Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA.
Diabetes Care. 2018 May;41(5):940-948. doi: 10.2337/dc17-1183. Epub 2018 Jan 30.
High-deductible health plans (HDHPs) are now the predominant commercial health insurance benefit in the U.S. We sought to determine the effects of HDHPs on emergency department and hospital care, adverse outcomes, and total health care expenditures among patients with diabetes.
We applied a controlled interrupted time-series design to study 23,493 HDHP members with diabetes, aged 12-64, insured through a large national health insurer from 2003 to 2012. HDHP members were enrolled for 1 year in a low-deductible (≤$500) plan, followed by 1 year in an HDHP (≥$1,000 deductible) after an employer-mandated switch. Patients transitioning to HDHPs were matched to 192,842 contemporaneous patients whose employers offered only low-deductible coverage. HDHP members from low-income neighborhoods ( = 8,453) were a subgroup of interest. Utilization measures included emergency department visits, hospitalizations, and total (health plan plus member out-of-pocket) health care expenditures. Proxy health outcome measures comprised high-severity emergency department visit expenditures and high-severity hospitalization days.
After the HDHP transition, emergency department visits declined by 4.0% (95% CI -7.8, -0.1), hospitalizations fell by 5.6% (-10.8, -0.5), direct (nonemergency department-based) hospitalizations declined by 11.1% (-16.6, -5.6), and total health care expenditures dropped by 3.8% (-4.3, -3.4). Adverse outcomes did not change in the overall HDHP cohort, but members from low-income neighborhoods experienced 23.5% higher (18.3, 28.7) high-severity emergency department visit expenditures and 27.4% higher (15.5, 39.2) high-severity hospitalization days.
After an HDHP switch, direct hospitalizations declined by 11.1% among patients with diabetes, likely driving 3.8% lower total health care expenditures. Proxy adverse outcomes were unchanged in the overall HDHP population with diabetes, but members from low-income neighborhoods experienced large, concerning increases in high-severity emergency department visit expenditures and hospitalization days.
高自付额健康计划（HDHPs）目前是美国主要的商业健康保险福利。我们旨在确定 HDHPs 对糖尿病患者的急诊和医院护理、不良结果以及总医疗保健支出的影响。
我们应用控制的中断时间序列设计，对 2003 年至 2012 年期间通过一家大型全国健康保险公司投保的 23,493 名年龄在 12-64 岁之间的 HDHP 糖尿病患者进行了研究。HDHP 成员在低免赔额（≤$500）计划中注册了一年，然后在雇主强制转换后在 HDHP（≥$1,000 免赔额）中注册了一年。转向 HDHPs 的患者与 192,842 名同期仅提供低免赔额保险的雇主的患者相匹配。（=8453）的低收入社区的 HDHP 成员是一个感兴趣的亚组。利用措施包括急诊就诊、住院和总（健康计划加成员自付额）医疗保健支出。代理健康结果指标包括高严重程度的急诊就诊支出和高严重程度的住院天数。
在 HDHP 转换后，急诊就诊减少了 4.0%（95%CI-7.8，-0.1），住院减少了 5.6%（-10.8，-0.5），直接（非急诊就诊）住院减少了 11.1%（-16.6，-5.6），总医疗保健支出下降了 3.8%（-4.3，-3.4）。整体 HDHP 队列中的不良结果没有变化，但来自低收入社区的成员经历了 23.5%（18.3，28.7）更高的高严重程度急诊就诊支出和 27.4%（15.5，39.2）更高的高严重程度住院天数。
在 HDHP 转换后，糖尿病患者的直接住院减少了 11.1%，可能导致总医疗保健支出降低 3.8%。在整体 HDHP 糖尿病患者人群中，代理不良结果没有变化，但来自低收入社区的成员经历了高严重程度急诊就诊支出和住院天数的大幅增加，令人担忧。
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