High-Deductible Insurance and Delay in Care for the Macrovascular Complications of Diabetes

Trends and postoperative outcomes of thyroidectomy after expansion and rise of health insurance deductibles in the fiscal year

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.

Enrollment in High-Deductible Health Plans and Incident Diabetes Complications

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.

Acute Diabetes Complications After Transition to a Value-Based Medication Benefit

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.

An Investigation of the Impact of Expanding High-Deductible Health Plans on Patient Decision for Cochlear Implant Surgery and Postoperative Outcomes

HYPOTHESIS

After the expansion of high deductibles, patients will delay cochlear implant (CI) surgery to the end of the year, and the risk of postoperative known risks will increase.

BACKGROUND

The Affordable Care Act was associated with increased enrollment in high-deductible health plans (HDHPs), which resulted in rising health insurance deductibles. Health insurance plans can cover a patient's cost of healthcare once the deductible is met. Patients have been shown to be economic rational decision makers and make decisions based on cost rather than health. They wait for their deductible to be met, typically at the end of the year, then proceed to have costly care. The goal of this study was to evaluate the impact of rising health insurance deductibles on the rate and postoperative outcomes of cochlear implantation and to assess changes by the Tax Cuts and Jobs Act.

METHODS

TriNetX was used to accumulate summary data on patients who obtained a CI between 2005 and 2022 at the beginning (quarter 1) and the end of the year (quarter 4) from the electronic medical records of 75 healthcare organizations. The trends in average rate of cochlear implantation and resultant postoperative known risks or complications were statistically evaluated.

RESULTS

After expansion of HDHPs, the rate of cochlear implantation between quarter 4 (19 cases per year) and quarter 1 (17 cases/year) was similar (p = 0.18). For all patient groups, the case volume significantly increased. Between quarter 4 and quarter 1, postoperative tinnitus was more common in the beginning of the year (risk ratio, 0.68; 95% confidence interval, 0.46-0.99).

CONCLUSIONS

The number of patients receiving CIs significantly increased despite the expansion of HDHPs. Tinnitus was a rare postoperative known risk in the beginning of the year. Patients are less likely concerned about cost of CI surgery because of the impact of hearing loss on quality of life.

"You Have to Rob Peter to Pay Paul So Your Kid Can Breathe": Using Qualitative Methods to Characterize Trade-Offs and Economic Impact of Asthma Care Costs

BACKGROUND

Economic analyses often focus narrowly on individual patients' health care use, while overlooking the growing economic burden of out-of-pocket costs for health care on other family medical and household needs.

OBJECTIVE

The aim of this study was to explore intrafamilial trade-offs families make when paying for asthma care.

RESEARCH DESIGN

In 2018, we conducted telephone interviews with 59 commercially insured adults who had asthma and/or had a child with asthma. We analyzed data qualitatively via thematic content analysis.

PARTICIPANTS

Our purposive sample included participants with high-deductible and no/low-deductible health plans. We recruited participants through a national asthma advocacy organization and a large nonprofit regional health plan.

MEASURES

Our semistructured interview guide explored domains related to asthma adherence and cost burden, cost management strategies, and trade-offs.

RESULTS

Participants reported that they tried to prioritize paying for asthma care, even at the expense of their family's overall financial well-being. When facing conflicting demands, participants described making trade-offs between asthma care and other health and nonmedical needs based on several criteria: (1) short-term needs versus longer term financial health; (2) needs of children over adults; (3) acuity of the condition; (4) effectiveness of treatment; and (5) availability of lower cost alternatives.

CONCLUSIONS

Our findings suggest that cost-sharing for asthma care often has negative financial consequences for families that traditional, individually focused economic analyses are unlikely to capture. This work highlights the need for patient-centered research to evaluate the impact of health care costs at the family level, holistically measuring short-term and long-term family financial outcomes that extend beyond health care use alone.

