Effect of switching to a high-deductible health plan on use of chronic medications

Evaluating Financial Incentives as a Tool to Increase Medication Adherence for Patients with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a common chronic disease with high rates of complications. Although there are successful treatments, rates of medication non-adherence remain high. This study aims to evaluate the impact of financial incentives on medication adherence in people living with T2DM.

METHODS

PubMed, Scopus, and Embase were searched via the terms "medication adherence," "diabetes," and "financial/economic incentive." Data on study characteristics, incentive type, and impact were extracted. The outcome measures included the proportion of days covered (PDC), mean possession ratio (MPR), percent adherent (PDC/MPR > 80%), and others. Two pooled Bayesian meta-analyses were conducted, analyzing the mean differences in PDC or MPR and the percentage of adherent patients (MPR > 80%).

RESULTS

The search yielded 8244 results with 126 full-text articles reviewed. In total, 22 studies that met the inclusion criteria were included. Among these 22 studies, 16 reported that financial incentives significantly increased medication adherence in all, four reported that they did not lead to significant changes in adherence, and two studies reported differing results per subgroup. For the pooled meta-analyses, the effect of financial incentives on percent adherent was significant in three studies (weighted Cohen's D: 0.03, P = 0.02) and in the ten studies assessed PDC/MPR, financial incentives significantly increased adherence (weighted Cohen's D: 0.02, 95%, P < 0.01).

CONCLUSION

This systematic review and meta-analysis demonstrated that financial incentives lead to statistically significant but possibly clinically irrelevant increases in medication adherence for patients living with T2DM.

Did Access to Ambulatory Care Moderate the Associations Between Visit Mode and Ancillary Services Utilization Across the COVID-19 Pandemic Period?

BACKGROUND/OBJECTIVE

In recent years, 2 circumstances changed provider-patient interactions in primary care: the substitution of virtual (eg, video) for in-person visits and the COVID-19 pandemic. We studied whether access to care might affect patient fulfillment of ancillary services orders for ambulatory diagnosis and management of incident neck or back pain (NBP) and incident urinary tract infection (UTI) for virtual versus in-person visits.

METHODS

Data were extracted from the electronic health records of 3 Kaiser Permanente Regions to identify incident NBP and UTI visits from January 2016 through June 2021. Visit modes were classified as virtual (Internet-mediated synchronous chats, telephone visits, or video visits) or in-person. Periods were classified as prepandemic [before the beginning of the national emergency (April 2020)] or recovery (after June 2020). Percentages of patient fulfillment of ancillary services orders were measured for 5 service classes each for NBP and UTI. Differences in percentages of fulfillments were compared between modes within periods and between periods within the mode to assess the possible impact of 3 moderators: distance from residence to primary care clinic, high deductible health plan (HDHP) enrollment, and prior use of a mail-order pharmacy program.

RESULTS

For diagnostic radiology, laboratory, and pharmacy services, percentages of fulfilled orders were generally >70-80%. Given an incident NBP or UTI visit, longer distance to the clinic and higher cost-sharing due to HDHP enrollment did not significantly suppress patients' fulfillment of ancillary services orders. Prior use of mail-order prescriptions significantly promoted medication order fulfillments on virtual NBP visits compared with in-person NBP visits in the prepandemic period (5.9% vs. 2.0%, P=0.01) and in the recovery period (5.2% vs. 1.6%, P=0.02).

CONCLUSIONS

Distance to the clinic or HDHP enrollment had minimal impact on the fulfillment of diagnostic or prescribed medication services associated with incident NBP or UTI visits delivered virtually or in-person; however, prior use of mail-order pharmacy option promoted fulfillment of prescribed medication orders associated with NBP visits.

Evaluation of High-Deductible Health Plans and Acute Glycemic Complications Among Adults With Diabetes

Importance

Optimal diabetes care requires regular monitoring and care to maintain glycemic control. How high-deductible health plans (HDHPs), which reduce overall spending but may impede care by increasing out-of-pocket expenses, are associated with risks of severe hypoglycemia and hyperglycemia is unknown.

Objective

To examine the association between an employer-forced switch to HDHP and severe hypoglycemia and hyperglycemia.

Design, Setting, and Participants

This retrospective cohort study used deidentified administrative claims data for privately insured adults with diabetes from a single insurance carrier with multiple plans across the US between January 1, 2010, and December 31, 2018. Analyses were conducted between May 15, 2020, and November 3, 2022.

Exposures

Patients with 1 baseline year of enrollment in a non-HDHP whose employers subsequently forced a switch to an HDHP were compared with patients who did not switch.

Main Outcomes and Measures

Mixed-effects logistic regression models were used to examine the association between switching to an HDHP and the odds of severe hypoglycemia and hyperglycemia (ascertained using diagnosis codes in emergency department [ED] visits and hospitalizations), adjusting for patient age, sex, race and ethnicity, region, income, comorbidities, glucose-lowering medications, baseline ED and hospital visits for hypoglycemia and hyperglycemia, and baseline deductible amount, and applying inverse propensity score weighting to account for potential treatment selection bias.

Results

The study population was composed of 42 326 patients who switched to an HDHP (mean [SD] age: 52 [10] years, 19 752 [46.7%] women, 7375 [17.4%] Black, 5740 [13.6%] Hispanic, 26 572 [62.8%] non-Hispanic White) and 202 729 patients who did not switch (mean [SD] age, 53 [10] years, 89 828 [44.3%] women, 29 551 [14.6%] Black, 26 689 [13.2%] Hispanic, 130 843 [64.5%] non-Hispanic White). When comparing all study years, switching to an HDHP was not associated with increased odds of experiencing at least 1 hypoglycemia-related ED visit or hospitalization (OR, 1.01 [95% CI, 0.95-1.06]; P = .85), but each year of HDHP enrollment did increase these odds by 2% (OR, 1.02 [95% CI, 1.00-1.04]; P = .04). In contrast, switching to an HDHP did significantly increase the odds of experiencing at least 1 hyperglycemia-related ED visit or hospitalization (OR, 1.25 [95% CI, 1.11-1.42]; P < .001), with each year of HDHP enrollment increasing the odds by 5% (OR, 1.05 [95% CI, 1.01-1.09]; P = .02).

