High-Deductible Health Plans Linked to Greater Risk of Complications from Diabetes, Study Shows

People with diabetes who were involuntarily switched into a high-deductible health plans (HDHPs) experienced twice the rate of eye-related diabetes complications, including blindness, and an increased rate of hospitalizations for heart attack and stroke, according to research results reported today in JAMA Network Open.

Lead author Rozalina G. McCoy, M.S., M.S., an associate professor at the University of Maryland School of Medicine, and her colleagues say their findings fit with the results of other research that shown that people high-deductible health plans skimp on care that is believed to help prevent diabetes complications.

Rozalina G. McCoy, M.D., M.S.

“Although preventive services are generally exempt fromcost sharing, chronic disease management services are not and individuals facing high out-of-pocket cost and deductibles may have to ration, delay or forgo necessary care,” they wrote in the discussion section of the study.

McCoy and many of the same researchers reported findings last year in JAMA Network Open looking at same group of people with diabetes in high-deductible health plans that showed a relationship with enrollment in the high-deductible health plans and an increased risk of hospital or emergency room visits for severe hyperglycemia.

The rate of end-stage kidney disease and lower-extremity complications were also more than double among those who were switched in high-deductible health plans compared those who were not, according to the findings McCoy and her colleagues reported today. They also found thatrisk of diabetes-related complications increased with each additional year of enrollment in a high-deductible health plan, a pattern that McCoy and her colleagues say is perhaps indicative of a cumulative effect of postponed or forgone care.

High-deductible health plans are controversial. Proponents say they encourage patients to be more selective about using healthcare services and shop for lower prices because they are exposed to expenditures. But research by McCoy and others have suggested that the effect on the use of healthcare is not selective. As result, people don’t get care that is designed to prevent complications and keep chronic conditions from getting worse.

McCoy and her colleagues also analyzed some of the interactions of high-deductible health plans with income, ethnicity and race. The results had some complexity to them. For example, the association of enrollment in a high-deductible health plan and hospitalization for heart attack and heart failure was stronger among people with higher incomes ($40,000 annual income and above) than those with lower incomes. They also found that the association between high-deductible high plan enrollment and end-stage kidney disease and proliferative retinopathy (a diabetes-related eye condition) was stronger among Black and Hispanic individuals than among Whites individuals but the association with hospitalization for heart attack was weaker. The data McCoy and her colleagues used did not include deaths, so the focus on hospitalizations for heart attack might be misleading if people in high-deductible health plans died of heart attacks outside the hospital.

Because this is a retrospective, McCoy and her colleagues cautioned that is into possible to draw causal inferences between high-deductible health plans and complications from diabetes. Still, the pattern of the associations is consistent and striking. Their data show that for adults with diabetes, switching to high-deductible health plan was associated with risks:

• 11% increased risk of hospitalization for myocardial infarction (heart attack)
• 15% increased risk of hospitalization for stroke
• 35% increased risk of hospitalization for heart failure
• 253% increased risk for end-stage kidney disease
• 223% increased risk for lower-extremity complication
• 117% increased risk for proliferative retinopathy
• 235% increased risk for blindness
• 228% increased risk for retinopathy

In this study and the one published last year in JAMA Network Open, McCoy and her colleagues compared just over 42,200 adults who were switched high-deductible health plans to just over 200,000 who were not switched. They classified health plans as high-deductible health plans if the deductible was at or above the deductible that would make the members eligible to participate in a health savings account. In 2010, that deductible was $1,200 per individual. It was gradually increased to $1,300 by 2018. To avoid selection bias, McCoy and her colleagues included only people who were involuntarily enrolled in high-deductible health plans in the high-deductible health plan group of their study. To identify involuntary enrollment, they identified all the insurance plans offered by an employer. If all of the plans offered by an employer were high-deductible health plans, the researchers deemed the enrollment involuntary.

The source of all of this data was the OptumLabs Data Warehouse, a database of deidentified administrative claims and electronic health record data maintained by Optum, the health services division of UnitedHealth Group.