Impact of Health Insurance Patterns on Chronic Health Conditions Among Older Patients

BACKGROUND

Patients have varying levels of chronic conditions and health insurance patterns as they become Medicare age-eligible. Understanding these dynamics will inform policies and reforms that direct capacity and resources for primary care clinics to care for these aging patients. This study 1) determined changes in chronic condition rates following Medicare age eligibility among patients with different insurance patterns and 2) estimated the number of chronically ill patients who remain inadequately insured post-Medicare eligibility among patients receiving care in community health centers.

METHOD

We used retrospective electronic health record data from 45,527 patients aged 62 to 68 from 990 community health centers in 25 states in 2014 to 2019. Insurance patterns (continuously insured, continuously uninsured, uninsured/discontinuously insured who gained insurance after age 65, lost insurance after age 65, discontinuously insured) and diagnosis of chronic conditions were defined at each visit pre- and post-Medicare eligibility. Difference-in-differences Poisson GEE models estimated changes of chronic condition rates by insurance groups pre- to post-Medicare age eligibility.

RESULTS

Post-Medicare eligibility, 72% patients were continuously insured, 14% gained insurance; and 14% were uninsured or discontinuously insured. The prevalence of multimorbidity (≥2 chronic conditions) was 77%. Those who gained insurance had a significantly larger increase in the rate of documented chronic conditions from pre- to post-Medicare (DID: 1.06, 95%CI:1.05-1.07) compared with the continuously insured group.

CONCLUSIONS

Post-Medicare age eligibility, a significant proportion of patients were diagnosed with new conditions leading to high burden of disease. One in 4 older adults continue to have inadequate health care coverage in their older age.

Fintech and medical expenses: What social workers should know

Individuals who cannot afford out of pocket medical expenses may reduce health care use, resulting in poorer health outcomes. To ease the situation, employers turn to financial technology ("fintech") health care credit applications. We examine whether an employer-sponsored credit fintech application (MedPut) helps employees manage medical expenses. Results of the analysis of variance (ANOVA) and probit regression models reveal MedPut users did worse financially and delayed health care due to cost more often than employees who did not use MedPut. Results may inform social work policy and direct practice perspectives on fin-tech and medical expenses.

Analysis of Postoperative Outcomes and Economic Behavior Trends of Tympanoplasty and Mastoidectomy With Expansion of High Deductible Health Plans

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.

Factors Associated with Annual Vision Screening in Diabetic Adults: Analysis of the 2019 National Health Interview Survey

Purpose

To determine the association(s) between receiving an annual eye exam and various economic, social, and geographic factors assessed in the 2019 National Health Interview Survey (NHIS) among adults with diabetes.

Patients and Methods

Data from adults 18 years of age and older relevant to self-reported non-gestational diabetes diagnosis and eye exam within the last 12 months were extracted from the 2019 NHIS dataset. A multivariate logistic regression model was used to determine associations between receiving an eye exam in the preceding 12 months and various economic, insurance-related, geographic, and social factors. Outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI).

Results

Among diabetic adults in the US, receiving an eye exam within the last 12 months was significantly associated with female sex (OR 1.29; 95% CI 1.05-1.58), residence in the Midwestern United States (OR 1.39; 95% CI 1.01-1.92), use of Veteran's Health Administration healthcare (OR 2.15; 95% CI 1.34-3.44), having a usual place to go for healthcare (OR 3.89; 95% CI 2.16-7.01), and the use of Private, Medicare Advantage, or other insurance (OR 3.66; 95% CI 2.42-5.53), use of Medicare only excluding Medicare Advantage (OR 3.18; 95% CI 1.95-5.30), dual eligibility for Medicare and Medicaid (OR 3.88; 95% CI 2.21-6.79), and use of Medicaid and other public health insurance (OR 3.04; 95% CI 1.89-4.88) compared to those without insurance. An educational attainment of less than high school (OR 0.66; 95% CI 0.48-0.92), and an educational attainment of high school or GED without any college (OR 0.62; 95% CI 0.47-0.81) reduced the odds of having an annual eye exam.

Conclusion

Economic, social, and geographic factors are associated with diabetic adults receiving an annual eye exam.

