Diabetes Outpatient Care and Acute Complications before and after High-deductible Insurance Enrollment ; JAMA Intern Med

Importance ; Effects of modern high-deductible health plans (HDHP) on chronically ill patients and adverse outcomes are unknown. ; Objective ; Determine HDHP effects on high-priority diabetes outpatient care and preventable acute complications. ; Design ; Controlled interrupted-time-series. ; Setting ; A large national health insurer from 2003–2012. ; Participants ; 12,084 HDHP members with diabetes age 12–64. HDHP members were enrolled for one year in a low-deductible (≤$500) plan followed by two years in a HDHP (≥$1000) after an employer-mandated switch. 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) diabetes patients were subgroups of interest. ; Exposure ; Employer-mandated HDHP transition. ; Main Outcomes and Measures ; High-priority outpatient visits, disease monitoring tests, and outpatient and emergency department visits for preventable acute diabetes complications. ; Results ; The overall, low-income, and HSA-eligible diabetes HDHP groups experienced increases in out-of-pocket medical expenditures of 49.4% (40.3%,58.4%), 51.7% (38.6%,64.7%), and 67.8% (47.9%,87.8%), respectively, relative to 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 while high-priority specialist visits declined by 5.5% (−9.6%,−1.5%) and 7.1% (−11.5%,−2.7%) in follow-up years 1 and 2 versus baseline, respectively. Outpatient acute diabetes complication visits were delayed in the overall and low-income HDHP cohorts at follow-up (adjusted hazard ratios: 0.94 [0.88,0.99] and 0.89 [0.81,0.98], respectively). The overall, low-income, and HSA-eligible diabetes HDHP groups experienced increased emergency department acute complication visits of 8.0% (4.6%,11.4%), 21.7% (14.5%,28.9%), and 15.5% (10.5%,20.6%) per year, respectively. ...