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.

Deductible imputation in administrative medical claims datasets.

OBJECTIVE: To validate imputation methods used to infer plan-level deductibles and determine which enrollees are in high-deductible health plans (HDHPs) in administrative claims datasets. DATA SOURCES AND STUDY SETTING: 2017 medical and pharmaceutical claims from OptumLabs Data Warehouse for US individuals <65 continuously enrolled in an employer-sponsored plan. Data include enrollee and plan characteristics, deductible spending, plan spending, and actual plan-level deductibles. STUDY DESIGN: We impute plan deductibles using four methods: (1) parametric prediction using individual-level spending; (2) parametric prediction with imputation and plan characteristics; (3) highest plan-specific mode of individual annual deductible spending; and (4) deductible spending at the 80th percentile among individuals meeting their deductible. We compare deductibles' levels and categories for imputed versus actual deductibles. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: All methods had a positive predictive value (PPV) for determining high- versus low-deductible plans of ≥87%; negative predictive values (NPV) were lower. The method imputing plan-specific deductible spending modes was most accurate and least computationally intensive (PPV: 95%; NPV: 91%). This method also best correlated with actual deductible levels; 69% of imputed deductibles were within $250 of the true deductible. CONCLUSIONS: In the absence of plan structure data, imputing plan-specific modes of individual annual deductible spending best correlates with true deductibles and best predicts enrollees in HDHPs.

Out-of-Pocket Costs and Outpatient Visits Among Patients With Cancer in High-Deductible Health Plans.

Importance: High-deductible health plans (HDHPs) have grown rapidly and may adversely affect access to comprehensive cancer care. Objective: To evaluate the association of HDHPs with out-of-pocket medical costs and outpatient physician visits among patients with cancer. Design, Setting, and Participants: Using 2003 to 2017 data from the deidentified Optum Clinformatics Data Mart database from individuals with employer-sponsored health coverage, adults aged 18 to 64 years with cancer who were enrolled in low-deductible (≤$500 annually) health plans during a baseline year were identified. Patients whose employers then mandated a switch to an HDHP (≥$1000 annual deductible) were assigned to the HDHP group, while contemporaneous individuals with cancer at baseline who had no option but to continue enrollment in low-deductible plans were assigned to the control group. The 2 groups were matched on demographic variables (age, sex, race and ethnicity, US Census region, rural vs urban, and neighborhood poverty level), cancer type, morbidity score, number of baseline physician visits by specialty type, baseline out-of-pocket costs, and employer characteristics. These cohorts were followed up for up to 3 years after the baseline year. Data were analyzed from July 2021 to December 2022. Exposures: Employer-mandated HDHP enrollment. Main Outcomes and Measures: Out-of-pocket medical expenditures and outpatient visits to primary care physicians, cancer specialists, and noncancer specialists. Results: After matching, the sample included 45 708 patients with cancer (2703 patients in the HDHP group and 43 005 matched individuals in the control group); mean (SD) age in the HDHP and control groups was 52.9 (9.3) years and 52.9 (2.3) years, respectively, with 58.5% females in both groups. The matching procedure yielded variable weights for each individual in the control group, resulting in a weighted control group sample of 2703 patients. Patients with cancer who were switched to HDHPs experienced an increase in annual out-of-pocket medical expenditures of 68.1% (95% CI, 51.0%-85.3%; absolute increase, $1349.80 [95% CI, $1060.30-$1639.20]) after the switch compared with those who remained in traditional health plans. At follow-up, the number of oncology visits did not differ between the 2 groups (relative difference, 0.1%; 95% CI, -8.4% to 9.4%); however, the HDHP group had 10.8% (95% CI, -15.5% to -5.9%) fewer visits to primary care physicians and 5.9% (95% CI, -11.2% to -0.3%) fewer visits to noncancer specialists. Conclusions and Relevance: Results of this cohort study suggest that after enrollment in HDHPs, patients with cancer experienced substantial increases in out-of-pocket medical costs. The number of visits to oncologists was unchanged during follow-up, but the number of visits to noncancer physicians was lower. These findings suggest that HDHPs are unlikely to unfavorably affect key oncology services but might lead to less comprehensive care of cancer survivors.

Impact of income-based public drug coverage deductibles on adherence to asthma medications.