Conclusions and Relevance

In this cohort study, employer-forced switching to an HDHP was associated with increased odds of potentially preventable acute diabetes complications, potentially because of delayed or deferred care. These findings suggest that employers should be more judicious in their health plan offerings, and health plans and policy makers should consider allowing preventive and high-value services to be exempt from deductible requirements.

Association between cost-sharing and drug prescribing in Korean elderly veterans with chronic diseases: A real-world claims data study

This study aimed to investigate the relationship between cost-sharing and drug prescribing and its appropriateness in Korean elderly veterans with chronic conditions. This is a cross-sectional study using real-world claims data. Veterans with primary hypertension or dyslipidemia were compared with two controls with higher levels of cost-sharing. Study subjects (age ≥65 years) were selected through stratified random sampling and matching the individual attributes. The primary outcome was the annual amount of drugs prescribed per patient, and the secondary outcomes included several other measures investigating multifaceted aspects of drug prescribing, medical institution utilization behavior, and prescribing appropriateness. Gamma regression models or logistic regression models were employed. Veterans were prescribed 59%~74% more drugs (exp (β) = 1.59 [95% confidence interval [CI] = 1.55-1.64] ~ 1.74 [1.70-1.79]) compared to the National Health Insurance (NHI) patients. This was attributed mainly to longer prescribing days (44%) and slightly more prescriptions (6%~7%) than NHI patients. Veterans spent 14%~15% higher medication costs. Veterans were less likely to visit multiple medical institutions by estimates of 0.77 (0.76-0.79) ~ 0.80 (0.79-0.82). Similar but smaller differences were observed between veterans and medical aid (MedAid) patients. The veteran patients showed a more than 50% increased risk of therapeutic duplication than the other two controls (adjusted odds ratio [ORs] = 1.47 [1.37-1.57] ~ 1.61 [1.50-1.72]). Inappropriate drug prescribing was also more common in veterans than the two controls (adjusted ORs = 1.20 [1.11-1.31] ~ 1.32 [1.22-1.43]). In Korean elderly veterans with chronic illnesses, a level of cost-sharing was associated with having more prescribed medicines, and increased inappropriate prescribing.

Association Between High Deductible Health Plans and Cost-Related Non-adherence to Medications Among Americans with Diabetes: an Observational Study

BACKGROUND

For people with diabetes, adherence to prescribed medications is essential. However, the rising prevalence of high-deductible health plans (HDHPs), and prices of diabetes medications such as insulin, could deter adherence.

OBJECTIVE

To assess the impact of HDHP on cost-related medication non-adherence (CRN) among non-elderly adults with diabetes in the US.

DESIGN

Repeated cross-sectional survey.

SETTING

National Health Interview Survey, 2011-2018.

PARTICIPANTS

A total of 7469 privately insured adults ages 18-64 with diabetes who were prescribed medications and enrolled in a HDHP or a traditional commercial health plan (TCP).

MAIN MEASURES

Self-reported measures of CRN were compared between enrollees in HDHPs and TCPs overall and among the subset using insulin. Analyses were adjusted for demographic and clinical characteristics using multivariable linear regression models.

KEY RESULTS

HDHP enrollees were more likely than TCP enrollees to not fill a prescription (13.4% vs 9.9%; adjusted percentage point difference (AD) 3.4 [95% CI 1.5 to 5.4]); skip medication doses (11.4% vs 8.5%; AD 2.8 [CI 1.0 to 4.7]); take less medication (11.1% vs 8.8%; AD 2.3 [CI 0.5 to 4.0]); delay filling a prescription to save money (14.4% vs 10.8%; AD 3.0 [CI 1.1 to 4.9]); and to have any form of CRN (20.4% vs 15.5%; AD 4.4 [CI 2.2 to 6.7]). Among those taking insulin, HDHP enrollees were more likely to have any CRN (25.1% vs 18.9%; AD 5.9 [CI 1.1 to 10.8]).

CONCLUSION

HDHPs are associated with greater CRN among people with diabetes, particularly those prescribed insulin. For people with diabetes, enrollment in non-HDHPs might reduce CRN to prescribed medications.

Impact of High Deductible Health Plans on Continuous Buprenorphine Treatment for Opioid Use Disorder

BACKGROUND

Long-term, continuous treatment with medication like buprenorphine is the gold standard for opioid use disorder (OUD). As high deductible health plans (HDHPs) become more prevalent in the commercial insurance market, they may pose financial barriers to people with OUD.

OBJECTIVE

To estimate the impact of HDHPs on continuity of buprenorphine treatment, concurrent visits for counseling/psychotherapy and OUD-related evaluation and management, and out-of-pocket spending.

DESIGN

Difference-in-differences analysis comparing trends in outcomes among enrollees whose employers offer an HDHP (treatment group) to enrollees whose employers never offer an HDHP (comparison group).

PARTICIPANTS

Enrollees with OUD from a national sample of commercial health insurance plans during 2007-2017 who initiate buprenorphine treatment.

MAIN MEASURES

Number of days of continuous buprenorphine treatment; probabilities of continuous buprenorphine treatment ≥30, ≥90, ≥180, and ≥365 days; probability of concurrent (i.e., within the same month) behavioral therapy (i.e., counseling or psychotherapy); probability of concurrent OUD-related evaluation and management visits; proportions of buprenorphine treatment episodes with counseling/psychotherapy and evaluation and management visits; and out-of-pocket (OOP) spending on buprenorphine, behavioral therapy, and evaluation and management visits.

