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1.
Kochanek  KD, Murphy  SL, Xu  J, Arias  E.  Deaths: final data for 2017.   Natl Vital Stat Rep. 2019;68(9):1-77.PubMedGoogle Scholar
2.
Case  A, Deaton  A.  Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century.   Proc Natl Acad Sci U S A. 2015;112(49):15078-15083. doi:10.1073/pnas.1518393112 PubMedGoogle ScholarCrossref
3.
Sidney  S, Quesenberry  CP  Jr, Jaffe  MG,  et al.  Recent trends in cardiovascular mortality in the United States and public health goals.   JAMA Cardiol. 2016;1(5):594-599. doi:10.1001/jamacardio.2016.1326 PubMedGoogle ScholarCrossref
4.
Shah  NS, Lloyd-Jones  DM, O’Flaherty  M,  et al.  Trends in cardiometabolic mortality in the United States, 1999-2017.   JAMA. 2019;322(8):780-782. doi:10.1001/jama.2019.9161 PubMedGoogle ScholarCrossref
5.
Sidney  S, Sorel  ME, Quesenberry  CP,  et al.  Comparative trends in heart disease, stroke, and all-cause mortality in the United States and a large integrated healthcare delivery system.   Am J Med. 2018;131(7):829-836.e1. doi:10.1016/j.amjmed.2018.02.014PubMedGoogle ScholarCrossref
6.
Ma  J, Ward  EM, Siegel  RL, Jemal  A.  Temporal trends in mortality in the United States, 1969-2013.   JAMA. 2015;314(16):1731-1739. doi:10.1001/jama.2015.12319 PubMedGoogle ScholarCrossref
7.
Gregg  EW, Hora  I, Benoit  SR.  Resurgence in diabetes-related complications.   JAMA. 2019;321(19):1867-1868. doi:10.1001/jama.2019.3471 PubMedGoogle ScholarCrossref
8.
Newhouse  JP.  Free for all? Lessons from the RAND Health Insurance Experiment. Harvard University Press; 1993.
9.
Wharam  JF, Zhang  F, Eggleston  EM, Lu  CY, Soumerai  SB, Ross-Degnan  D.  Effect of high-deductible insurance on high-acuity outcomes in diabetes: a Natural Experiment for Translation in Diabetes (NEXT-D) study.   Diabetes Care. 2018;41(5):940-948. doi:10.2337/dc17-1183 PubMedGoogle ScholarCrossref
10.
Wharam  JF, Zhang  F, Eggleston  EM, Lu  CY, Soumerai  S, Ross-Degnan  D.  Diabetes outpatient care and acute complications before and after high-deductible insurance enrollment: a Natural Experiment for Translation in Diabetes (NEXT-D) study.   JAMA Intern Med. 2017;177(3):358-368. doi:10.1001/jamainternmed.2016.8411PubMedGoogle ScholarCrossref
11.
Wharam  JF, Lu  CY, Zhang  F,  et al.  High-deductible insurance and delay in care for the macrovascular complications of diabetes.   Ann Intern Med. 2018;169(12):845-854. doi:10.7326/M17-3365 PubMedGoogle ScholarCrossref
12.
Claxton  GRM, Long  M, Damico  A, Sawyer  B.  2017 Employer Health Benefits Survey. [Internet] Kaiser Family Foundation and Health Research & Education Trust; 2017.
13.
Fendrick  AM, Chernew  ME.  Value-based insurance design: a “clinically sensitive” approach to preserve quality of care and contain costs.   Am J Manag Care. 2006;12(1):18-20. PubMedGoogle Scholar
14.
Reid  RJ, Roos  NP, MacWilliam  L, Frohlich  N, Black  C.  Assessing population health care need using a claims-based ACG morbidity measure: a validation analysis in the Province of Manitoba.   Health Serv Res. 2002;37(5):1345-1364. doi:10.1111/1475-6773.01029 PubMedGoogle ScholarCrossref
15.
Johns Hopkins University. The Johns Hopkins ACG System. Accessed June 2, 2018. https://www.hopkinsacg.org/advantage/
16.
Kaiser Family Foundation. The Kaiser Family Foundation Employer Health Benefits 2019 Annual Survey. Published 2019. Accessed January 30, 2019. http://files.kff.org/attachment/Report-Employer-Health-Benefits-Annual-Survey-2019
17.
Schreyögg  J, Stargardt  T, Tiemann  O.  Costs and quality of hospitals in different health care systems: a multi-level approach with propensity score matching.   Health Econ. 2011;20(1):85-100. doi:10.1002/hec.1568 PubMedGoogle ScholarCrossref
18.
