How do higher deductibles impact care for chronic disease?

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Out-of-pocket costs with high deductible health plans may discourage some poor and chronically ill patients from getting needed care, a U.S. study of diabetics suggests.

Researchers examined data on about 12,000 people with diabetes who enrolled for one year in health insurance plans with annual deductibles of no more than $500, then switched for two years to plans with a deductible of at least $1,000.

Overall, the switch to insurance with higher out-of-pocket costs wasn't tied to meaningful changes in how often these diabetics got outpatient checkups or tests to monitor their disease, researchers report in JAMA Internal Medicine.

But after the switch, emergency department visits for preventable diabetes complications spiked for poor patients.

"The majority of diabetes patients enrolling in high-deductible plans did not experience the adverse health outcomes we measured, but vulnerable subgroups such as those with low incomes or additional chronic conditions had evidence of adverse outcomes such as increased emergency department visits for acute complications," said study leader Dr. Frank Wharam, a health policy researcher at Harvard University in Boston.

"Our results indicate that more tailored health insurance plans might be needed," Wharam added by email.

High-deductible health plans have been increasing over the last decade and are now the most common form of private health insurance, Wharam said. He expects these plans to be a centerpiece of efforts by U.S. president-elect Donald Trump to replace Obamacare, or the Affordable Care Act.

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In high-deductible plans, primary care check-ups tend to have lower costs, but patients typically pay more for things like specialists, emergency department visits and hospital care.

The theory is that patients with these plans will think more carefully about whether they need care when they're spending more of their own money. Ideally, this would motivate patients to only get the care they need and skip expensive services that aren't proven to work, such as unnecessary MRIs for uncomplicated low back pain.

In the diabetes study, annual emergency department visits rose by 8 percent overall after people switched to high-deductible plans but climbed 22 percent for poor patients.

A separate study in the same issue of the journal, however, found somewhat different results: chronically ill patients with high-deductible plans were no more likely to delay or skip care due to out-of-pocket costs than people in low deductible plans.

For this study, researchers examined nationally representative data collected from 2011 to 2013 on nearly 17,000 individuals, including 4,120 people with high deductibles, 7,767 with low deductibles and 5,290 with no deductible.

Overall, 7,639 study participants had at least one chronic illness, such as diabetes, heart disease, high blood pressure, asthma, joint disease, cancer or mental health disorders.

While high-deductible plans were associated with greater out-of-pocket costs than low-deductible options, this didn't translate into more frequent delayed or skipped care.

"Patients who decide to skip or delay necessary care . . . risk serious and costly complications," said study co-author Dr. Joel Segel of Pennsylvania State University in University Park.

"This is why it is really important for patients who have a lot of `skin in the game' to work with their providers to figure out which care they need and which care they don't, and for providers to be aware of the implications of deductibles for their patients with chronic conditions," Segel added by email.

One fix would be to create health plans that have lower out-of-pocket costs for "high-value" care, or interventions that are Dr. Mark Fendrick of the University of Michigan argues in an editorial accompanying the studies.

"We support an educated and engaged consumer, but do not feel that financial barriers should be used to deter patients from necessary care," Fendrick said by email.

"Instead, in the high value health plan, consumer out of pocket costs (would be) linked to the clinical benefit of the service," Fendrick added. "Low out of pocket costs for high value services, high out of pocket costs for services that do not improve health."