High-deductible Research Articles

Out-of-Pocket Spending for Asthma-Related Care Among Commercially Insured Patients, 2004-2016

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. To analyze OOP spending for asthma-related care overall, across types of care, and by income. 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. 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. 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.

The Effect of Monthly Cost‐Sharing Limits on Out‐of‐Pocket Costs for Privately Insured Patients

Research ObjectiveDespite the Affordable Care Act increasing access to health insurance for millions of previously uninsured Americans, underinsurance is a persistent problem. A key contributor to underinsurance is growing enrollment in high deductible health plans for those on the health insurance exchanges and in employer‐sponsored health plans. Because annual deductibles do not reflect the economic realities of how people are paid or how they pay for other expenses, it is worthwhile to consider alternatives to annual cost‐sharing limits as an option for improving access to care.Study DesignWe used the 2018 IBM MarketScan® Commercial Claims and Encounters database to assess changes in patient out‐of‐pocket and plan spending under either a $250 or $500 in‐network monthly out‐of‐pocket maximum. We also estimated spending assuming uncapped out‐of‐network costs or with $500 or $1,000 monthly out‐of‐network out‐of‐pocket maximums. We calculated the percentage of enrollees who would benefit from each scenario and share of total costs shifted back to plans as a percentage of total health care spending under each scenario.Population StudiedThose under age 65 who were enrolled for the full year, excluding those in HMO or POS with capitation plans.Principal FindingsEnrollee annual mean and highest month mean out‐of‐pocket costs decreased in all scenarios. For in‐network care, annual mean out‐of‐pocket costs fall by $380 (49%) under a $250 monthly cap and by $269 (35%) under a $500 monthly cap. For out‐of‐network care, annual savings averaged 35% and 22% under the $500 and $1,000 out‐of‐network caps, respectively. When considering savings for the highest month of out‐of‐pocket costs, representing peak burden of cost‐sharing, we estimated mean patient spending decreases between 48% and 68% (from $480 under the status quo). The percentage of enrollees benefitting from these monthly caps ranges from 23% to 37% and the portion of total health care costs shifted from enrollees back to plans ranges from 4% to 7%. The latter estimate reflects potential increases in premiums expected as a result of such a policy change, absent any behavioral effects on health care use.ConclusionsInstead of a large annual deductible, plans could spread the annual deductible over the year to improve affordability for patients. Patients with acute illnesses could get necessary care without facing a deductible that is more than their monthly take‐home pay, and those with chronic needs would be better able to spread their costs throughout the year instead of facing a single large bill at the beginning of every year. There may be some increases in so‐called inefficient health care use, commonly referred to as moral hazard, due to lower cost‐sharing; however, there is a practical limit to the amount of care that can be scheduled within one month. Conversely, under the current annual cost‐sharing limits, patients who reach their out‐of‐pocket maximum early have the opportunity to use care with no cost‐sharing for a substantial portion of the year.Implications for Policy or PracticeMonthly cost‐sharing limits could improve affordability of care for those in high‐deductible health plans.

Nonelderly Adult Cancer Survivors in High Deductible Health Plan: Healthcare Expenditure, Utilization and Access.

Background: To compare healthcare expenditure, utilization and access between nonelderly adult cancer survivors enrolled in a high deductible health plan with a health savings account (“HDHP+HSA”), HDHP without HSA (“HDHP alone”) and low deductible health plan (“LDHP”). Methods: 1735 cancer survivors, aged 18–64 years, with continuous private coverage identified from the 2012–2017 Medical Expenditure Panel Survey: HDHP alone (n = 353), HDHP+HSA (n = 242) and LDHP (n = 1140). Healthcare expenditures, utilization and inability/delay obtaining medical care were analyzed using generalized linear regressions with inverse propensity score weighting and doubly robust estimation. Results: HDHP alone group (23,255 USD) had significantly higher total healthcare expenditure compared to HDHP+HSA (15,580 USD, p = 0.012) and LDHP (16,261 USD, p = 0.016). HDHP alone (6089 USD; p = 0.002) and HDHP+HSA (5743 USD; p = 0.012) groups had significantly higher out-of-pocket (OOP) expenditure compared to LDHP (4853 USD). HDHP alone (17,128 USD, p = 0.010) and LDHP (12,645 USD, p = 0.045) had significantly higher private insurer payments compared to HDHP+HSA (9216 USD). No differences were found in utilization or inability/delay obtaining medical care across groups. Conclusions: Non-elderly adult cancer survivors with continuous coverage and comparable sociodemographic characteristics enrolled in HDHP with HSA displayed the lowest healthcare costs compared to HDHP without HSA and LDHP. HDHP+HSA had a significantly higher OOP expenditure than LDHP. No significant differences were observed in utilization or access among groups.