BACKGROUND: Cost-related nonadherence to medications can be a barrier to asthma management. OBJECTIVE: To quantify the impact of public drug plan deductibles on adherence to asthma medications. METHODS: We used a quasi-experimental regression discontinuity analysis to determine whether thresholds in deductibles for public drug coverage, determined on the basis of annual household income, decreased medication use among lower-income children and adults with asthma in British Columbia from 2013 to 2018. Using dispensed medication records, we evaluated deductible thresholds at annual household incomes of $15,000 (a deductible increase from 0% to 2% of annual household income), and $30,000 (a deductible increase from 2% to 3% annual household income). We evaluated medication costs, use, the ratio of inhaled corticosteroids-containing controller medications to total medications, excessive use of short-acting ß-agonists, and the proportion of days covered by controller therapies. All costs are reported in 2020 Canadian dollars. RESULTS: Overall, 88,935 individuals contributed 443,847 person-years of follow-up (57% of female sex, mean age 31 years). Public drug subsidy decreased by -$41.74 (95% CI, -$28.34 to -$55.13) at the $15,000-deductible threshold, a 28% reduction, and patient costs increased by $48.45 (95% CI, $35.37-$61.53). The $30,000 deductible threshold did not affect public drug costs (P = .31), but patient costs increased by $27.65 (95% CI, $15.22-$40.09), which is an 11% increase. Asthma-related medication use, inhaled corticosteroids-to-total medication ratio, excessive use of short-acting ß-agonists, and proportion of days covered by controller therapies were not impacted by deductible thresholds. CONCLUSION: Income-based deductibles reduced public drug costs with no effect on asthma-related medication use, adherence to controller therapies, or excessive reliever therapy use in lower-income individuals with asthma.

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.

Association of High-Deductible Health Plans and Time to Surgery for Breast and Colon Cancer.

BACKGROUND: High-deductible health plans (HDHPs) have been shown to delay timing of breast and colon cancer screening, although the relationship to the timing of cancer surgery is unknown. The objective of this study was to characterize timing of surgery for breast and colon cancer patients undergoing cancer operations following routine screening. STUDY DESIGN: Data from the IBM MarketScan Commercial Claims Database from 2007 to 2016 were queried to identify patients who underwent screening mammogram and/or colonoscopy. The calendar quarters of screening and surgery were analyzed with ordinal logistic regression. The time from screening to surgery (time to surgery, TTS) was evaluated using a Cox proportional hazard function. RESULTS: Among 32,562,751 patients who had screening mammograms, 0.7% underwent breast cancer surgery within the following year. Among 9,325,238 patients who had screening colonoscopies, 0.9% were followed by colon cancer surgery within a year. The odds of screening (OR 1.146 for mammogram, 1.272 for colonoscopy; p < 0.001) and surgery (OR 1.120 for breast surgery, 1.219 for colon surgery; p < 0.001) increased each quarter for HDHPs compared to low-deductible health plans. Enrollment in an HDHP was not associated with a difference in TTS. Screening in Q3 or Q4 was associated with shorter TTS compared to screening in Q1 (hazard ratio 1.061 and 1.046, respectively; p < 0.001). CONCLUSIONS: HDHPs were associated with delays in screening and surgery. However, HDHPs were not associated with delays in TTS. Interventions to improve cancer care outcomes in the HDHP population should concentrate on reducing barriers to timely screening.

Impact of Coinsurance Reduction Policy on Healthcare Utilization Among Children Under 15.

BACKGROUND: On October 1, 2017, a new coinsurance reduction policy for children under 15 was introduced to minimize the lack of inpatient medical services for economic reasons and secure children's access to medical care. METHODS: This study analyzes the effect of this coinsurance reduction policy on healthcare utilization using data from the National Health Insurance Service-National Sample Cohort between 2015 and 2019. Groups were classified by 3 case groups and a control group according to age. The dependent variables were inpatient cost, admission, length of hospitalization, outpatient cost and visit, and total cost. The difference-in-differences method was used to examine changes in healthcare utilization among the case and control groups after policy implementation. RESULTS: Children of the age group 1-5 exhibited an increase in inpatient services and a decrease in outpatient services. There was a 16.17% increase in inpatient cost, 8.55% increase in inpatient admission, 10.67% increase in inpatient length of hospitalization, -9.14% decline in outpatient cost, and -6.79% decline in outpatient visits. Regarding children in the age groups of 6-10 and 11-15, the effect of the policy was inconclusive. CONCLUSION: The reduction in coinsurance rate policy in hospitalization among children has increased inpatient services and reduced outpatient services for 1-5-year-olds-a substitute effect was observed in this group. There is need for further research to examine the long-term effects of the coinsurance reduction policy.