KEY RESULTS

HDHPs were associated with an average increase of $98 (95% CI: $48, $150) on OOP spending on buprenorphine per treatment episode but no change in the number of days of continuous buprenorphine treatment or concurrent use of related services.

CONCLUSIONS

HDHPs do not reduce continuity of buprenorphine treatment among commercially insured enrollees with OUD but may increase financial burden for this population.

Do high-deductible health plans affect price paid for childbirth?

OBJECTIVE

To test whether out-of-pocket costs and negotiated hospital prices for childbirth change after enrollment in high-deductible health plans (HDHPs) and whether price effects differ in markets with more hospitals.

DATA SOURCES

Administrative medical claims data from 2010 to 2014 from three large commercial insurers with plans in all U.S. states provided by the Health Care Cost Institute (HCCI).

STUDY DESIGN

I identify employer groups that switched from non-HDHPs in 1 year to HDHPs in a subsequent year. I estimate enrollees' change in out-of-pocket costs and negotiated hospital prices for childbirth after HDHP switch, relative to a comparison group of employers that do not switch plans. I use a triple-difference design to estimate price changes for enrollees in markets with more hospital choices. Finally, I re-estimate models with hospital-fixed effects.

DATA COLLECTION

From the HCCI sample, childbearing women enrolled in an employer-sponsored plan with at least 10 people.

PRINCIPAL FINDINGS

Switching to an HDHP increases out-of-pocket cost $227 (p < 0.001; comparison group base $790) and has no meaningful effect on hospital-negotiated prices (-$26, p = 0.756; comparison group base $5821). HDHP switch is associated with a marginally statistically significant price increase in markets with three or fewer hospitals ($343, p = 0.096; comparison group base $5806) and, relative to those markets, with a price decrease in markets with more than three hospitals (-$512; p = 0.028). Predicted prices decrease from $5702 to $5551 after HDHP switch in markets with more than three hospitals due primarily to lower prices conditional on using the same hospital.

CONCLUSIONS

Prices for childbirth in markets with more hospitals decrease after HDHP switch due to lower hospital prices for HDHPs relative to prices at those same hospitals for non-HDHPs. These results reinforce previous findings that HDHPs do not promote price shopping but suggest negotiated prices may be lower for HDHP enrollees.

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

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.

Impact of High Deductible Health Plans on Diabetes Care Quality and Outcomes: Systematic Review

OBJECTIVE

To provide a review of the impact of high deductible health plans (HDHPs) on the utilizations of services required for optimal management of diabetes and subsequent health outcomes.

METHODS

Systematic literature review of studies published between January 1, 2000, and May 7, 2021, was conducted that examined the impact of HDHP on diabetes monitoring (eg, recommended laboratory and surveillance testing), routine care (eg, ambulatory appointments), medication management (eg, medication initiation, adherence), and acute health care utilization (eg, emergency department visits, hospitalizations, incident complications).

RESULTS

Of the 303 reviewed articles, 8 were relevant. These studies demonstrated that HDHPs lower spending at the expense of reduced high-value diabetes monitoring, routine care, and medication adherence, potentially contributing to the observed increases in acute health care utilization. Additionally, patient out-of-pocket costs for recommended screenings doubled, and total health care expenditures increased by 49.4% for HDHP enrollees compared with enrollees in traditional health plans. Reductions in disease monitoring and routine care and increases in acute health care utilization were greatest in lower-income patients. None of the studies examined the impact of HDHPs on access to diabetes self-management education, technology use, or glycemic control.

CONCLUSION

Although HDHPs reduce some health care utilization and costs, they appear to do so at the expense of limiting high-value care and medication adherence. Policymakers, providers, and payers should be more cognizant of the potential for negative consequences of HDHPs on patients' health.

Controller Medication Use and Exacerbations for Children and Adults With Asthma in High-Deductible Health Plans

IMPORTANCE

High-deductible health plans (HDHPs) are increasingly common and associated with decreased medication use in some adult populations. How children are affected is less certain.

OBJECTIVE

To examine the association between HDHP enrollment and asthma controller medication use and exacerbations.

DESIGN, SETTING, AND PARTICIPANTS

For this longitudinal cohort study with a difference-in-differences design, data were obtained from a large, national, commercial (and Medicare Advantage) administrative claims database between January 1, 2002, and December 31, 2014. Children aged 4 to 17 years and adults aged 18 to 64 years with persistent asthma who switched from traditional plans to HDHPs or remained in traditional plans (control group) by employer choice during a 24-month period were identified. A coarsened exact matching technique was used to balance the groups on characteristics including employer and enrollee propensity to have HDHPs. In most HDHPs, asthma medications were exempt from the deductible and subject to copayments. Statistical analyses were conducted from August 13, 2019, to January 19, 2021.

EXPOSURE

Employer-mandated HDHP transition.

MAIN OUTCOMES AND MEASURES

Thirty-day fill rates and adherence (based on proportion of days covered [PDC]) were measured for asthma controller medications (inhaled corticosteroid [ICS], leukotriene inhibitors, and ICS long-acting β-agonists [ICS-LABAs]). Asthma exacerbations were measured by rates of oral corticosteroid bursts and asthma-related emergency department visits among controller medication users.

RESULTS

The HDHP group included 7275 children (mean [SD] age, 10.8 [3.3] years; 4402 boys [60.5%]; and 5172 non-Hispanic White children [71.1%]) and 17 614 adults (mean [SD] age, 41.1 [13.4] years; 10 464 women [59.4%]; and 12 548 non-Hispanic White adults [71.2%]). The matched control group included 45 549 children and 114 141 adults. Compared with controls, children switching to HDHPs experienced significant absolute decreases in annual 30-day fills only for ICS-LABA medications (absolute change, -0.04; 95% CI, -0.07 to -0.01). Adults switching to HDHPs did not have significant reductions in 30-day fills for any controllers. There were no statistically significant differences in PDC, oral steroid bursts, or asthma-related emergency department visits for children or adults. For the 9.9% of HDHP enrollees with health savings account-eligible HDHPs that subjected medications to the deductible, there was a significant absolute decrease in PDC for ICS-LABA compared with controls (-4.8%; 95% CI, -7.7% to -1.9%).

