How Does Switching to HDHPs Affect Diabetes Care?

Full access

For patients with diabetes—including but not limited to low-income patients—switching to high-deductible health plan (HDHPs) leads to major increases in emergency department visits for preventable acute diabetic complications, reports a study in JAMA Internal Medicine.

The researchers analyzed the effects of an employer-mandated switch to HDHPs in 12,084 diabetic patients, aged 12 to 64 years. All were enrolled in a low-deductible plan ($500 or less) for 1 year, followed by 2 years in an HDHP ($1000 or higher). The HDHP patients were propensity score-matched to patients who remained on low-deductible plans only.

The effects of switching to an HDHP on diabetes outpatient care and acute complications were assessed, including ED visits for preventable complications. Subgroup analyses focused on 4121 low-income patients and 1899 patients eligible for health savings accounts (HSAs).

Out-of-pocket costs increased for diabetic patients in the year after switching to HDHPs: by 49.4% overall, 51.7% for low-income patients, and 67.8% for HSA-eligible patients. There was no change in high-priority primary care visits or use of disease monitoring tests. However, high-priority specialist visits decreased by 5.5% in the first year and 7.1% in the second year.

After the switch to an HDHP, outpatient visits for acute diabetes complications were delayed in both the overall and low-income cohorts: adjusted hazard ratio 0.94 and 0.89, respectively. Annual ED visits for acute complications increased by 8.0% for all patients, 15.5% in HSA-eligible patients, and 21.7% in low-income patients.

Switching to an HDHP does not appear to affect outpatient visits and disease monitoring for diabetic patients. However, rates of ED visits for preventable acute diabetes complications are substantially increased, particularly for low-income, high-morbidity, and HSA-eligible patients. With the increasing focus on HDHPs in the US healthcare system, the authors discuss implications for preventing adverse effects on diabetes care [Wharam FJ, et al. Diabetes outpatient care and acute complications before and after high-deductible insurance enrollment: a Natural Experiment for Translation in Diabetes (NEXT-D) study. JAMA Intern Med 2017; doi:10.1001/jamainternmed.2016.8411].