title: Diabetes Outpatient Care and Acute Complications Before and After High-Deductible Insurance Enrollment: A Natural Experiment for Translation in Diabetes (NEXT-D) Study.
abstract: High-deductible health plans (HDHPs) have expanded under the Affordable Care Act and are expected to play a major role in the future of US health policy. The effects of modern HDHPs on chronically ill patients and adverse outcomes are unknown.
  
  
  
  To determine the association of HDHP with high-priority diabetes outpatient care and preventable acute complications.
  
  
  
  Controlled interrupted-time-series study using a large national health insurer database from January 1, 2003, to December 31, 2012. A total of 12 084 HDHP members with diabetes, aged 12 to 64 years, who were enrolled for 1 year in a low-deductible (≤$500) plan followed by 2 years in an HDHP (≥$1000) after an employer-mandated switch were included. Patients transitioning to HDHPs were propensity-score matched with contemporaneous patients whose employers offered only low-deductible coverage. Low-income (n = 4121) and health savings account (HSA)-eligible (n = 1899) patients with diabetes were subgroups of interest. Data analysis was performed from February 23, 2015, to September 11, 2016.
  
  
  
  Employer-mandated HDHP transition.
  
  
  
  High-priority outpatient visits, disease monitoring tests, and outpatient and emergency department visits for preventable acute diabetes complications.
  
  
  
  In the 12 084 HDHP members included after the propensity score match, the mean (SD) age was 50.4 (10.0) years; 5410 of the group (44.8%) were women. The overall, low-income, and HSA-eligible diabetes HDHP groups experienced increases in out-of-pocket medical expenditures of 49.4% (95% CI, 40.3% to 58.4%), 51.7% (95% CI, 38.6% to 64.7%), and 67.8% (95% CI, 47.9% to 87.8%), respectively, compared with controls in the year after transitioning to HDHPs. High-priority primary care visits and disease monitoring tests did not change significantly in the overall HDHP cohort; however, high-priority specialist visits declined by 5.5% (95% CI, -9.6% to -1.5%) in follow-up year 1 and 7.1% (95% CI, -11.5% to -2.7%) in follow-up year 2 vs baseline. Outpatient acute diabetes complication visits were delayed in the overall and low-income HDHP cohorts at follow-up (adjusted hazard ratios, 0.94 [95% CI, 0.88 to 0.99] for the overall cohort and 0.89 [95% CI, 0.81 to 0.98] for the low-income cohort). Annual emergency department acute complication visits among HDHP members increased by 8.0% (95% CI, 4.6% to 11.4%) in the overall group, 21.7% (95% CI, 14.5% to 28.9%) in the low-income group, and 15.5% (95% CI, 10.5% to 20.6%) in the HSA-eligible group.
  
  
  
  Patients with diabetes experienced minimal changes in outpatient visits and disease monitoring after an HDHP switch, but low-income and HSA-eligible HDHP members experienced major increases in emergency department visits for preventable acute diabetes complications.
authors.affiliation: Harvard Medical School and Harvard Pilgrim Health Care Institute, Department of Population Medicine, Boston, Massachusetts.
authors.forename: J Frank
authors.initials: JF
authors.lastname: Wharam
authors.affiliation: Harvard Medical School and Harvard Pilgrim Health Care Institute, Department of Population Medicine, Boston, Massachusetts.
authors.forename: Fang
authors.initials: F
authors.lastname: Zhang
authors.affiliation: Harvard Medical School and Harvard Pilgrim Health Care Institute, Department of Population Medicine, Boston, Massachusetts.
authors.forename: Emma M
authors.initials: EM
authors.lastname: Eggleston
authors.affiliation: Harvard Medical School and Harvard Pilgrim Health Care Institute, Department of Population Medicine, Boston, Massachusetts.
authors.forename: Christine Y
authors.initials: CY
authors.lastname: Lu
authors.affiliation: Harvard Medical School and Harvard Pilgrim Health Care Institute, Department of Population Medicine, Boston, Massachusetts.
authors.forename: Stephen
authors.initials: S
authors.lastname: Soumerai
authors.affiliation: Harvard Medical School and Harvard Pilgrim Health Care Institute, Department of Population Medicine, Boston, Massachusetts.
authors.forename: Dennis
authors.initials: D
authors.lastname: Ross-Degnan
mesh_terms: D000293:Adolescent; D000328:Adult; D000553:Ambulatory Care / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data; D003669:Deductibles and Coinsurance / Q000639:trends; D048909:Diabetes Complications / Q000191:economics / Q000628:therapy; D003920:Diabetes Mellitus / Q000191:economics / Q000453:epidemiology / Q000628:therapy; D004608:Eligibility Determination / Q000379:methods; D005260:Female; D006264:Health Benefit Plans, Employee / Q000191:economics / Q000458:organization & administration / Q000639:trends; D006801:Humans; D065186:Interrupted Time Series Analysis; D008297:Male; D008875:Middle Aged; D014481:United States / Q000453:epidemiology