Sexual Orientation, High-Deductible Health Plans, And Financial Barriers To Care.

Among US adults in 2013-18, we found high-deductible health plan enrollment to be the lowest among heterosexual and gay/lesbian adults in families with incomes below 200 percent of the federal poverty level and the highest among bisexual adults in families with incomes at or above 400 percent of poverty. Gay/lesbian and bisexual adults in these plans experienced greater financial barriers to health care than heterosexual adults.

Choice of high-deductible health plans among enrollees with a substance use disorder.

INTRODUCTION: High-deductible health plans (HDHPs) expose enrollees to increased out-of-pocket costs for their medical care, which can exacerbate the undertreatment of substance use disorders (SUDs). However, the factors that influence whether an enrollee with SUD chooses an HDHP are not well understood. In this study, we examine the factors associated with an individual with an SUD's decision to enroll in an HDHP. METHODS: Using de-identified administrative commercial claims and enrollment data from OptumLabs (2007-2017), we identified individuals at employers offering at least one HDHP and one non-HDHP plan. We modeled whether an enrollee chose an HDHP using linear regression on plan and enrollee demographic characteristics. Key plan characteristics included whether a plan had a health savings account (HSA) or a health reimbursement arrangement (HRA). Key demographic variables included age, race/ethnicity, census block income range, census block highest educational attainment, and sex. We separately investigate new enrollment decisions (i.e., not previously enrolled in an HDHP) and re-enrollment decisions, as well as decisions among single enrollees and families of differing sizes. The study also adjusted models for additional plan characteristics, employer and year fixed effects, and census division. Robust standard errors were clustered at the employer level. RESULTS: The sample comprised 30,832 plans and 318,334 enrollees. Among enrollees with new enrollment decisions, 24.6 % chose an HDHP; 93.8 % of HDHP enrollees chose to re-enroll in an HDHP. The study found the presence of a plan HRA to be associated with a higher probability of new and re-enrollment in an HDHP. We found that older enrollees with SUD were less likely to newly enroll in an HDHP, while enrollees who were non-White, living in lower-income census blocks, and living in lower educational attainment census blocks were more likely to newly enroll in an HDHP. Higher levels of health care utilization in the prior year were associated with a lower probability of newly enrolling in an HDHP but associated with a higher probability of re-enrolling. CONCLUSION: Given the emerging evidence that HDHPs may discourage SUD treatment, greater HDHP enrollment could exacerbate health disparities.

The Effects of High Deductible Health Plans on Breast Cancer Treatment and Reconstruction.

BACKGROUND: High-deductible health plans (HDHP) have expanded rapidly creating the potential for substantially increased out-of-pocket (OOP) costs. The associated financial strain has been associated with the decision to forego care, but the impact on patients undergoing breast cancer reconstruction is not known. We examined the impact of HDHPs vs. LDHPs and OOP maximums on breast reconstruction. METHODS: Between January 2014 and 2020, patients who had breast reconstruction by the 2 senior authors were retrospectively evaluated. Information on patient's insurance contract was collected. Criteria for HDHP and LDHP were defined following section 223(c)(2)(A) of the Internal Revenue Code. All aspects of cancer diagnosis, cancer treatment, and surgical procedures were reviewed. RESULTS: About 507 patients (262 in LDHPs and 245 in HDHPs) were reviewed. Patients treated with neoadjuvant chemotherapy were more likely to be enrolled in HDHPs (25.7% vs. 36.8%, P < .01). There was no significant difference in total operations, number of revisions, or length of reconstruction in days or calendar years. Additionally, no difference existed in the choice of autologous implant reconstruction. CONCLUSION: The cost-sharing burden of HDHPs creates the potential for patients to forego care, and thus, effort should be directed toward increasing patient education concerning health plan benefits. Utilization of postdeductible spending, as well as resources of health savings accounts, may limit the adverse effects of HDHPs. This study also emphasizes the importance for providers to increase cost transparency.

