Impacts of high-deductible health plans on patients with diabetes: A systematic review of the literature

Highlights

• This review on high-deductible health plans (HDHPs) included 11 studies.

• Diabetic patients in HDHPs might fail treatment adherence and prescription refills.

• Low-income patients in HDHPs use less preventive care and more emergency visits.

Abstract

Background and objectives

High-deductible health plans (HDHPs) as a type of consumer-directed health insurance plan aim to control unnecessary service utilization and share the responsibility in payments and care with the patient. Our objective was to systematically pool the medical and non-medical impacts of HDHPs on patients with diabetes.

Methods

We searched databases, including PubMed, Scopus, Embase, and Wiley, to identify relevant published studies. We outlined the eligibility criteria based on the study population, intervention, comparison, outcome, and types of studies (PICOT). We included peer-reviewed quantitative studies published in English, including quasi-experimental, observational, and cross-sectional studies in this review. We used the narrative data synthesis method to categorize and interpret the results.

Results

Initial search yielded 149 results. After removing duplicates and screening for relevant titles and abstracts, and reviewing full texts, 11 studies met eligibility criteria. Overall, diabetic patients with HDHP were less likely to adhere to treatment and prescription refills, utilize fewer healthcare services and medications, and more likely to have acute emergency visits than their counterparts enrolled in low-deductible plans. However, the results on overall healthcare costs and the final health outcome were unclear.

Conclusions

It appears that HDHPs negatively impact low-income diabetic patients by leading them to forgo preventive and primary care services and experience excessive preventable emergency department visits. The socioeconomic characteristics of patients must be considered when developing HDHP policies, and adjustments should be made to HDHPs accordingly.

Introduction

High deductible health plans (HDHPs) are becoming an increasingly popular insurance plan choice by employers. These plans require greater cost-sharing on the part of consumers and suggest a more cost-effective alternative than traditional health plans. Between 2010 and 2016 alone, enrollment in HDHPs by adults under age 65 increased from 25.3% to 40.0% and, between 2017 and 2018, this percentage rose from 43.7% to 47.0% [1,2]. Consumers enrolled in an HDHP typically have lower monthly premiums coupled with higher deductibles that can range from $1400 for individual coverage to $2800 for family coverage [3]. HDHPs are often linked to a health savings account (HSA) which allows the consumer to save pre-tax income and potentially offset the cost of high deductibles and other medical expenses associated with the HDHP [4]. It is suggested that HDHPs urge consumers to make higher-value decisions about their healthcare expenditures and thereby curb overutilization of healthcare services [5]. However, this suggestion also assumes that consumers can aptly make value-based decisions and simultaneously raises the concern that consumers may delay seeking medical services and interventions they genuinely need. Of particular note is that the high costs associated with HDHPs may cause consumers with chronic conditions to forgo necessary medical services leading to decreased quality of life and increased mortality.

In several studies, HDHP enrollment was associated with a significant reduction in preventative care utilization, office visits, and non-emergency visits [6]. Consumers not only decreased utilization of inappropriate and medically unnecessary healthcare services such as low-risk emergency department visits, but also decreased utilization of high-severity emergency department visits, diagnostic testing, and experienced decreased medication adherence. Although HDHP enrollment was generally associated with decreased costs, more is left to be uncovered on the potential adverse effects of HDHPs on consumers to improve patient outcomes.

In this study, we focused on the impact of HDHPs on patients with a chronic health condition: diabetes. As of 2018, 34.2 million Americans in the United States had diabetes, representing 10.5% of the US population [7]. Diabetes is most prevalent (26.8%) in individuals over the age of 65 and poses a significant cost burden for the US healthcare system [7]. For instance, in 2017, the total direct and indirect estimated costs associated with diagnosed diabetes were $327 billion [7]. Patients with diabetes have an increased risk for health complications such as kidney failure, blindness, heart attacks, strokes, and lower-limb amputations [8]. Adequate disease management is necessary to improve health outcomes and comorbidity-associated complications.

With the rise of HDHPs to the forefront of US health insurance offerings, it is critical to understand how patients with diabetes are impacted by what these health plans have to offer. We reviewed the literature and analyzed how HDHP enrollment impacts medication utilization, use of medical services, and healthcare costs among patients with diabetes. To our knowledge, there is no recent literature review about the effects of HDHP enrollment on patients with diabetes. Through this review, we aim to fill existing knowledge gaps to inform future research and policy.