Evaluation of High-Deductible Health Plans and Acute Glycemic Complications Among Adults With Diabetes

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.

Association between high deductible health plan coverage and age at pediatric umbilical hernia repair

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.

A Medical and Moral Imperative: Testimony for the U.S. Senate Budget Committee "Medicare for All" Hearing

On May 12, 2022, Senator Bernie Sanders held a hearing in the U.S. Senate Budget Committee on Medicare for All legislation. These were the first such hearings in the U.S. Senate. In testimony presented to the Budget Committee, I argued that the achievement of Medicare for All was a medical and moral imperative. I explored the problem of uninsurance, noting that 30 million Americans remain uninsured at a cost of more than 30,000 deaths annually. I contended that improving the quality of coverage was equally crucial, describing how some 41 million Americans remain underinsured at a grave cost to their health and financial wellbeing. Finally, I examined the economics of Medicare for All reform, and showed how the reduction of the enormous administrative waste in American healthcare could save hundreds of billions of dollars a year. Medicare for All, I concluded, is the one health reform that could expand and improve coverage for all while simultaneously controlling costs.

Diabetes Microvascular Disease Diagnosis and Treatment After High-Deductible Health Plan Enrollment

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.

Evaluating Natural Experiments that Impact the Diabetes Epidemic: an Introduction to the NEXT-D3 Network

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.

Association Between High Deductible Health Plans and Cost-Related Non-adherence to Medications Among Americans with Diabetes: an Observational Study

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.

Association Between High-Deductible Health Plans and Hernia Acuity

IMPORTANCE

About half of people younger than 65 years with private insurance are enrolled in a high-deductible health plan (HDHP). While these plans entail substantially higher out-of-pocket costs for patients with chronic medical conditions who require ongoing care, their effect on patients undergoing surgery who require acute care is poorly understood. It is plausible that higher out-of-pocket costs may lead to delays in care and more complex surgical conditions.

OBJECTIVE

To determine the association between enrollment in HDHPs and presentation with incarcerated or strangulated hernia.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort analysis included privately insured patients aged 18 to 63 years from a large commercial insurance claims database who underwent a ventral or groin hernia operation from January 2016 through June 2019 and classified their coverage as either a traditional health plan or an HDHP per the Internal Revenue Service's definition. Multivariable regression, adjusting for demographic and clinical covariates, was used to examine the association between enrollment in an HDHP and the primary outcome of presentation with an incarcerated or strangulated hernia.

EXPOSURES

Traditional health plan vs HDHP.

MAIN OUTCOMES AND MEASURES

Presence of an incarcerated or strangulated hernia per International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes.

RESULTS

Among 83 281 patients (71.9% men and 28.1% women; mean [SD] age, 48.7 [10.9] years) who underwent hernia surgery, 27 477 (33.0%) were enrolled in an HDHP and 21 876 (26.2%) had a hernia that was coded as incarcerated or strangulated. The mean annual deductible was considerably higher for those in the HDHP group than their traditional health plan counterparts (unadjusted mean [SD], $3635 [$2094] vs $705 [$737]; adjusted, -$2931; P < .001). Patients in the HDHP group were more likely to present with an incarcerated or strangulated hernia (adjusted odds ratio, 1.07; 95% CI, 1.03-1.11; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, enrollment in an HDHP was associated with higher odds of presenting with an incarcerated or strangulated hernia, which is more likely to require emergency surgery that precludes medical optimization. These data suggest that, among patients with groin and ventral hernias, enrollment in an HDHP may be associated with delays in surgical care that result in complex disease presentation.

Public Health Expenditures and Clinical and Social Complexity of Tuberculosis Cases-Alameda County, California, July-December 2017

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.

Differences in Diabetic Prescription Drug Utilization and Costs Among Patients With Diabetes Enrolled in Colorado Marketplace and Medicaid Plans, 2014-2015

Importance

Increasing prices of antidiabetic medications in the US have raised substantial concerns about the effects of drug affordability on diabetes care. There has been little rigorous evidence comparing the experiences of patients with diabetes across different types of insurance coverage.

