes: results from the NEXT-D 2.0 network. BMJ Open Diabetes Res Care 2021; 9:e002524. [PMID: 34933875 PMCID: PMC8679065 DOI: 10.1136/bmjdrc-2021-002524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/13/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Karen R Siegel
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Edward W Gregg
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Obidiugwu Kenrik Duru
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, California, USA
| | - Lizheng Shi
- Tulane University School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Carol M Mangione
- Division of General Internal Medicine, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Pamela L Thornton
- Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Steve Clauser
- Patient-Centered Outcomes Research Institute, Washington, DC, USA
| | - Mohammed K Ali
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
- Department of Global Heatlh, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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