High-Deductible Plans Lead Diabetics to Forgo, Delay Treatment

November 27, 2018 - Workers with diabetes who switched to high-deductible health plans requiring additional out-of-pocket expenses are more apt to put off necessary check-ups, a new Annals of Internal Medicine study finds.

A growing proportion of Americans — including those with diabetes — have high-deductible health insurance plans in which they must pay up to about $1,000 to $7,000 out-of-pocket yearly if they use healthcare services, researchers note. The out-of-pocket costs of those who converted to higher-deductible plans jumped by an average of 43 percent to 53 percent compared to those who remained in low-deductible plans throughout the study.

However, studies up to now haven’t clearly shown how this added cost might impact the degree to which people use healthcare.

Following the discovery of a major symptom or complications during the study (e.g., leg pain), those who shifted to high-deductible plans were six percent less likely to seek treatment, nine percent less likely to obtain the first diagnostic test they needed, and nine percent less likely to undergo procedures for treatment of these complications.

“We found that delays or reductions in care for cardiovascular disease persisted over a relatively long follow-up and occurred even for services that are used for life-threatening conditions,” said lead author Frank Wharam, MB, BCh, BAO, MPH, of Harvard Medical School and Harvard Pilgrim Health Care Institute in Boston.

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While the study did not researcher whether or how costs might have played a part in how long patients waited to obtain necessary exams, lab tests, or treatments, money likely played a role, Wharam said by email.

“We can speculate that diabetes patients’ knowledge of the high cost of care, and a desire to save money, led to these patterns,” Wharam said.

“Someone whose care is free because insurance covers it would be more likely to seek care at the first sign of a symptom,” added Mark Pauly, PhD, of the Wharton School and the Perelman School of Medicine at the University of Pennsylvania.

Between 2003 and 2012, a single large health insurance company in the United States provided all of the patients in the study with employer-sponsored health insurance. What’s more, in any given year, their employers didn’t offer more than one option for insurance.

The research team was unable to verify why patients may have chosen to delay needed care. Consequently, it was impossible to prove whether increased costs were partially or completely responsible, the authors noted.

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“I am not aware of any rigorous studies that ask about motives and thought processes, but the economic model would suggest that a person who would have to pay more would delay care for mild symptoms that might resolve on their own,” said Pauly.

Researchers examined data on almost 34,000 people with diabetes. Initially, they had employer-sponsored health plans with deductibles of a maximum of $500 — that is, until their employers switched to offering only plans with deductibles of at least $1,000. The team also looked at a comparison group of almost 295,000 workers with diabetes who consistently had deductibles of $500 or less.

Before the first group switched to higher deductible health plans, there were no meaningful differences between the groups in how long patients waited to get care for complications that can be life-threatening without timely treatment, the study found.

However, over the four years after some employers switched to offering only high-deductible plans, the patients on these plans waited an average of 1.5 months longer than people on low-deductible plans to seek care for new symptoms of cardiovascular complications associated with diabetes, 1.9 months longer for diagnostic tests, and 3.1 months longer for medical procedures to treat these complications.

Consumer-directed care, high-deductible health plans (HDHPs), and financial benefits related to healthcare spending have increased in popularity and demand by employees from 2017 to 2018, HealthPayerIntelligence.com recently reported.

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The State of Employee Benefits Report found that 70 percent of employers offered their employees at least one high-deductible health plan and have increased other financial benefits that support cost-effective healthcare decision making.

The authors of the report contend that employers feel an urgency to combat rising care costs through consumer-directed health plan features that put cost-effective healthcare decision making into employees’ hands.

“When it comes to employee benefits, today’s employers are tasked with balancing their need to rein in health care spending with their ability to attract, engage and retain top talent,” the report said.

“As the job market becomes more competitive and the workforce becomes more diverse, focusing on plan fit — the degree to which employees’ benefits align with their unique health and financial needs — is crucial to controlling costs without compromising coverage.”

Last year, the National Center for Health Statistics found a double-digit increase in the use of high-deductible employer health plans, which placed a heightened economic strain on members,

Prompted by higher out-of-pocket costs, beneficiaries reported struggling to pay medical bills, or postponing or failing to obtain care.

In 2016, nearly four in ten adults were enrolled in an employer-based high deductible health plan, according to preliminary data from the National Health Interview Survey. Enrollment in employer-based high deductible health plans shot-up 10 percent between 2011 to 2016 from 26.3 to 39.3 percent.

As one of the most prevalent chronic conditions in healthcare, diabetes care cost $245 billion in 2016. Seventy-one percent of diabetes treatment costs ($176 billion) were related to direct healthcare expenses, equating to 20 percent of US healthcare spending.