Wharam  JF, Zhang  F, Landon  BE, LeCates  R, Soumerai  S, Ross-Degnan  D.  Colorectal cancer screening in a nationwide high-deductible health plan before and after the Affordable Care Act.   Med Care. 2016;54(5):466-473. doi:10.1097/MLR.0000000000000521 PubMedGoogle ScholarCrossref
19.
Iacus  SM, King  G, Porro  G.  Multivariate matching methods that are monotonic imbalance bounding.   J Am Stat Assoc. 2011;106(493):345-361. doi:10.1198/jasa.2011.tm09599 Google ScholarCrossref
20.
Iacus  S, King  G, Porro  G. CEM: Coarsened Exact Matching Software. Accessed May 19, 2017. https://gking.harvard.edu/cem
21.
Iacus  SM, King  G, Porro  G.  Causal inference without balance checking: coarsened exact matching.   Polit Anal. 2012;20(1):1-24. doi:10.1093/pan/mpr013 Google ScholarCrossref
22.
Kiyota  Y, Schneeweiss  S, Glynn  RJ, Cannuscio  CC, Avorn  J, Solomon  DH.  Accuracy of Medicare claims-based diagnosis of acute myocardial infarction: estimating positive predictive value on the basis of review of hospital records.   Am Heart J. 2004;148(1):99-104. doi:10.1016/j.ahj.2004.02.013 PubMedGoogle ScholarCrossref
23.
Kumamaru  H, Judd  SE, Curtis  JR,  et al.  Validity of claims-based stroke algorithms in contemporary Medicare data: Reasons for Geographic and Racial Differences in Stroke (REGARDS) study linked with Medicare claims.   Circ Cardiovasc Qual Outcomes. 2014;7(4):611-619. doi:10.1161/CIRCOUTCOMES.113.000743 PubMedGoogle ScholarCrossref
24.
Social Security Administration. Requesting SSA’s Death Information. Accessed August 28, 2019. https://www.ssa.gov/dataexchange/request_dmf.html
25.
Levin  MA, Lin  HM, Prabhakar  G, McCormick  PJ, Egorova  NN.  Alive or dead: validity of the Social Security Administration Death Master File after 2011.   Health Serv Res. 2019;54(1):24-33. doi:10.1111/1475-6773.13069 PubMedGoogle ScholarCrossref
26.
American Community Survey. Accessed September 28, 2017. https://www.census.gov/programs-surveys/acs/
27.
United States Census Bureau. Census Tracts. Accessed June 2, 2018. https://www2.census.gov/geo/pdfs/education/CensusTracts.pdf
28.
Krieger  N, Chen  JT, Waterman  PD, Rehkopf  DH, Subramanian  SV.  Race/ethnicity, gender, and monitoring socioeconomic gradients in health: a comparison of area-based socioeconomic measures—the Public Health Disparities Geocoding Project.   Am J Public Health. 2003;93(10):1655-1671. doi:10.2105/AJPH.93.10.1655 PubMedGoogle ScholarCrossref
29.
Fiscella  K, Fremont  AM.  Use of geocoding and surname analysis to estimate race and ethnicity.   Health Serv Res. 2006;41(4, pt 1):1482-1500. doi:10.1111/j.1475-6773.2006.00551.x PubMedGoogle Scholar
30.
Yang  DDJ. A unified approach to measuring the effect size between two groups using SAS®. Presented at: the SAS Global Forum 2012—Statistics and Data Analysis; April 22-25, 2012; Orlando, Florida.
31.
Williams  R.  Using the margins command to estimate and interpret adjusted predictions and marginal effects.   Stata J. 2012;12(2):308-331. doi:10.1177/1536867X1201200209 Google ScholarCrossref
32.
Woolhandler  S, Himmelstein  DU.  Consumer directed healthcare: except for the healthy and wealthy it’s unwise.   J Gen Intern Med. 2007;22(6):879-881. doi:10.1007/s11606-007-0187-3 PubMedGoogle ScholarCrossref
33.
Wharam  JF, Ross-Degnan  D, Rosenthal  MB.  The ACA and high-deductible insurance—strategies for sharpening a blunt instrument.   N Engl J Med. 2013;369(16):1481-1484. doi:10.1056/NEJMp1309490 PubMedGoogle ScholarCrossref
34.
Internal Revenue System. Additional preventive care benefits permitted to be provided by a high deductible health plan under § 223. Published 2019. Accessed September 7, 2019. https://www.irs.gov/pub/irs-drop/n-19-45.pdf
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    Original Investigation
    Health Policy
    July 24, 2020