National Trends in Out-of-Pocket Costs Among U.S. Adults With Diabetes Aged 18-64 Years: 2001-2017.

To assess national trends in out-of-pocket (OOP) costs among adults aged 18-64 years with diabetes in the U.S. Using data from the 2001-2017 Medical Expenditure Panel Survey, we estimated total per person annual OOP costs (insurance premiums, prescription drug costs, inpatient and outpatient deductibles, copays, and other payments not covered by insurance) and high OOP cost rate, defined as the percentage of people with OOP spending >10% of their family's pretax income. We examined trends overall, by subgroup (insurance type, income level, insulin use, size of patient's employer, and whether the patient was enrolled in a high deductible health plan), and by type of service. Changes in trends were identified using joinpoint analysis; costs were adjusted to 2017 U.S. dollars. From 2001 to 2017, OOP costs decreased 4.3%, from $4,328 to $4,139, and the high OOP cost rate fell 32%, from 28 to 19% (P < 0.001). Changes in the high OOP cost rate varied by subgroup, declining among those with public or no insurance and those with an income <200% of the federal poverty level (P < 0.001) but remaining stable among those with private insurance and higher income. Drug prescription OOP costs decreased among all subgroups (P < 0.001). Decreases in total (-$58 vs. -$37, P < 0.001) and prescription (-$79 vs. -$68, P < 0.001) OOP costs were higher among insulin users than noninsulin users. OOP costs among U.S. nonelderly adults with diabetes declined, especially among those least able to afford them. Future studies may explore factors contributing to the decline in OOP costs and the impact on the quality of diabetes care and complication rates.

Impact of High Deductible Health Plans on Continuous Buprenorphine Treatment for Opioid Use Disorder.

Long-term, continuous treatment with medication like buprenorphine is the gold standard for opioid use disorder (OUD). As high deductible health plans (HDHPs) become more prevalent in the commercial insurance market, they may pose financial barriers to people with OUD. To estimate the impact of HDHPs on continuity of buprenorphine treatment, concurrent visits for counseling/psychotherapy and OUD-related evaluation and management, and out-of-pocket spending. Difference-in-differences analysis comparing trends in outcomes among enrollees whose employers offer an HDHP (treatment group) to enrollees whose employers never offer an HDHP (comparison group). Enrollees with OUD from a national sample of commercial health insurance plans during 2007-2017 who initiate buprenorphine treatment. Number of days of continuous buprenorphine treatment; probabilities of continuous buprenorphine treatment ≥30, ≥90, ≥180, and ≥365 days; probability of concurrent (i.e., within the same month) behavioral therapy (i.e., counseling or psychotherapy); probability of concurrent OUD-related evaluation and management visits; proportions of buprenorphine treatment episodes with counseling/psychotherapy and evaluation and management visits; and out-of-pocket (OOP) spending on buprenorphine, behavioral therapy, and evaluation and management visits. HDHPs were associated with an average increase of $98 (95% CI: $48, $150) on OOP spending on buprenorphine per treatment episode but no change in the number of days of continuous buprenorphine treatment or concurrent use of related services. HDHPs do not reduce continuity of buprenorphine treatment among commercially insured enrollees with OUD but may increase financial burden for this population.

