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High-Deductible Health Plans Detrimental for Those With Diabetes

Individuals with diabetes who are forced to switch to high-deductible health plans have more episodes of severe hypo- and hyperglycemia than those on conventional insurance plans, according to a new study.

Previous studies have shown that people with diabetes who are enrolled in high-deductible health plans (HDHPs) have an increased financial burden, lower medication adherence, and more low-severity emergency department visits, and they delay care for cardiovascular conditions.  

But no study has looked at the plans’ impact on acute diabetes complications and glycemic control, write the authors in JAMA Network Open.

They found evidence that the high-dollar plans were associated with increased odds of severe hypoglycemic and hyperglycemic events, and that the risk increased with each successive year of enrollment. Low-income individuals, Blacks, and Hispanics were disproportionately more impacted, noted senior author Rozalina G. McCoy, MD, Mayo Clinic in Rochester, Minnesota, and colleagues.

Overall, “enrollees may be rationing or foregoing necessary care, which is detrimental to their health and ultimately increases the morbidity, mortality, and costs associated with diabetes,” they conclude.

A systematic review of eight studies published in Endocrine Practice in 2021 back up this latest finding. That analysis reported enrollees in HDHPs often forego routine care and monitoring, and that they have lower medication adherence, leading to an increase in total healthcare expenditures for emergency department visits, hospitalizations, and preventable complications.

Increased Frequency of Hypoglycemia Is Detrimental

The new study published in JAMA Network Open was based on data for adults enrolled in private insurance programs from 2010 to 2018. Researchers analyzed medical and pharmacy claims data contained in a large health insurance claims database, comparing adults with diabetes who had been in an HDHP for at least 1 year (and after a year of being in a conventional plan), with those who were in a conventional plan.

They identified 42,326 individuals who had been switched from a conventional plan to an HDHP. Of those, 7375 (17.4%) were Black, 5740 (13.6%) were Hispanic, 26,572 (62.8%) were non-Hispanic White, and 6880 (16.3%) had a household income below $40,000 a year.

Baseline characteristics of the 202,729 people in conventional plans were similar to those in the HDHP group. 

The median deductible for individuals in the HDHP group was $1500 and for families it was $3000, compared with $350 and $800, respectively, for those in conventional plans.

The odds of having any severe hypoglycemic event were significantly higher in the HDHP group (odds ratio [OR], 1.11; P < .001). Each year of HDHP enrollment increased the odds of a hypoglycemia-related ED or hospital visit by 2% (OR, 1.02; P = .04).  

Aware that only a small number of severe hypoglycemic events, as well as an unknown number of such events, result in an emergency department visit or hospitalization, and that “the decision to seek ED or hospital care may be influenced by health plan assignment,” the authors also looked at office visits where severe, or any, hypoglycemia or hyperglycemia was coded or documented.

The proportion of HDHP enrollees where hypoglycemia was coded was 14% higher than for conventional plan enrollees (OR, 1.14; P < .001), with each year of the high-dollar plan enrollment increasing these odds by 6% (OR, 1.06; P < .001).

The tally of hypoglycemic events is an underestimate because HDHP enrollees might “forego ambulatory care for cost-related reasons,” write the authors. Hypoglycemia might also be treated at home. But that is not necessarily a positive, they note.

“The increased frequency of severe hypoglycemia — no matter where managed and discussed — is a sign of detrimental effects of HDHP enrollment for people living with diabetes.”

They found that individuals of racial and ethnic minorities were less likely than White patients to have an increase in hypoglycemia-related office visits, which suggests that those patients were deferring care, write McCoy and colleagues.

Switching to an HDHP was associated with a significant increase in the odds of having at least one hyperglycemia-related ED or hospital visit per year (OR, 1.25; P < .001). Each successive year in the plan increased these odds by 5% (OR, 1.05; P = .02). However, the authors found no increase in hyperglycemia-related office visits.

“Because severe dysglycemic events may be prevented with optimal glycemic management, the increase in the frequency of their occurrence suggests important gaps in access to and implementation of diabetes therapy,” write the authors.

They note that people with diabetes already face high out-of-pocket expenses. A high-deductible plan might make care even less affordable, they write.

“Individuals may be forced to ration medications, glucose-monitoring supplies, diabetes self-management education, food, and other essential cares to the detriment of their health,” they note.

The authors add that because the study was observational, they could not delve into the root causes of the glycemic events or whether, for instance, any HDHP enrollees also had health savings accounts (HSAs) that might help defray costs.

They suggest that employers offer a wide variety of health plans, or if they are only offering a high-deductible plan that they be more transparent about potential costs. “Previous studies have shown that enrollees are not fully aware of the details within their health plans and may be focusing on reducing the cost of monthly premiums — not overall care — when choosing health plans.”

The authors also said employers should find ways to fund HSAs for people with low incomes — those who appear to be most vulnerable to the effects of HDHPs. 

A study published in JAMA Internal Medicine in 2017 found that low-income and HSA-eligible individuals with diabetes switched to an HDHP had major increases in emergency department visits for preventable acute diabetes complications.

The study was funded by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the Mayo Clinic K2R Research Award, and the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. McCoy has reported receiving grants from the NIDDK, grants from AARP, grants from the Patient-Centered Outcomes Research Institute, and personal fees from Emmi for the development of patient education materials about diabetes outside the submitted work.

JAMA Netw Open. Published online January 20, 2023. Full text

Alicia Ault is a Lutherville, Maryland-based freelance journalist whose work has appeared in publications including JAMA,, The New York Times, and The Washington Post. You can find her on Twitter: @aliciaault.

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