CONCLUSIONS AND RELEVANCE

This cohort study found that in a population where medications were exempt from the deductible for most enrollees, HDHP enrollment was associated with minimal or no reductions in controller medication use for children and adults and no change in asthma exacerbations. These findings suggest a potential benefit from exempting asthma medications from the deductible in HDHPs.

Development and evaluation of a patient-centered quality indicator for the appropriateness of type 2 diabetes management

INTRODUCTION

Current diabetes quality measures are agnostic to patient clinical complexity and type of treatment required to achieve it. Our objective was to introduce a patient-centered indicator of appropriate diabetes therapy indicator (ADTI), designed for patients with type 2 diabetes, which is based on hemoglobin A1c (HbA1c) but is also contextualized by patient complexity and treatment intensity.

RESEARCH DESIGN AND METHODS

A draft indicator was iteratively refined by a multidisciplinary Delphi panel using existing quality measures, guidelines, and published literature. ADTI performance was then assessed using OptumLabs Data Warehouse data for 2015. Included adults (n=206 279) with type 2 diabetes were categorized as clinically complex based on comorbidities, then categorized as treated appropriately, overtreated, or undertreated based on a matrix of clinical complexity, HbA1c level, and medications used. Associations between ADTI and emergency department/hospital visits for hypoglycemia and hyperglycemia were assessed by calculating event rates for each treatment intensity subset.

RESULTS

Overall, 7.4% of patients with type 2 diabetes were overtreated and 21.1% were undertreated. Patients with high complexity were more likely to be overtreated (OR 5.60, 95% CI 5.37 to 5.83) and less likely to be undertreated (OR 0.65, 95% CI 0.62 to 0.68) than patients with low complexity. Overtreated patients had higher rates of hypoglycemia than appropriately treated patients (22.0 vs 6.2 per 1000 people/year), whereas undertreated patients had higher rates of hyperglycemia (8.4 vs 1.9 per 1000 people/year).

CONCLUSIONS

The ADTI may facilitate timely, patient-centered treatment intensification/deintensification with the goal of achieving safer evidence-based care.

High-deductible health plans and low-value imaging in the emergency department

OBJECTIVE

To examine the effect of an employer-mandated switch to high-deductible health plans (HDHP) on emergency department (ED) low-value imaging.

DATA SOURCES

Claims data of a large national insurer between 2003 and 2014.

STUDY DESIGN

Difference-in-differences analysis with matched control groups.

DATA COLLECTION/EXTRACTION METHODS

The primary outcome is low-value imaging during ED visits for syncope, headache, or low back pain. We included members aged 19-63 years whose employers offered only low-deductible (≤$500) plans for one (baseline) year and, in the next (follow-up) year, offered only HDHPs (≥$1000). Contemporaneous members whose employers offered only low-deductible plans for two consecutive years served as controls. The groups were matched by person and employer propensity for HDHP switch, employer size, baseline calendar year, and baseline year quarterly number of total and imaged ED visits for each condition. We modeled the visit-level probability of low-value imaging using multivariable logistic regression with member-clustered standard errors. We also calculated population level monthly cumulative ED visit rates and modeled their trends using generalized linear regression adjusting for serial autocorrelation.

PRINCIPAL FINDINGS

After matching, we included 524 998 members in the HDHP group and 5 448 803 in the control group with a mean age of approximately 42 years and 48% female in both groups. On visit-level analyses, there were no significant differential changes in the probability of low-value imaging use in the HDHP and control groups. In population-level analyses, compared with control group members, members who switched to HDHPs experienced a relative decrease of 5.9% (95% CI - 10.3, -1.6) in ED visits for the study conditions and a relative decrease of 5.1% (95%CI -9.6, -0.6) in the subset of ED visits with low-value imaging.

CONCLUSION

Though HDHP switches decreased ED utilization, they had no significant effect on low-value imaging use after patients have decided to seek ED care.

Deductibles in Health Insurance, Beneficial or Detrimental: A Review Article

BACKGROUND

One of the ways for cost-sharing in health system that has been taken into consideration in recent years in some developed countries is paying deductibles. In case of using deductibles, the insured people more carefully and accurately will use health care services, and potentially many unnecessary costs will be avoided.

METHODS

To investigate the evidence of deductibles in health systems across the world, a literature review was conducted by searching the materials published in databases including ISI web of science, PubMed, Scopus and also Google scholar search engine from 2000 to 2017. Besides the related websites including WHO and the World Bank were searched. Inclusion criteria were studies carried out only in health insurance, English language, and the year of the study.

RESULTS

The most important positive impacts of deductibles were decrease in utilization of different services, high profitability for the young and healthy people, lower health benefit claims by the insured people, and increase in financial profitability of health insurance organization. Besides, the most negative impacts increase in out of pocket burdens and also higher hospitalization over time.

CONCLUSION

Deductible plans have their own advantages and disadvantages for the insured and insurance organizations in terms of financial dimensions as well as utilization of health services, and explicitly none of these plans can be flawless. Given the increasing costs of health systems and the potential moral hazard of insured persons, it seems these systems sooner or later should inevitably move towards new cost-sharing plans, including deductibles.

Association Between Switching to a High-Deductible Health Plan and Discontinuation of Type 2 Diabetes Treatment

IMPORTANCE

High-deductible health plans (HDHPs) are a common cost-savings option for employers but may lead to underuse of necessary treatments because beneficiaries bear the full cost of health care, including medications, until a deductible is met.