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

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. To assess the impact of HDHP on cost-related medication non-adherence (CRN) among non-elderly adults with diabetes in the US. Repeated cross-sectional survey. National Health Interview Survey, 2011-2018. 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). 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. 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]). 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.

Out-of-Pocket Costs for Patients Undergoing Thyroid Surgery.

The aim of this study was to determine out-of-pocket costs (OOPC) in patients undergoing thyroidectomy for benign and malignant conditions in a commercially insured US population. Little is known about OOPC for thyroid surgery in the United States. Retrospective cohort study using claims of patients undergoing thyroidectomy from the IBM Watson Marketscan database from 2008 to 2017. OOPCs accrued from 90 days before surgery to 360 days after thyroid surgery were quantified. Costs were divided into expenditures for inpatient care, outpatient care and outpatient drug costs and over three time periods: from 90 days preoperatively to 30 days post operatively, from 30 days post operatively to 90 days postoperatively, and from 90 days to 1 year after surgery. A total of 45,971 commercially insured patients aged 18 to 95 years who underwent thyroidectomy were identified after excluding patients who changed coverage and patients on capitated plans. The median OOPC per patient in the study period of 90 days before surgery to 360 days after surgery was $2434 [interquartile range (IQR) $1273-$4226], the median insurance reimbursement was $15,520 (IQR $7653-$29,149). Patients undergoing thyroidectomy for malignant conditions had a median OOPC of $3019 (IQR $1596-$5021) compared to $2271 (IQR $1201-3954) for benign conditions ( P < 0.0001).Patients with preferred provider organization coverage had a median OOPC of $2624 (IQR $1458-$4358) compared to HMO patients with a median OOPC of $1529 (IQR $739 to 3058), and high deductible health plans with a median OOPC of $4265 (IQR $2788-$6210) ( P < 0.0001). Despite commercial insurance coverage, patients face substantial OOPCs in the surgical management of thyroid disease in the United States.

Do high-deductible health plans affect price paid for childbirth?

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. 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). 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. From the HCCI sample, childbearing women enrolled in an employer-sponsored plan with at least 10 people. 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. 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.

Health Insurance Deductibles and Health Care–Seeking Behaviors in a Consumer-Driven Health Care System With Universal Coverage

Characteristics of a health care system can facilitate forgoing of health care owing to economic reasons and can influence population health. Whether health insurance deductibles are associated with forgoing of health care in a consumer-driven health care system with universal coverage, such as the Swiss health system, remains to be determined. To assess the association between insurance plan deductibles and forgoing of health care with consideration of socioeconomic factors. This cross-sectional study was conducted in Geneva, Switzerland, using data collected from January 1, 2007, to December 31, 2019. Population-based samples were obtained yearly through random stratified sampling by age and sex of the general population aged 20 to 74 years. Participants were invited to an appointment at 1 of the 3 study sites in Geneva, where they completed a sociodemographic and health questionnaire. Insurance plan deductible level. The main outcome was forgoing of health care owing to economic reasons. Unadjusted and multivariable Poisson models were used to assess the association between deductible level and forgoing of health care. Differences in forgoing health care across the range of health insurance deductibles or household income levels were quantified using the relative index of inequality (RII). The study group included 11 872 participants (5974 [50.3%] male; median age, 48.1 years [interquartile range, 38.7-59.1 years]); 1146 (9.7%) reported forgoing health care. Participants with high-deductible plans reported forgoing health care more frequently than those with low-deductible plans (331 [13.5%] vs 591 [8.7%]). In adjusted analysis, higher-deductible plans were associated with a greater likelihood of forgoing health care (RII, 2.2; 95% CI, 1.7-3.0; P < .001) independently of socioeconomic status, known comorbidities, and cardiovascular risk factors. Deductible level was associated with forgoing of health care among participants younger than 40 years (RII, 2.5; 95% CI, 1.6-4.0; P < .001) and those aged 40 to 64 years (RII, 1.9; 95% CI, 1.3-2.9; P = .002) but not among those older than 65 years (RII, 2.9; 95% CI, 0.8-10.4; P = .11). In this cross-sectional study, high insurance plan deductibles were associated with forgoing of health care independent of socioeconomic status and preexisting conditions in a universal consumer-driven health care system with good population outcomes in Switzerland. Uncovering health care system design features that could lead to suboptimal population care may help decision makers improve their current health care system design to achieve better outcomes.

