High-deductible insurance tied to delays in care for diabetics

Diabetics who have transitioned to an employer-mandated, high-deductible insurance plan are significantly more likely to delay healthcare visits for macrovascular symptoms, diagnostic tests and procedures, researchers reported Nov. 20 in the Annals of Internal Medicine.

The study looked at treatment-seeking behavior among 33,957 patients who moved from a low-deductible plan to a high-deductible plan and compared it to the behavior of 294,942 diabetics who remained enrolled in low-deductible plans throughout the study period. Low-deductible plans were defined as $500 or less per person per year, while high-deductible plans required out-of-pocket spending of at least $1,000 per year.

Compared to patients who remained in low-deductible plans, those with greater cost-sharing sought care for the first major symptom of coronary heart disease, peripheral artery disease or macrovascular disease 1.5 months later. They also delayed diagnostic testing for those conditions by 1.9 months and the first procedure-based treatment by 3.1 months.

“The ‘major symptoms’ measure was intended to include conditions that represent recognizable macrovascular disease at a stage where intervention can prevent subsequent major complications and that patients can identify themselves so that they can decide whether to delay care,” wrote Harvard Medical School researchers led by J. Frank Wharam, MB BCh, MPH.

These symptoms included angina, transient ischemic attack, intermittent claudication, lower-limb ulcers and resting ischemic pain, among others. The diagnostic tests included a range of imaging techniques for each disease, while the procedure-based treatments encompassed PCI and coronary artery bypass grafting for coronary heart disease, cerebrovascular endarterectomy and stenting for cerebrovascular disease and arterial angioplasty, thrombectomy and stenting, among others, for peripheral vascular disease.

“Our study indicates that these delays or reductions persisted over a relatively long follow-up and occurred even for services that are used for life-threatening conditions,” Wharam and colleagues wrote. “These findings raise the possibility that patients in high-deductible plans present with more advanced disease; experience more adverse events, such as strokes, myocardial infarctions, and amputations; and have a higher death rate.

“However, previous research found that intermediate health end points were unchanged among persons with high cost sharing, raising the possibility that major adverse outcomes of macrovascular disease will be unchanged.”

To that point, the researchers noted they didn’t examine the health outcomes in each group, only the differences in how long it took patients to seek care. In addition, the findings may not be generalizable to newly insured or newly diagnosed patients or those with extremely high deductibles.

Another limitation, they said, is “our measures did not distinguish appropriate care from unnecessary care, and a proportion of the changes we detected could represent forgoing unnecessary or low-value services.”

Even so, Wharam et al. believe their study should serve as an important warning to policymakers, patients, employers and clinicians.

“We recommend that clinicians and care management teams monitor the type of insurance that patients with diabetes have and consider further outreach and education for those with high-deductible plans,” they wrote. “Until the effects of high-deductible plans on long-term macrovascular complications of diabetes are better understood, policymakers and employers should remain cautious in encouraging uptake of such plans among vulnerable patients with diabetes, especially given recent evidence of adverse short-term health outcomes.”

In a related editorial, Mark V. Pauly, PhD, with the University of Pennsylvania, suggested the delays in seeking care could’ve reflected delays in actually needing care among high-deductible participants.

“Because some people with chronic illness facing such an insurance change would choose to switch jobs, those who remain might have less severe diabetes,” he wrote. “Persons with diabetes in a high-deductible plan might be motivated to adopt healthy behaviors if they know they have to pay for acute events. … So perhaps the longer time to treatment observed by Wharam and colleagues is evidence of better health rather than (or in addition to) a problem with access or a high threshold for care seeking.”

But even considering that potential explanation, Pauly agreed the issues raised by Wharam et al. are worth watching.

“High cost sharing is a powerful tool; the authors prudently recommend caution to employers and policymakers considering high-deductible plans,” he wrote. “One thing is certain: The switch is going to be a bumpy ride.”