OBJECTIVES

To evaluate the association between switching from a non-HDHP to an HDHP and discontinuation of antihyperglycemic medication and to assess whether the association differs in patients using branded vs generic antihyperglycemic medications.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective matched cohort study used administrative claims from MarketScan databases to identify commercially insured adult patients with type 2 diabetes who used at least 1 antihyperglycemic medication in 2013. Patients in the HDHP cohort (n = 1490) were matched by propensity scores to a non-HDPH control cohort (n = 1490). Data were collected and analyzed from January 1, 2013, through December 31, 2014.

EXPOSURES

Switching from a non-HDHP in 2013 to a full replacement HDHP in 2014 (no non-HDHP option offered) vs staying on a non-HDHP.

MAIN OUTCOMES AND MEASURES

Difference-in-differences models estimated discontinuation of branded and generic antihyperglycemic medications.

RESULTS

Among the 2980 patients included in the analysis (1932 men [64.8%]; mean [SD] age, HDHP cohort: 52.6 [6.9] years; non-HDHP cohort: 52.7 [7.3] years), no difference between the HDHP and non-HDHP cohorts was found in unadjusted follow-up discontinuation rates for all antihyperglycemic medications (255 [22.7%] vs 255 [23.3%]; P = .72); however, among patients using branded medication, a significantly greater proportion of patients in the HDHP group did not refill branded medications (81 of 396 [20.5%] vs 61 of 437 [14.0%]; P = .009). Difference-in-differences models were not statistically significant.

CONCLUSIONS AND RELEVANCE

These findings suggest switching to an HDHP is associated with discontinuation specifically of branded medications. Unintended health consequences may result and should be considered by employers making health care benefit decisions.

Determinants in Initial Treatment Choice for Diabetic Macular Edema

PURPOSE

To assess how patient choices (out-of-pocket costs, insurance plan, geographic region) impact initiation of therapy for diabetic macular edema (DME).

DESIGN

Retrospective cohort study using administrative medical claims data from a large, national insurer.

PARTICIPANTS

All patients newly diagnosed with DME from 2013 through 2016 were observed for 90 days after diagnosis or until first treatment was received.

METHODS

Multivariate logistic regression was used to create odds ratios comparing different baseline demographic and patient-related factors.

MAIN OUTCOME MEASURES

The primary outcome was the odds of receiving the different possible initial treatments for DME (anti-vascular endothelial growth factor [VEGF], focal laser treatment, steroids, or observation), no treatment, and not following up.

RESULTS

Of the 6220 newly diagnosed DME patients, 3010 (48.4%) underwent a follow-up examination within 90 days of diagnosis, and of those, 1453 patients (48.3%) received treatment in the observation window, including 614 (20.4%) with bevacizumab, 191 (6.3%) with ranibizumab or aflibercept, 560 (18.6%) with focal laser, 38 (1.3%) with steroid injection, and 50 (1.7%) with an injection of an unspecified drug. Having a copay (vs. $0) lowered the odds of receiving any treatment (odds ratio [OR] = 0.60; 95% confidence interval [CI], 0.51-0.71; P < 0.001) and of receiving each treatment individually (anti-VEGF treatment: OR = 0.72; 95% CI, 0.59-0.88; bevacizumab: OR = 0.73; 95% CI, 0.59-0.91; ranibizumab or aflibercept: OR, 0.70; 95% CI, 0.49-0.99; focal laser: OR = 0.44; 95% CI, 0.35-0.55; P < 0.001). Contrary to having a copay, having a high deductible and type of insurance plan were not associated with initiating treatment (P > 0.41 for all comparisons). Patients in the Northeast showed lower odds of initiating anti-VEGF treatment (OR = 0.60; 95%CI, 0.44-0.82; P < 0.001) and specifically bevacizumab (OR = 0.47; 95% CI, 0.33-0.67; P < 0.001). Furthermore, Northeast patients who were treated with anti-VEGF showed a higher odds of receiving ranibizumab or aflibercept compared with bevacizumab (OR = 2.39; 95% CI, 1.31-4.37; P < 0.001). Southern Midwest patients showed a higher odds of treatment (anti-VEGF: OR = 1.35; 95%CI, 1.02-1.77; P < 0.001; bevacizumab: OR = 1.40; 95% CI, 1.04-1.87; focal laser: OR = 1.39; 95% CI, 1.01-1.89; P < 0.001).

CONCLUSIONS

Patient choices such as copays and where they live are important factors in determining the initial choice of treatment for DME.

Impact of Health Plan Deductibles and Health Insurance Marketplace Enrollment on Health Care Experiences

High-deductible health plans (HDHPs) have become increasingly prevalent among employer-sponsored health plans and plans offered through the Health Insurance Marketplace in the United States. This study examined the impact of deductible levels on health care experiences in terms of care access, affordability, routine checkup, out-of-pocket cost, and satisfaction using data from the Health Reform Monitoring Survey. The study also tested whether the experiences of Marketplace enrollees differed from off-Marketplace individuals, controlling for deductible levels. Results from multivariable and propensity score weighted regression models showed that many of the outcomes were adversely affected by deductible levels and Marketplace enrollment. These results highlight the importance of efforts to help individuals choose the plan that fits both their medical needs and their budgets. The study also calls for more attention to improving provider acceptance of HDHPs and Marketplace plans as these plans become increasingly common over time.

Impact of high-deductible insurance on adjuvant hormonal therapy use in breast cancer

OBJECTIVE

High-deductible health plans (HDHPs) have become the predominant commercial health insurance arrangement in the US. HDHPs require substantial out-of-pocket (OOP) costs for most services but often exempt medications from high cost sharing. We examined effects of HDHPs on OOP costs and utilization of adjuvant hormonal therapy (AHT), which are fundamental care for patients with breast cancer.