Association of High-Deductible Health Plans With Health Care Use and Costs for Patients With Cardiovascular Disease.

Background By increasing cost sharing, high-deductible health plans (HDHPs) aim to reduce low-value health care use. The association of HDHPs with health care use and costs in patients with chronic cardiovascular disease is unknown. Methods and Results This longitudinal cohort study analyzed 57 690 privately insured patients, aged 18 to 64 years, from a large commercial claims database with chronic cardiovascular disease from 2011 to 2019. Health care entities in which all or most beneficiaries switched from being in a traditional plan to an HDHP were identified. A difference-in-differences design was used to account for differences between individuals who remained in traditional plans and those who switched to HDHPs and to assess changes in health care use and costs. Among the 934 individuals in the HDHP group and the 56 756 in the traditional plan group, switching to an HDHP was not associated with statistically significant changes in annual outpatient visits, hospitalizations, or emergency department visits (-8.3% [95% CI, -16.8 to 1.1], -28.5% [95% CI, -62.1 to 34.6], and 11.2% [95% CI, -20.9 to 56.5], respectively). Switching to an HDHP was associated with an increase of $921 (95% CI, $743-$1099) in out-of-pocket costs but no statistically significant difference in total health care costs. Conclusions Among commercially insured patients with chronic cardiovascular disease, switching to an HDHP was not associated with a change in health care use but was associated with an increase in out-of-pocket costs. Although health care use by individuals with chronic cardiovascular disease may not be sensitive to higher cost sharing associated with HDHP enrollment, there may be a significant increase in patients' financial burden.

Individuals Eligible for Lung Cancer Screening Less Likely to Receive Screening When Enrolled in Health Plans With Deductibles.

BACKGROUND: In 2015, the Centers for Medicare & Medicaid Services and commercial insurance plans began covering lung cancer screening (LCS) without patient cost-sharing for all plans. We explore the impact of enrolling into a deductible plan on the utilization of LCS services despite having no out-of-pocket cost requirement. METHODS: This retrospective study analyzed data from the Population-based Research to Optimize the Screening Process Lung Consortium. Our cohort included non-Medicare LCS-eligible individuals enrolled in managed care organizations between February 5, 2015, and February 28, 2019. We estimate a series of sequential logistic regression models examining utilization across the sequence of events required for baseline LCS. We report the marginal effects of enrollment into deductible plans compared with enrollment in no-deductible plans. RESULTS: The total effect of deductible plan enrollment was a 1.8 percentage-point (PP) decrease in baseline LCS. Sequential logistic regression results that explore each transition separately indicate deductible plan enrollment was associated with a 4.3 PP decrease in receipt of clinician visit, a 1.7 PP decrease in receipt of LCS order, and a 7.0 PP decrease in receipt of baseline LCS. Reductions persisted across all observable races and ethnicities. CONCLUSIONS: These findings suggest individuals enrolled in deductible plans are more likely to forgo preventive LCS services despite requiring no out-of-pocket costs. This result may indicate that increased cost-sharing is associated with suboptimal choices to forgo recommended LCS. Alternatively, this effect may indicate individuals enrolling into deductible plans prefer less health care utilization. Patient outreach interventions at the health plan level may improve LCS.

Utilization and Spending With Preventive Drug Lists for Asthma Medications in High-Deductible Health Plans.