Referral Linkage to Preexposure Prophylaxis Care and Persistence on Preexposure Prophylaxis in an Integrated Health Care System.

Successful linkage to preexposure prophylaxis (PrEP) and retention in care are important for HIV prevention. We examined gaps in PrEP care following referral and factors associated with PrEP linkage and persistence in an integrated health care system in the United States. We identified individuals referred for PrEP from 2014 to 2017 at the Kaiser Permanente Southern California using electronic health records and assessed linkage to care, PrEP prescription orders and fills, and PrEP persistence (medication possession ratio ≥80%) in the year after the first fill. We evaluated demographic and clinical factors potentially associated with PrEP linkage and persistence using a series of multivariable modified Poisson regression models. Of 2995 referred individuals, 74.9% were linked to PrEP care. Nearly all those linked to care were prescribed PrEP and filled a prescription, but only 47.4% of those who filled a prescription were persistent on PrEP. Individuals aged <25 years (vs ≥25 years), female subjects (vs males), and individuals with high-deductible insurance (vs no high deductible) were less likely to be linked to care. Individuals aged <25 years and Hispanics (vs non-Hispanic whites) were less likely to be persistent. Those with alcohol use disorder were more likely to be linked to PrEP care but less likely to be persistent. New HIV diagnoses occurred in 38 individuals, and only 1 had PrEP in possession at diagnosis. We observed PrEP care gaps and disparities among individuals referred for PrEP. Patient-centered interventions are needed in primary care to address barriers to successful PrEP linkage and persistence.

Potentially inappropriate prescriptions: Associations with the health insurance contract and the quality of the patient–physician relationship?

ContextPotentially Inappropriate Prescriptions (PIP) are often used as an indicator of potential drug overuse or misuse to limit adverse drug events in older people. ObjectiveTo determine whether PIP exposure differs as a function of the patient's health insurance scheme and the patient–physician relationship. MethodsOur dataset was collected from two surveys delivered to two cohorts of the Swiss Lc65+ study, together with a stratified random sample of older people in the Swiss canton of Vaud. The study sample consisted of 1,595 people aged 68 years and older living in the community and reporting at least one prescription drug. Logit regression models of PIP risk were run for various categories of variables: health related, socioeconomic, health insurance scheme and patient–physician relationship. Results17% of our respondents had at least one PIP. Our results suggested that being enrolled in a health plan with restriction in the patient's choice of providers and having higher deductibles were associated with lower PIP risk. PIP risk did not differ as a function of the quality of the patient–physician relationship. ConclusionOur study helps to raise awareness about the organizational risk factors of PIP and, more specifically, how health insurance contracts could play a role in improving the management of drug consumption among community-dwelling older people.

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

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. Using a commercial and Medicare Advantage claims database, we identified members 19 to 63 years old whose employers exclusively offered low-deductible (≤$500) plans in 1 year, then, at an index date, mandated enrollment in HDHPs (≥$1000) for a subsequent year. We matched them with contemporaneous members whose employers only offered low-deductible plans. Primary outcomes included population rates of index ED visits with a principal diagnosis of nonspecific chest pain, admission during index ED visits, and index ED visits followed by noninvasive cardiac testing within 3 and 30 days, coronary revascularization, and acute myocardial infarction hospitalization within 30 days. We performed a cumulative interrupted time-series analysis, comparing changes in annual outcomes between the HDHP and control groups before and after the index date using aggregate-level segmented regression. Members from higher-poverty neighborhoods were a subgroup of interest. After matching, we included 557 501 members in the HDHP group and 5 861 990 in the control group, with mean ages of 42.0 years, 48% to 49% female, and 67% to 68% non-Hispanic White individuals. Employer-mandated HDHP switches were associated with a relative decrease of 4.3% (95% CI, -5.9 to -2.7; absolute change, -4.5 [95% CI, -6.3 to -2.8] per 10 000 person-years) in nonspecific chest pain ED visits and 11.3% (95% CI, -14.0 to -8.6) decrease (absolute change, -1.7 per 10 000 person-years [95% CI, -2.1 to -1.2]) in visits leading to hospitalization. There was no significant decrease in subsequent noninvasive testing or revascularization procedures. An increase in 30-day acute myocardial infarction admissions was not statistically significant (15.9% [95% CI, -1.0 to 32.7]; absolute change, 0.3 per 10 000 person-years [95% CI, -0.01 to 0.5]) but was significant among members from higher-poverty neighborhoods. Employer-mandated HDHP switches were associated with decreased nonspecific chest pain ED visits and hospitalization from these ED visits, but no significant change in post-ED cardiac testing. However, HDHP enrollment was associated with increased 30-day acute myocardial infarction admission after ED diagnosis of nonspecific chest pain among members from higher-poverty neighborhoods.