METHODS

This controlled quasi-experimental study used claims data (2003-2012) from a large national health insurer. We included 986 women with incident early-stage breast cancer, age 25-64 years, insured by employers that mandated a transition from low-deductible (≤ $500/year) to high-deductible (≥ $1000/year) coverage, and 3479 propensity score-matched controls whose employers offered only low-deductible plans. We examined AHT utilization and OOP costs per person-year before and after the HDHP switch.

RESULTS

At baseline, the OOP costs for AHT were $40.41 and $36.55 per person-year among the HDHP and control groups. After the HDHP switch, the OOP costs for AHT were $91.76 and $72.98 per person-year among the HDHP and control groups, respectively. AHT OOP costs increased among HDHP members relative to controls but the change was not significant (relative change 13.72% [95% CI - 9.25, 36.70%]). AHT use among HDHP members did not change compared to controls (relative change of 2.73% [95% CI - 14.01, 19.48%]); the change in aromatase inhibitor use was - 11.94% (95% CI - 32.76, 8.88%) and the change in tamoxifen use was 20.65% (95% CI - 8.01, 49.32%).

CONCLUSION

We did not detect significant changes in AHT use after the HDHP switch. Findings might be related to modest increases in overall AHT OOP costs, the availability of low-cost generic tamoxifen, and patient awareness that AHT can prolong life and health. Minimizing OOP cost increases for essential medications might represent a feasible approach for maintaining medication adherence among HDHP members with incident breast cancer.

Impact of Out-of-Pocket Pharmacy Costs on Branded Medication Adherence Among Patients with Type 2 Diabetes

BACKGROUND

Medication adherence is pivotal for the successful treatment of diabetes. However, medication adherence remains a major concern, as nonadherence is associated with poor health outcomes. Studies have indicated that increasing patients' share of medication costs significantly reduces adherence. Little is known about a potential out-of-pocket (OOP) cost threshold where substantial reduction in adherence may occur.

OBJECTIVE

To examine the impact of diabetes OOP pharmacy costs on antihyperglycemic medication adherence and identify the potential threshold at which significant reduction in adherence may occur among patients with type 2 diabetes mellitus (T2DM).

METHODS

This was an observational, retrospective cohort study using longitudinal U.S. pharmacy and medical claims data from the IMS Health Medical Claims (Dx) database. Patients with T2DM who initiated therapy with a branded antihyperglycemic medication during the index period (January 1, 2011, to December 31, 2011) and had 3 years of follow-up data were included. The primary outcome was adherence to antihyperglycemic medications, measured as the number of days covered. Propensity scores were calculated using baseline sociodemographic and clinical characteristics to control for potential confounding factors. Four strata were created based on mean propensity scores. Across each stratum, patients were assigned to 5 diabetes OOP pharmacy (including generics) cost levels: $0-$10, $11-$40, $41-$50, $51-$75, and > $75. Multivariate regression models were used to estimate association of diabetes OOP pharmacy costs and adherence for each stratum. Sensitivity analyses were conducted to assess the impact of total OOP pharmacy costs and index drug category OOP costs on adherence.

RESULTS

A total of 15,416 patients were assessed. Across each stratum in the diabetes OOP pharmacy cost analysis group, mean patient age ranged from 52.3 to 56.1 years, mean number of antihyperglycemic medication classes ranged from 1.5 to 3.2, and mean household income ranged from $60,763 to $79,373. Most patients used a commercial plan (55%-85%). The propensity-stratified multivariate regression model revealed an overall negative relationship between diabetes OOP pharmacy costs and adherence across several OOP cost levels. Diabetes OOP pharmacy cost level $51-$75 appeared as the threshold at which adherence reduced significantly (77-78 fewer days of coverage over 3 years of follow-up; P < 0.05) when compared with the lowest OOP costs ($0-$10) across all strata. Adherence reduced further (99-145 fewer days of coverage; P < 0.0001) for the higher diabetes OOP pharmacy cost levels (> $75) when compared with the lowest OOP cost levels. Sensitivity analyses with total OOP pharmacy costs and index drug category OOP costs revealed negative association with adherence across all strata.

CONCLUSIONS

Diabetes OOP pharmacy cost was negatively associated with patient adherence, and a potential OOP cost threshold ($51-$75) was identified at which adherence reduced significantly. The study findings may be beneficial in informing the design of health care plans to achieve optimal adherence and improve disease management in patients with T2DM.

DISCLOSURES

This study was funded by Eli Lilly and Company. Eli Lilly and Company was involved in the study design; collection, analysis, and interpretation of data; preparation of the manuscript; and decision to submit for publication. Fu is an employee of Eli Lilly and Company. Taylor and Kwan are employees of Lilly USA. Fu and Kwan hold stock or stock options in Eli Lilly and Company. Bibeau was an employee of Eli Lilly and Company at the time of this study and initial submission of this manuscript. Bibeau is currently employed by Janssen Scientific Affairs. The abstract for this study was presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2016; April 19-22, 2016; San Francisco, California. Bibeau and Fu contributed to the study design and collected the data. All authors contributed equally to data interpretation and manuscript preparation and revision.

Diabetes Outpatient Care and Acute Complications Before and After High-Deductible Insurance Enrollment: A Natural Experiment for Translation in Diabetes (NEXT-D) Study

IMPORTANCE

High-deductible health plans (HDHPs) have expanded under the Affordable Care Act and are expected to play a major role in the future of US health policy. The effects of modern HDHPs on chronically ill patients and adverse outcomes are unknown.

OBJECTIVE

To determine the association of HDHP with high-priority diabetes outpatient care and preventable acute complications.