    Association Between Switching to a High-Deductible Health Plan and Major Cardiovascular Outcomes

    Author Affiliations
    • 1Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
    • 2Department of Medicine, Duke University School of Medicine, Durham, North Carolina
    • 3Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
    • 4Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
    • 5Harvard Kennedy School, Cambridge, Massachusetts
    • 6National Bureau of Economic Research, Cambridge, Massachusetts
    JAMA Netw Open. 2020;3(7):e208939. doi:10.1001/jamanetworkopen.2020.8939
    Key Points español 中文 (chinese)

    Question  Are high-deductible health plans associated with an increased risk of major cardiovascular events?

    Finding  This cohort study included 156 962 individuals with cardiovascular disease risk factors who experienced mandated enrollment in health insurance plans with high deductibles but relatively low medication costs, a common value-based feature. Members with high-deductible health plans did not have detectable increases in major adverse cardiovascular events compared with 1 467 758 members with low-deductible health plans.

    Meaning  Among patients with cardiovascular disease risk factors in this study, enrollment in typical high-deductible health plans was not associated with increased risk of major adverse cardiovascular events during 4 follow-up years.

    Abstract

    Importance  Most people with commercial health insurance in the US have high-deductible plans, but the association of such plans with major health outcomes is unknown.

    Objective  To describe the association between enrollment in high-deductible health plans and the risk of major adverse cardiovascular outcomes.

    Design, Setting, and Participants  This cohort study examined matched groups before and after an insurance design change. Data were from a large national commercial (and Medicare Advantage) health insurance claims data set that included members enrolled between January 1, 2003, and December 31, 2014. The study group included 156 962 individuals with risk factors for cardiovascular disease who were continuously enrolled in low-deductible (≤$500) health plans during a baseline year followed by up to 4 years in high-deductible (≥$1000) plans with typical value-based features after an employer-mandated switch. The matched control group included 1 467 758 individuals with the same risk factors who were contemporaneously enrolled in low-deductible plans. Data were analyzed from December 2017 to March 2020.

    Exposures  Employer-mandated transition to a high-deductible health plan.

    Main Outcomes and Measures  Time to first major adverse cardiovascular event defined as myocardial infarction or stroke.

    Results  The study group included 156 962 individuals and the control group included 1 467 758 individuals; the mean age of members was 53 years (SD: high-deductible group, 6.7 years; control group, 6.9 years), 47% were female, and approximately 48% lived in low-income neighborhoods. First major adverse cardiovascular events among high-deductible health plan members did not differ relative to controls at follow-up vs baseline (adjusted hazard ratio, 1.00; 95% CI, 0.89-1.13). Findings were similar among subgroups with diabetes (adjusted hazard ratio, 0.93; 95% CI, 0.75-1.16) and with other cardiovascular risk factors (adjusted hazard ratio, 0.93; 95% CI, 0.81-1.07).

    Conclusions and Relevance  Mandated enrollment in high-deductible health plans with typical value-based features was not associated with increased risk of major adverse cardiovascular events.

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