Objective

To compare the utilization patterns and costs of prescription drugs to treat diabetes among low-income adults with Medicaid vs those with Marketplace insurance in Colorado during 2014 and 2015.

Design, Setting, and Participants

This cross-sectional study included diabetic patients enrolled in Colorado Medicaid and Marketplace plans who were aged 19 to 64 years and had incomes between 75% and 200% of the federal poverty level during 2014 and 2015. Data analysis was conducted from September 2020 to April 2021.

Exposures

Health insurance through Colorado Medicaid or Colorado's state-based Marketplace.

Main Outcomes and Measures

Primary outcomes were drug utilization (prescription drug fills) and drug costs (total costs and out-of-pocket costs). The secondary outcome was months with an active prescription for noninsulin antidiabetic medications. An all payer claims database was combined with income data, and linear models were used to adjust for clinical and demographic confounders.

Results

Of 22 788 diabetic patients included in the study, 20 245 were enrolled in Medicaid and 2543 in a Marketplace plan. Marketplace-eligible individuals were older (mean [SD] age, 52.12 [10.60] vs 47.70 [11.33] years), and Medicaid-eligible individuals were more likely to be female (12 429 [61.4%] vs 1413 [55.6%]). Medicaid-eligible patients were significantly more likely than Marketplace-eligible patients to fill prescriptions for dipeptidyl peptidase 4 inhibitors (adjusted difference, -3.7%; 95% CI, -5.3 to -2.1; P < .001) and sulfonylureas (adjusted difference, -6.6%; 95% CI, -8.9 to -4.3; P < .001). Overall rates of insulin use were similar in the 2 groups (adjusted difference, -2.3%; -5.1 to 0.5; P = .11). Out-of-pocket costs for noninsulin medications were 84.4% to 95.2% lower and total costs were 9.4% to 54.2% lower in Medicaid than in Marketplace plans. Out-of-pocket costs for insulin were 76.7% to 94.7% lower in Medicaid than in Marketplace plans, whereas differences in total insulin costs were mixed. The percentage of months of apparent active medication coverage was similar between the 2 groups for 4 of 5 drug classes examined, with Marketplace-eligible patients having a greater percentage of months than Medicaid-eligible patients for sulfonylureas (adjusted difference, 5.3%; 95% CI, 0.3%-10.4%; P = .04).

Conclusions and Relevance

In this cross-sectional study, drug utilization across multiple drug classes was higher and drug costs were significantly lower for adults with diabetes enrolled in Medicaid than for those with subsidized Marketplace plans. Patients with Marketplace coverage had a similar percentage of months with an active prescription as patients with Medicaid coverage.

Impacts of high-deductible health plans on patients with diabetes: A systematic review of the literature

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.

Impact of High Deductible Health Plans on Diabetes Care Quality and Outcomes: Systematic Review

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.

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

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.

Impact of High-Deductible Health Plans on Medication Use Among Individuals With Bipolar Disorder

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.

Impact of High-Deductible Health Plans on Emergency Department Patients With Nonspecific Chest Pain and Their Subsequent Care

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.

Health Insurance Coverage: What Comes After The ACA?

The Affordable Care Act (ACA) led to the largest expansion of health insurance in the US in fifty years, bringing the uninsurance rate to its lowest recorded level in 2016. But even at that point, nearly thirty million people lacked health insurance, and millions more still struggled to afford needed medical care. Recent studies also indicate a partial erosion of the ACA's coverage gains since 2017. This article identifies the underlying causes of these problems and evaluates potential policy remedies. Topics include the slow but steady growth of state expansions of eligibility for Medicaid; new waiver approaches in Medicaid, including work requirements; high cost sharing and premium growth in both the Marketplaces and employer coverage; and proposed systemic overhauls such as Medicare for All.

Comparative Effectiveness of Vertical Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass for Diabetes Treatment: A Claims-based Cohort Study

OBJECTIVE

The aim of the study was to compare diabetes outcomes following vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB).