Coverage and Timing of Influenza Vaccination Among Privately Insured Pregnant Women in the United States, 2010-2018.

Pregnant women are at increased risk of serious complications from influenza and are recommended to receive an influenza vaccination during pregnancy. The objective of this study was to assess trends, timing patterns, and associated factors of influenza vaccination among pregnant women. We used 2010-2018 MarketScan data on 1 286 749 pregnant women aged 15-49 who were privately insured to examine trends and timing patterns of influenza vaccination coverage. We examined descriptive statistics and identified factors associated with vaccination uptake by using multivariate log-binomial and Cox proportional hazard models. In-plan influenza vaccination coverage before delivery increased from 22.0% during the 2010-2011 influenza season to 33.2% during the 2017-2018 influenza season. About two-thirds of vaccinated women received the vaccine in September or October during each influenza season. For women who delivered in September through May, influenza vaccination coverage increased rapidly at the beginning of influenza season and flattened after October. For women who delivered in June through August, influenza vaccination coverage increased gradually until February and flattened thereafter. Most vaccinated women who delivered before January received the vaccine in the third trimester. Increased likelihood of being vaccinated was associated with age 31-40, living in a metropolitan statistical area, living outside the South, enrollment in a consumer-driven or high-deductible health plan, being spouses or dependents of policy holders, and delivery in November through January. Despite increases during the past several years, vaccination uptake is still suboptimal, particularly after October. Health care provider education on timing of vaccination and recommendations throughout influenza seasons are needed to improve influenza vaccination coverage among pregnant women.

809-P: The Impact of High-Deductible Health Plans (HDHPS) and Out-of-Pocket (OOP) Costs on Access to Care in Diabetes

Background: HDHP use and high OOP costs are associated with decreased healthcare resource use (HCRU) and access to care, among those with lower incomes, or racial and ethnic minorities. The potential impact on diabetes care is a public health concern, given that regular access to medications is critical to avoid severe complications. The objective of this study was to characterize the impact of HDHPs and high OOP costs on access to care and HCRU among Americans with diabetes, and the interaction of race/ethnicity and income. Methods: A systematic review was performed using Medline/EMBASE to identify records from the past 10 years, describing the impact of HDHPs, or high OOP costs or copayments, on access to care (e.g., not pursuing care because of cost) or HCRU (e.g., medication use, physician visits). The focus of the review was on Americans with diabetes; whether the impact of race/ethnicity and income was reported was also captured. Results: From 2707 abstracts, 2 described the impact of HDHPs among those with diabetes and 9, high OOP/copayment costs. Four studies (36.4%) reported the impact of race/ethnicity: Black and non-Hispanic patients with diabetes tended to be at higher risk of non-adherence than white patients. Three studies (27.2%) reported the impact of income: Lower-income patients with diabetes were at higher risk of non-adherence and decreased HCRU, versus higher-income patients. Only one study reported on both race/ethnicity and income, but not the interaction of these. Conclusions: These findings suggest that HDHP use and high OOP costs are associated with decreased HCRU and adherence among Americans with diabetes. This effect may be more pronounced among those of non-white race/ethnicity or with low income. Notably, no studies reported the impact of HDHPs and high OOP costs on access to care. Understanding how race/ethnicity and income interact will be important to fully recognize the impact of HDHPs and high OOP costs on outcomes among Americans with diabetes. Disclosure S. M. Szabo: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. E. Kuti: Employee; Self; Boehringer Ingelheim Pharmaceuticals, Inc. M. Friesen: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. D. Reardon: Employee; Self; Boehringer Ingelheim Pharmaceuticals, Inc. E. Jaykus: Employee; Self; Boehringer Ingelheim Pharmaceuticals, Inc. R. Corepal: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. B. M. K. Donato: Employee; Self; Boehringer Ingelheim Pharmaceuticals, Inc. Funding Boehringer Ingelheim