DESIGN, SETTING, AND PARTICIPANTS

Controlled interrupted-time-series study using a large national health insurer database from January 1, 2003, to December 31, 2012. A total of 12 084 HDHP members with diabetes, aged 12 to 64 years, who were enrolled for 1 year in a low-deductible (≤$500) plan followed by 2 years in an HDHP (≥$1000) after an employer-mandated switch were included. Patients transitioning to HDHPs were propensity-score matched with contemporaneous patients whose employers offered only low-deductible coverage. Low-income (n = 4121) and health savings account (HSA)-eligible (n = 1899) patients with diabetes were subgroups of interest. Data analysis was performed from February 23, 2015, to September 11, 2016.

EXPOSURES

Employer-mandated HDHP transition.

MAIN OUTCOMES AND MEASURES

High-priority outpatient visits, disease monitoring tests, and outpatient and emergency department visits for preventable acute diabetes complications.

RESULTS

In the 12 084 HDHP members included after the propensity score match, the mean (SD) age was 50.4 (10.0) years; 5410 of the group (44.8%) were women. The overall, low-income, and HSA-eligible diabetes HDHP groups experienced increases in out-of-pocket medical expenditures of 49.4% (95% CI, 40.3% to 58.4%), 51.7% (95% CI, 38.6% to 64.7%), and 67.8% (95% CI, 47.9% to 87.8%), respectively, compared with controls in the year after transitioning to HDHPs. High-priority primary care visits and disease monitoring tests did not change significantly in the overall HDHP cohort; however, high-priority specialist visits declined by 5.5% (95% CI, -9.6% to -1.5%) in follow-up year 1 and 7.1% (95% CI, -11.5% to -2.7%) in follow-up year 2 vs baseline. Outpatient acute diabetes complication visits were delayed in the overall and low-income HDHP cohorts at follow-up (adjusted hazard ratios, 0.94 [95% CI, 0.88 to 0.99] for the overall cohort and 0.89 [95% CI, 0.81 to 0.98] for the low-income cohort). Annual emergency department acute complication visits among HDHP members increased by 8.0% (95% CI, 4.6% to 11.4%) in the overall group, 21.7% (95% CI, 14.5% to 28.9%) in the low-income group, and 15.5% (95% CI, 10.5% to 20.6%) in the HSA-eligible group.

CONCLUSIONS AND RELEVANCE

Patients with diabetes experienced minimal changes in outpatient visits and disease monitoring after an HDHP switch, but low-income and HSA-eligible HDHP members experienced major increases in emergency department visits for preventable acute diabetes complications.

Pharmaceutical policies: effects of cap and co-payment on rational use of medicines

BACKGROUND

Growing expenditures on prescription medicines represent a major challenge to many health systems. Cap and co-payment policies are intended as an incentive to deter unnecessary or marginal utilisation, and to reduce third-party payer expenditures by shifting parts of the financial burden from insurers to patients, thus increasing their financial responsibility for prescription medicines. Direct patient payment policies include caps (maximum numbers of prescriptions or medicines that are reimbursed), fixed co-payments (patients pay a fixed amount per prescription or medicine), co-insurance (patients pay a percentage of the price), ceilings (patients pay the full price or part of the cost up to a ceiling, after which medicines are free or are available at reduced cost) and tier co-payments (differential co-payments usually assigned to generic and brand medicines). This is the first update of the original review.

OBJECTIVES

To determine the effects of cap and co-payment (cost-sharing) policies on use of medicines, healthcare utilisation, health outcomes and costs (expenditures).

SEARCH METHODS

For this update, we searched the following databases and websites: The Cochrane Central Register of Controlled Trials (CENTRAL) (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, Cochrane Library; MEDLINE, Ovid; EMBASE, Ovid; IPSA, EBSCO; EconLit, ProQuest; Worldwide Political Science Abstracts, ProQuest; PAIS International, ProQuest; INRUD Bibliography; WHOLIS, WHO; LILACS), VHL; Global Health Library WHO; PubMed, NHL; SCOPUS; SciELO, BIREME; OpenGrey; JOLIS Library Network; OECD Library; World Bank e-Library; World Health Organization, WHO; World Bank Documents & Reports; International Clinical Trials Registry Platform (ICTRP), WHO; ClinicalTrials.gov, NIH. We searched all databases during January and February 2013, apart from SciELO, which we searched in January 2012, and ICTRP and ClinicalTrials.gov, which we searched in March 2014.

SELECTION CRITERIA

We defined policies in this review as laws, rules or financial or administrative orders made by governments, non-government organisations or private insurers. We included randomised controlled trials, non-randomised controlled trials, interrupted time series studies, repeated measures studies and controlled before-after studies of cap or co-payment policies for a large jurisdiction or system of care. To be included, a study had to include an objective measure of at least one of the following outcomes: medicine use, healthcare utilisation, health outcomes or costs (expenditures).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study limitations. We reanalysed time series data for studies with sufficient data, if appropriate analyses were not reported.

MAIN RESULTS

We included 32 full-text articles (17 new) reporting evaluations of 39 different interventions (one study - Newhouse 1993 - comprises five papers). We excluded from this update eight controlled before-after studies included in the previous version of this review, because they included only one site in their intervention or control groups. Five papers evaluated caps, and six evaluated a cap with co-insurance and a ceiling. Six evaluated fixed co-payment, two evaluated tiered fixed co-payment, 10 evaluated a ceiling with fixed co-payment and 10 evaluated a ceiling with co-insurance. Only one evaluation was a randomised trial. The certainty of the evidence was found to be generally low to very low.Increasing the amount of money that people pay for medicines may reduce insurers' medicine expenditures and may reduce patients' medicine use. This may include reductions in the use of life-sustaining medicines as well as medicines that are important in treating chronic conditions and medicines for asymptomatic conditions. These types of interventions may lead to small decreases in or uncertain effects on healthcare utilisation. We found no studies that reliably reported the effects of these types of interventions on health outcomes.