BACKGROUND

There are few comparative studies on diabetes outcomes after VSG and RYGB.

METHODS

We used a US-wide commercial insurance claims database to identify adults with diabetes undergoing VSG or RYGB in 2010 to 2016. We matched patients on baseline insulin use, total diabetes medication burden, age, presence of diabetes complications, and follow-up duration, and used adjusted Cox proportional hazards models to compare diabetes medication discontinuation between procedures. We used difference-in-differences analyses to compare changes in medication use intensity up to 2 years after surgery.

RESULTS

The matched cohort included 1111 VSG and 922 RYGB patients: 16% were younger than 40 years, 11% were 60 years or older, 67% were women, 67% had a body mass index of 40 kg/m2 or higher, and 23% were on insulin at the time of surgery. Thirteen percent were lost to follow-up at 1 year, and 30% at 2 years after surgery. Patients with VSG were less likely than matched RYGB patients to discontinue all diabetes medications (hazard ratio 0.80, 95% confidence interval 0.72-0.88). Although both groups had substantial decreases in medication use after surgery, RYGB patients had an 86% (32%, 140%) lower total diabetes medication dose than VSG by the second half of postoperative year 2.

CONCLUSIONS

In a large claims-based, nationwide cohort of bariatric patients with diabetes, those undergoing RYGB were more likely to come off all medications than those undergoing VSG. Patients with diabetes should consider this potential benefit of RYGB when making informed decisions about obesity treatments.

Deductible Status in the Pediatric Population: A Barrier to Appropriate Care?

OBJECTIVE

The objective of this study is to evaluate the impact of high-deductible health plans on elective surgery (tonsillectomy) in the pediatric population.

STUDY DESIGN

Cross-sectional study.

SETTING

Health claims database from a third-party payer.

METHODS

Data were reviewed for children up to 18 years of age who underwent tonsillectomy or arm fracture repair (nonelective control) from 2016 to 2019. Incidence of surgery by health plan deductible (high, low, or government insured) and met or unmet status of deductibles were compared.

RESULTS

A total of 10,047 tonsillectomy claims and 9903 arm fracture repair claims met inclusion and exclusion criteria. The incidence of tonsillectomy was significantly different across deductible plan types. Patients with met deductibles were more likely to undergo tonsillectomy. In patients with deductibles ≥$4000, a 1.75-fold increase in tonsillectomy was observed in those who had met their deductible as compared with those who had not. These findings were not observed in controls (nonelective arm fracture). For those with met deductibles, those with high deductibles were much more likely to undergo tonsillectomy than those with low, moderate, and government deductibles. Unmet high deductibles were least likely to undergo tonsillectomy.

CONCLUSIONS

Health insurance plan type influences the incidence of pediatric elective surgery such as tonsillectomy but not procedures such as nonelective repair of arm fracture. High deductibles may discourage elective surgery for those deductibles that are unmet, risking inappropriate care of vulnerable pediatric patients. However, meeting the deductible may increase incidence, raising the question of overutilization.

High-Deductible Health Plans and Healthcare Access, Use, and Financial Strain in Those with Chronic Obstructive Pulmonary Disease

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.

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

PURPOSE OF REVIEW

Even with insurance coverage increasing over time among the population with diabetes, a large proportion continues to have poorly controlled disease. The purpose of this narrative literature review is to describe the social determinants of poor management of type 2 diabetes among the insured population and illustrate drivers of poor outcomes beyond insurance coverage.

RECENT FINDINGS

Despite the provision of health insurance, social determinants play a significant role in shaping diabetes outcomes, especially for economic instability (employment, out-of-pocket expenses associated with diabetes management), food insecurity, education and literacy, access to quality health care (health systems designed to effectively manage chronic disease), neighborhood and the built environment (segregated neighborhoods, socioeconomic conditions of communities, housing), and social and community context (discrimination, social support). Multiple social determinants shape poor diabetes outcomes among the insured. These determinants are now being further exacerbated by the COVID-19 pandemic, which has created the worst economic crisis for US families since the Great Depression. The evidence of this review points to the imperative need for more multilevel intervention approaches to address these determinants in the management of diabetes.

