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Original Investigation
Health Care Reform
March 2017

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

Author Affiliations
  • 1Harvard Medical School and Harvard Pilgrim Health Care Institute, Department of Population Medicine, Boston, Massachusetts
JAMA Intern Med. 2017;177(3):358-368. doi:10.1001/jamainternmed.2016.8411
Key Points

Question  How does high-deductible insurance enrollment affect diabetes outpatient care and acute complications?

Findings  In this controlled interrupted-time-series study that included 24 168 patients with diabetes, high-deductible health plan members experienced minimal changes in outpatient visits and disease monitoring. However, low-income and health savings account–eligible high-deductible health plan members experienced statistically significant increases in emergency department visits for preventable acute diabetes complications.

Meaning  Vulnerable patients with diabetes switching to high-deductible insurance experienced major increases in acute diabetes complications and might require protection under improved health insurance designs.


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.