AUTHORS' CONCLUSIONS

The diversity of interventions and outcomes addressed across studies and differences in settings, populations and comparisons made it difficult to summarise results across studies. Cap and co-payment polices may reduce the use of medicines and reduce medicine expenditures for health insurers. However, they may also reduce the use of life-sustaining medicines or medicines that are important in treating chronic, including symptomatic, conditions and, consequently, could increase the use of healthcare services. Fixed co-payment with a ceiling and tiered fixed co-payment may be less likely to reduce the use of essential medicines or to increase the use of healthcare services.

Impact of a high-deductible health plan on outpatient visits and associated diagnostic tests

BACKGROUND

By shifting a greater share of out-of-pocket medical costs to consumers, high-deductible health plans (HDHP) might discourage use of essential outpatient services.

OBJECTIVE

The objective of the study was to examine the impact of an HDHP on outpatient visits and associated laboratory and radiology tests.

RESEARCH DESIGN/SUBJECTS

We used a pre-post with comparison group study design to examine the differential change in outpatient service utilization among 7953 adults who were switched from a traditional Health Maintenance Organization plan to an HDHP compared with 7953 adults remaining in traditional plans. HDHP members had full coverage of preventive laboratory tests and modest copayments for outpatient visits, similar to controls, but faced full cost sharing under the deductible for radiology tests and laboratory tests not classified as preventive.

RESULTS

Compared with controls, the HDHP group experienced moderate relative decreases in overall office visits (incidence rate ratios = 0.91, or a 9% relative reduction; 95% confidence interval: 0.88, 0.94) and visits for higher-priority (0.91; 0.85, 0.97) and lower-priority (0.89; 0.81, 0.99) chronic conditions. There were no significant differences in changes in visit rates for acute higher-priority or lower-priority conditions (both 0.93; 0.86, 1.01) or preventive laboratory tests (0.97; 0.93, 1.02). HDHP members showed moderate relative reductions in the use of general laboratory tests (0.91; 0.86, 0.97) but not radiology tests (0.97; 0.91, 1.03).

CONCLUSIONS

Chronic outpatient visits declined among HDHP members, although preventive laboratory tests and acute visits remained unchanged. HDHP patients with chronic illnesses who have more contact with the health care system might be more likely to reduce utilization because of increased exposure to costs associated with ambulatory visits.

Neurobiology of placebo effects: expectations or learning?

Contemporary learning theories suggest that conditioning is heavily dependent on the processing of prediction errors, which signal a discrepancy between expected and observed outcomes. This line of research provides a framework through which classical theories of placebo effects, expectations and conditioning, can be reconciled. Brain regions related to prediction error processing [anterior cingulate cortex (ACC), orbitofrontal cortex or the nucleus accumbens] overlap with those involved in placebo effects. Here we examined the possibility that the magnitude of objective neurochemical responses to placebo administration would depend on individual expectation-effectiveness comparisons. We show that such comparisons and not expectations per se predict behavioral placebo responses and placebo-induced activation of µ-opioid receptor-mediated neurotransmission in regions relevant to error detection (e.g. ACC). Expectations on the other hand were associated with greater µ-opioid system activation in the dorsolateral prefrontal cortex but not with greater behavioral placebo responses. The results presented aid the elucidation of molecular and neural mechanisms underlying the relationship between expectation-effectiveness associations and the formation of placebo responses, shedding light on the individual differences in learning and decision making. Expectation and outcome comparisons emerge as a cognitive mechanism that beyond reward associations appears to facilitate the formation and sustainability of placebo responses.

Impact of emerging health insurance arrangements on diabetes outcomes and disparities: rationale and study design

Consumer-directed health plans combine lower premiums with high annual deductibles, Internet-based quality-of-care information, and health savings mechanisms. These plans may encourage members to seek better value for health expenditures but may also decrease essential care. The expansion of high-deductible health plans (HDHPs) represents a natural experiment of tremendous proportion. We designed a pre-post, longitudinal, quasi-experimental study to determine the effect of HDHPs on diabetes quality of care, outcomes, and disparities. We will use a 13-year rolling sample (2001-2013) of members of an HDHP and members of a control group. To reduce selection bias, we will limit participants to those whose employers mandate a single health insurance type. The study will measure rates of monthly hemoglobin A1c, lipid, and albuminuria testing; availability of blood glucose test strips; and rates of retinal examinations, high-severity emergency department visits, and preventable hospitalizations. Results could be used to design health plan features that promote high-quality care and better outcomes among people who have diabetes.

High deductible health plans: does cost sharing stimulate increased consumer sophistication?

OBJECTIVE

To determine whether increased cost sharing in health insurance plans induces higher levels of consumer sophistication in a non-elderly population.

STUDY DESIGN

This analysis is based on the collection of survey and demographic data collected from enrollees in the RAND health insurance experiment (HIE). During the RAND HIE, enrollees were randomly assigned to different levels of cost sharing (0, 25, 50 and 95%).

METHODS

The study population compromises about 2000 people enrolled in the RAND HIE, between the years 1974 and 1982. Effects on health-care decision making were measured using the results of a standardized questionnaire, administered at the beginning and end of the experiment. Points of enquiry included whether or not enrollees' (i) recognized the need for second opinions (ii) questioned the effectiveness of certain therapies and (iii) researched the background/skill of their medical providers. Consumer sophistication was also measured for regular health-care consumers, as indicated by the presence of a chronic disease.

PRINCIPAL FINDINGS

We found no statically significant changes (P < 0.05) in the health-care decision-making strategies between individuals randomized to high cost sharing plans and low cost sharing plans. Furthermore, we did not find a stronger effect for patients with a chronic disease.

CONCLUSIONS

The evidence from the RAND HIE does not support the hypothesis that a higher level of cost sharing incentivizes the development of consumer sophistication. As a result, cost sharing alone will not promote individuals to become more selective in their health-care decision-making.