Factors Associated With Avoiding Health Care Among Community-Dwelling Medicare Beneficiaries With Type 2 Diabetes

Introduction

Health care avoidance by Medicare beneficiaries with chronic conditions such as type 2 diabetes can result in adverse health and economic outcomes. The objective of this study was to describe factors associated with choices to avoid health care among Medicare beneficiaries with type 2 diabetes.

Methods

We used a survey-weighted logistic model and the nationally representative 2016 Medicare Current Beneficiary Survey to analyze data on 1,782 Medicare beneficiaries aged ≥65 with type 2 diabetes, to examine associations between Medicare beneficiaries’ decisions to avoid health care and multiple factors (eg, dissatisfaction with information given by providers, health problems that should have been discussed with providers but were not, worry about health more than other people their age).

Results

Of our study sample, 26.1% reported they avoid health care. Five factors were associated with avoiding health care: delaying care (vs not) because of costs (adjusted odds ratio [aOR] = 2.06; P = .005); having health problems that should have been discussed with providers but were not (vs having discussions) (aOR = 1.50; P = .04); worrying (vs not) about health more than other people their age (aOR = 2.13; P < .001); self-reporting “other” minority race (vs non-Hispanic White) (aOR = 2.01; P = .006); and education levels. Participants with less than a high school diploma (aOR = 1.95; P = .001) and participants with a high school diploma only (aOR = 1.49; P = .049) were more likely than participants with an education beyond high school to report avoiding health care.

Conclusion

Approximately 1 in 4 Medicare beneficiaries with type 2 diabetes avoid health care. We found inequities in care-seeking behavior by race/ethnicity and education level. Health care perceptions and lack of appropriate discussion of health care concerns with health care providers are also associated with this behavior. Clinical interventions (eg, improved patient–provider communication) and educational outreach are needed to decrease the numbers of Medicare beneficiaries who avoid health care.

High-deductible health plans and low-value imaging in the emergency department

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.

Perioperative Serum 25-Hydroxyvitamin D Levels as a Predictor of Postoperative Opioid Use and Opioid Use Disorder: a Cohort Study

IMPORTANCE

Vitamin D deficiency is associated with chronic pain syndromes and higher opioid use among cancer patients, but its association with opioid use among opioid-naïve subjects following a major surgical procedure with acute pain has not been explored.

OBJECTIVE

To determine the association between serum 25-hydroxyvitamin D (25(OH)D) levels, opioid use, and opioid use disorder.

METHODS

We identified commercially insured subjects aged 18-64 years with available perioperative serum 25-hydroxyvitamin D (25D) levels who underwent one of nine major surgical procedures in 2000-2014. Primary outcomes were dose and duration of opioid use measured using pharmacy claims. Secondary outcome was opioid use disorder captured using diagnosis codes. Multivariable negative binomial models with generalized estimating equations were performed examining the association between 25D levels and postoperative opioid use measures, adjusting for age, sex, race/ethnicity, Charlson score, education, income, latitude, and season of blood draw. Adjusted Cox regression was used to examine the association with opioid use disorder.

RESULTS

Among 5446 subjects, serum 25(OH)D was sufficient (≥ 20 ng/mL) among 4349 (79.9%) subjects, whereas 837 (15.4%) had insufficient (12 to < 20 ng/mL) and 260 (4.8%) had deficient (< 12 ng/mL) levels. On multivariable analysis, as compared with subjects with sufficient 25(OH)D levels, subjects with deficient 25(OH)D levels had 1.7 more days (95% CI 0.76, 2.58) of opioid use per year and had 98.7 higher morphine milligram equivalent dose (95% CI 55.7, 141.8) per year. Among 11,713 study cohort, subjects with deficient 25(OH)D levels were more likely to be diagnosed with opioid use disorders (HR 2.41; 95% CI 1.05, 5.52).