Importance: High-deductible health plans with health savings accounts (HDHP-HSAs) incentivize patients to use less health care, including necessary care. Preventive drug lists (PDLs) exempt high-value medications from the deductible, reducing out-of-pocket cost sharing; the associations of PDLs with health outcomes among patients with asthma is unknown. Objective: To evaluate the associations of a PDL for asthma medications on utilization, adverse outcomes, and patient spending for HDHP-HSA enrollees with asthma. Design, Setting, and Participants: This case-control study used matched groups of patients with asthma before and after an insurance design change using a national commercial health insurance claims data set from 2004-2017. Participants included patients aged 4 to 64 years enrolled for 1 year in an HDHP-HSA without a PDL in which asthma medications were subject to the deductible who then transitioned to an HDHP-HSA with a PDL that included asthma medications; these patients were compared with a matched weighted sample of patients with 2 years of continuous enrollment in an HDHP-HSA without a PDL. Models controlled for patient demographics and asthma severity and were stratified by neighborhood income. Analyses were conducted from October 2020 to June 2023. Exposures: Employer-mandated addition of a PDL that included asthma medications to an existing HDHP-HSA. Main Outcomes and Measures: Outcomes of interest were utilization of asthma medications on the PDL (controllers and albuterol), asthma exacerbations (oral steroid bursts and asthma-related emergency department use), and out-of-pocket spending (all and asthma-specific). Results: A total of 12 174 participants (mean [SD] age, 36.9 [16.9] years; 6848 [56.25%] female) were included in analyses. Compared with no PDL, PDLs were associated with increased rates of 30-day fills per enrollee for any controller medication (change, 0.10 [95% CI, 0.03 to 0.17] fills per enrollee; 12.9% increase) and for combination inhaled corticosteroid long-acting ß2-agonist (ICS-LABA) medications (change, 0.06 [95% CI, 0.01 to 0.10] fills per enrollee; 25.4% increase), and increased proportion of days covered with ICS-LABA (6.0% [0.7% to 11.3%] of days; 15.6% increase). Gaining a PDL was associated with decreased out-of-pocket spending on asthma care (change, -$34 [95% CI, -$47 to -$21] per enrollee; 28.4% difference), but there was no significant change in asthma exacerbations and no difference in results by income. Conclusions and Relevance: In this case-control study, reducing cost-sharing for asthma medications through a PDL was associated with increased adherence to controller medications, notably ICS-LABA medications used by patients with more severe asthma, but was not associated with improved clinical outcomes. These findings suggest that PDLs are a potential strategy to improve access and affordability of asthma care for patients in HDHP-HSAs.

Minimum generosity levels in a competitive health insurance market.

An important condition for optimal health insurance is that the level of health care coverage is inversely related to the elasticity of demand. We show that this condition is not satisfied for voluntary deductibles in the Netherlands, which are optional deductibles on top of the mandatory deductible introduced by the Dutch government. We find that low-risk types, that mainly choose voluntary deductibles, have a lower elasticity of demand than high-risk types. Moreover, we show that voluntary deductibles introduce equity problems as it results in non-trivial cross subsidies from high-risk to low-risk types. Capping the level of voluntary deductibles (imposing minimum generosity) is likely to be welfare enhancing in the Netherlands.

High-deductible Health Plans and Nonfatal Opioid Overdose.

OBJECTIVES: Opioid-related overdose is a public health emergency in the United States. Meanwhile, high-deductible health plans (HDHPs) have become more prevalent in the United States over the last 2 decades, raising concern about their potential for discouraging high-need populations, like those with opioid use disorder (OUD), from engaging in care that may mitigate the probability of overdose. This study assesses the impact of an employer offering an HDHP on nonfatal opioid overdose among commercially insured individuals with OUD in the United States. RESEARCH DESIGN: We used deidentified insurance claims data from 2007 to 2017 with 97,788 person-years. We used an intent-to-treat, difference-in-differences regression framework to estimate the change in the probability of a nonfatal opioid overdose among enrollees with OUD whose employers began offering an HDHP insurance option during the study period compared with the change among those whose employer never offered an HDHP. We also used an event-study model to account for dynamic time-varying treatment effects. RESULTS: Across both comparison and treatment groups, 2% of the sample experienced a nonfatal opioid overdose during the study period. Our primary model and robustness checks revealed no impact of HDHP offer on the probability of a nonfatal overdose. CONCLUSIONS: Our study suggests that HDHP offer was not associated with an observed increase in the probability of nonfatal opioid overdose among commercially insured person-years with OUD. However, given the strong evidence that medications for OUD (MOUD) can reduce the risk of overdose, research should explore which facets of insurance design may impact MOUD use.

Does Being Poor and Sick Modify the Effect of Individuals on High-Deductible Health Plan (HDHP) Reporting Delayed/Foregone Care?