Health Savings Plans and Disparities in Access to Care by Race and Ethnicity

High-deductible health plans are often touted to motivate patients to become informed healthcare purchasers; however, racial/ethnic minorities report that high deductibles prevent them from seeking the needed care. One proposed way to mitigate the financial burden of high-deductible health plans is the use of health savings plans. This cross-sectional study investigates whether chronically ill Blacks and Hispanics enrolled in high-deductible health plans experience greater access to care difficulties than non-Hispanic Whites and whether racial/ethnic disparities are mitigated by the use of health savings plans. Weighted, multivariate, linear probability regression models were estimated (analyses were conducted in December 2020), adjusting for individual attributes and contextual factors that may explain the variation in health care access. Chronically ill, U.S.-born Black, Hispanic, and White adults enrolled in a high-deductible health plan from the National Health Interview Survey in 2011-2018 were included. Associations were tested among 3 independent variables-being Black, being Hispanic, and health savings plan utilization (and their interaction)-and access to healthcare outcomes of interest, including affordability-related access, provider-related access, and delayed care. Blacks and Hispanics were less likely to use health savings plans, and Blacks were more likely to experience problems with access to health care. Although the use of health savings plans was found to have a minimal effect on reducing racial/ethnic disparities in affordability-related access, there was also evidence that health savings plans compounded racial/ethnic disparities in provider-related access. Understanding how health savings plans function to improve access to care within racial/ethnic minority groups may help to inform policy approaches related to their use.

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

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. 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. 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. 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.

Controller Medication Use and Exacerbations for Children and Adults With Asthma in High-Deductible Health Plans

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. To examine the association between HDHP enrollment and asthma controller medication use and exacerbations. 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. Employer-mandated HDHP transition. 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. 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%). 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.

Questioning the Value of High-Deductible Health Plans for Children With Chronic Conditions

Questioning the Value of High-Deductible Health Plans for Children With Chronic Conditions

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

The objective of this study is to evaluate the impact of high-deductible health plans on elective surgery (tonsillectomy) in the pediatric population. Cross-sectional study. Health claims database from a third-party payer. 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. 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. 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.

ACA Mandate Led To Substantial Increase In Contraceptive Use Among Women Enrolled In High-Deductible Health Plans.

The Affordable Care Act (ACA) mandated that private health plans cover contraceptives without out-of-pocket expenses for patients. Previously, long-acting reversible contraceptives (LARCs) were subject to deductibles, making them a higher-cost service for women with high-deductible health plans (HDHPs); however, the ACA mandate applied to HDHPs as well as traditional health plans. Using a national commercial claims database, we examined LARC use among continuously enrolled reproductive-age women between 2010 and 2017, comparing 9,014 women enrolled in HDHPs with 443,363 women enrolled in non-HDHPs. Using a quasi-experimental difference-in-differences analysis, we found that pre-ACA HDHP enrollees had lower LARC initiation rates than women in non-HDHPs and that rates of LARC initiation increased by 35percent more postmandate for women in HDHPs than for women in traditional plans. These findings suggest that the ACA had a particularly important impact for women in HDHPs, who faced higher pre-ACA out-of-pocket expenses for these contraceptive methods.