CONCLUSION

Patients undergoing common surgical procedures with deficient 25D levels are more likely to have higher opioid use and an increased risk of opioid use disorder compared to those with sufficient levels. Serum 25D levels may serve as a biomarker to identify subjects at increased risk of opioid misuse.

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

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.

Increased awareness, inadequate treatment, and poor control of cardiovascular risk factors in American young adults: 2005-2016

INTRODUCTION

There are little contemporary data about cardiovascular risk factors among young adults. We defined trends in diabetes mellitus (DM), hypertension, and hypercholesterolemia in American adults aged 18-44 years.

METHODS

The National Health and Nutrition Examination Study serial cross-sectional surveys were used to define three time periods: 2005-2008, 2009-2012, and 2013-2016. Age-adjusted weighted trends of prevalence, awareness, treatment, and control of DM, hypertension, and hypercholesterolemia were calculated by linear regression modelling in the overall sample, males, and females. Trends were calculated after adjustment for age, race, body mass index, smoking status, education attainment, income, insurance status, and number of healthcare visits.

RESULTS

From 2005-2008 to 2013-2016, 15,171 participants were identified. DM prevalence was stable ∼3%, hypertension prevalence was stable ∼11.0%, and hypercholesterolemia prevalence declined from 11.5% to 9.0% (ptrend = 0.02). DM awareness stayed stable between 61.1 and 74.1%, hypertension awareness increased from 68.7 to 77.7% (ptrend = 0.05), and hypercholesterolemia awareness was stable between 46.8 and 54.1%. DM and hypertension treatment improved markedly (ptrend < 0.001 and 0.05, respectively) but the hypercholesterolemia treatment was stable ∼30%. DM control improved across survey periods (7.7-17.4%, ptrend = 0.04) but hypertension control (∼50%) and hypercholesterolemia control (∼13%) remained stable. Prevalence, awareness, treatment, and control trends also differed between males and females.

CONCLUSIONS

There is a stable prevalence of DM, high and stable prevalence of hypertension, and declining prevalence of hypercholesterolemia among young Americans. Despite stable or increasing awareness of diabetes and hypertension, there are inadequate treatment and control trends for DM, hypertension, and hypercholesterolemia.

Health Care Crisis by the Numbers

We summarize recent data on health and health care in the United States. Many millions suffer financial distress due to medical bills and forego needed care because of costs. Pay-for-performance programs have failed to achieve the results promised and in some cases have backfired. Health care firms expend huge amounts on marketing that provides no benefit to patients. Millions of health care workers, particularly women of color, are so poorly paid that they live in poverty, and gender-based pay inequities remain common in the health sector. Polls continue to show strong popular support for a single-payer reform, but politicians continue to resist it.

Illuminating an Invisible Epidemic: A Systemic Review of the Clinical and Economic Benefits of Early Diagnosis and Treatment in Inflammatory Disease and Related Syndromes

Healthcare expenditures in the United States are growing at an alarming level with the Centers for Medicare and Medicaid Services (CMS) projecting that they will reach $5.7 trillion per year by 2026. Inflammatory diseases and related syndromes are growing in prevalence among Western societies. This growing population that affects close to 60 million people in the U.S. places a significant burden on the healthcare system. Characterized by relatively slow development, these diseases and syndromes prove challenging to diagnose, leading to delayed treatment against the backdrop of inevitable disability progression. Patients require healthcare attention but are initially hidden from clinician's view by the seemingly generalized, non-specific symptoms. It is imperative to identify and manage these underlying conditions to slow disease progression and reduce the likelihood that costly comorbidities will develop. Enhanced diagnostic criteria coupled with additional technological innovation to identify inflammatory conditions earlier is necessary and in the best interest of all healthcare stakeholders. The current total cost to the U.S. healthcare system is at least $90B dollars annually. Through unique analysis of financial cost drivers, this review identifies opportunities to improve clinical outcomes and help control these disease-related costs by 20% or more.