OBJECTIVE: To assess the influence of being both poor and sick on the association of high-deductible health plans (HDHPs) with delayed/forgone care. FINDINGS: In this cross-sectional study that included 14,203 respondents, representing 120 million Americans, individuals insured by HDHPs had 2.23 times the odds of delayed/foregone care compared with non-HDHP insureds. When examined across strata of income and health status, the association yielded similar odds of delayed/foregone care. Additionally, the interaction of being poor and sick on the association of HDHPs to delayed/foregone care was not statistically significant. Meaning. Being insured on a HDHP affected delayed/foregone care largely consistently, regardless of health, income, or combined health/income category.

Do High-Deductible Health Plans Incentivize Changing the Timing of Substance Use Disorder Treatment?

A high-deductible health plan (HDHP) may incentivize enrollees to limit health care use at the beginning of a plan year, when they are responsible for 100% of costs, or to increase the use of care at the end of the year, when enrollees may have less cost exposure. We investigated both the impact of the deductible reset that occurs at the beginning of a plan year and the option to enroll in an HDHP on the use of substance use disorder (SUD) treatment services over the course of a health plan year. We found decreases in SUD treatment use following the increase in cost exposure related to a deductible reset. There was no variation in this behavior between HDHP offer enrollees and comparison enrollees who were not offered an HDHP. These findings reinforce that cost-sharing poses a barrier to SUD care and continuity of care, which can increase the risk of adverse clinical outcomes.

High Deductible Health Plans and Use of Free Preventive Services Under the Affordable Care Act.

The Affordable Care Act aimed to increase use of preventive services by eliminating cost-sharing to consumers. However, patients may be unaware of this benefit or they may not seek preventive services if they anticipate that the cost of potential diagnostic or treatment services will be too high, both more likely among those in high deductible health plans. We used nationally representative private health insurance claims (100% sample of IBM® MarketScan®) for the United States from 2006 to 2018, restricting the data to enrollment and claims for non-elderly adults who were enrolled for the full plan year. The cross-sectional sample (185 million person-years) is used to describe trends in preventive service use and costs from 2008 through 2016. The cohort sample (9 million people) focuses on the elimination of cost-sharing for certain high-value preventive services in late 2010, requiring continuous enrollment across 2010 and 2011. We examine whether HDHP enrollment is associated with use of eligible preventive services using semi-parametric difference-in-differences to account for endogenous plan selection. Our preferred model implies that HDHP enrollment was associated with a reduction of the post-ACA change in any use of eligible preventive services by 0.2 percentage points or 12.5%. Cancer screenings were unaffected but HDHP enrollment was associated with smaller increases in wellness visits, immunizations, and screening for chronic conditions and sexually transmitted infections. We also find that the policy was ineffective at reducing out-of-pocket costs for the eligible preventive services, likely due to implementation issues.

Impact of High Deductible Health Plans on U.S. Adults With Chronic Pain.

INTRODUCTION: Chronic pain affects an estimated 20% of U.S. adults. Because high-deductible health plans have captured a growing share of the commercial insurance market, it is unknown how high-deductible health plans impact care for chronic pain. METHODS: Using 2007-2017 claims data from a large national commercial insurer, statistical analyses conducted in 2022-2023 estimated changes in enrollee outcomes before and after their firm began offering a high-deductible health plan compared with changes in outcomes in a comparison group of enrollees at firms never offering a high-deductible health plan. The sample included 757,530 commercially insured adults aged 18-64 years with headache, low back pain, arthritis, neuropathic pain, or fibromyalgia. Outcomes, measured at the enrollee year level, included the probability of receiving any chronic pain treatment, nonpharmacologic pain treatment, and opioid and nonopioid prescriptions; the number of nonpharmacologic pain treatment days; number and days' supply of opioid and nonopioid prescriptions; and total annual spending and out-of-pocket spending. RESULTS: High-deductible health plan offer was associated with a 1.2 percentage point reduction (95% CI= -1.8, -0.5) in the probability of any chronic pain treatment and an $11 increase (95% CI=$6, $15) in annual out-of-pocket spending on chronic pain treatments among those with any use, representing a 16% increase in average annual out-of-pocket spending over the pre-high deductible health plan offer annual average. Results were driven by changes in nonpharmacologic treatment use. CONCLUSIONS: By reducing the use of nonpharmacologic chronic pain treatments and marginally increasing out-of-pocket costs among those using these services, high-deductible health plans may discourage more holistic, integrated approaches to caring for patients with chronic pain conditions.