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

Mammography Rates 3 Years After the 2009 US Preventive Services Task Force Guidelines Changes

Purpose In November 2009, the US Preventive Services Task Force (USPSTF) changed its mammography recommendations from every 1 to 2 years among women age ≥ 40 years to personalized screening decisions for women age 40 to 49 years and screening every 2 years for women age 50 to 74 years. Methods We studied mammography trends among 5.5 million women age 40 to 64 years enrolled in a large national health insurer. We used 2005 to 2009 mammography trends to predict 2012 rates. Our primary measure was the estimated difference between observed and predicted 2012 annual and biennial mammography rates. We stratified results by age group and race/ethnicity. Results Among women age 40 to 49 years, 2012 mammography rates declined by 9.9% (95% CI, −10.4% to −9.3%) relative to the predicted 2012 rate. Decreases were lowest among black women (−2.3%; 95% CI, −6.3% to 1.8%) and highest among Asian women (−17.4; 95% CI, −20.0 to −14.8). Annual mammography rates among women age 50 to 64 years declined by 6.1% (95% CI, −6.5% to −5.7%) by 2012. Regarding biennial mammography rates, women age 40 to 49 years experienced a 9.0% relative reduction (95% CI, −9.6% to −8.4%). White, Hispanic, and Asian women age 40 to 49 years demonstrated similar relative reductions of approximately 9% to 11%, whereas black women had no detectable changes (0.1%; 95% CI, −4.0% to 4.3%). Women age 50 to 64 years had a 6.2% relative reduction (95% CI, −6.6% to −5.7%) in biennial mammography that was similar among white, Hispanic, and Asian women. Black women age 50 to 64 years did not have changes in biennial mammography (0.4%; 95% CI, −2.6% to 3.5%). Conclusion Three years after publication of the 2009 USPSTF guidelines, mammography rates declined by 6% to 17% among white, Hispanic, and Asian women but not among black women. Small reductions in biennial mammography might be an unintended consequence of the updated guidelines

Emergency Department Use and Subsequent Hospitalizations Among Members of a High-Deductible Health Plan

Context Patients evaluated at emergency departments often present with nonemergency conditions that can be treated in other clinical settings. High-deductible health plans have been promoted as a means of reducing overutilization but could also be related to worse outcomes if patients defer necessary care. Objectives To determine the relationship between transition to a high-deductible health plan and emergency department use for low- and high-severity conditions and to examine changes in subsequent hospitalizations. Design, Setting, and Participants Analysis of emergency department visits and subsequent hospitalizations among 8724 individuals for 1 year before and after their employers mandated a switch from a traditional health maintenance organization plan to a high-deductible health plan, compared with 59 557 contemporaneous controls who remained in the traditional plan. All persons were aged 1 to 64 years and insured by a Massachusetts health plan between March 1, 2001, and June 30, 2005. Main Outcome Measures Rates of first and repeat emergency department visits classified as low, indeterminate, or high severity during the baseline and follow-up periods, as well as rates of inpatient admission after emergency department visits. Results Between the baseline and follow-up periods, emergency department visits among members who switched to high-deductible coverage decreased from 197.5 to 178.1 per 1000 members, while visits among controls remained at approximately 220 per 1000 (−10.0% adjusted difference in difference; 95% confidence interval [CI], −16.6% to −2.8%; P = .007). The high-deductible plan was not associated with a change in the rate of first visits occurring during the study period (−4.1% adjusted difference in difference; 95% CI, −11.8% to 4.3%). Repeat visits in the high-deductible group decreased from 334.6 to 255.3 visits per 1000 members and increased from 321.1 to 334.4 per 1000 members in controls (−24.9% difference in difference; 95% CI, −37.5% to −9.7%; P = .002). Low-severity repeat emergency department visits decreased in the high-deductible group from 142.5 to 92.1 per 1000 members and increased in controls from 128.0 to 132.5 visits per 1000 members (−36.4% adjusted difference in difference; 95% CI, −51.1% to −17.2%; P<.001), whereas a small decrease in high-severity visits in the high-deductible group could not be excluded. The percentage of patients admitted from the emergency department in the high-deductible group decreased from 11.8 % to 10.9% and increased from 11.9% to 13.6% among controls (−24.7% adjusted difference in difference; 95% CI, −41.0% to −3.9%; P = .02). Conclusions Traditional health plan members who switched to high-deductible coverage visited the emergency department less frequently than controls, with reductions occurring primarily in repeat visits for conditions that were not classified as high severity, and had decreases in the rate of hospitalizations from the emergency department. Further research is needed to determine long-term health care utilization patterns under high-deductible coverage and to assess risks and benefits related to clinical outcomes

Emergency Department Use and Subsequent Hospitalizations Among Members of a High-Deductible Health Plan

Context Patients evaluated at emergency departments often present with nonemergency conditions that can be treated in other clinical settings. High-deductible health plans have been promoted as a means of reducing overutilization but could also be related to worse outcomes if patients defer necessary care. Objectives To determine the relationship between transition to a high-deductible health plan and emergency department use for low- and high-severity conditions and to examine changes in subsequent hospitalizations. Design, Setting, and Participants Analysis of emergency department visits and subsequent hospitalizations among 8724 individuals for 1 year before and after their employers mandated a switch from a traditional health maintenance organization plan to a high-deductible health plan, compared with 59 557 contemporaneous controls who remained in the traditional plan. All persons were aged 1 to 64 years and insured by a Massachusetts health plan between March 1, 2001, and June 30, 2005. Main Outcome Measures Rates of first and repeat emergency department visits classified as low, indeterminate, or high severity during the baseline and follow-up periods, as well as rates of inpatient admission after emergency department visits. Results Between the baseline and follow-up periods, emergency department visits among members who switched to high-deductible coverage decreased from 197.5 to 178.1 per 1000 members, while visits among controls remained at approximately 220 per 1000 (−10.0% adjusted difference in difference; 95% confidence interval [CI], −16.6% to −2.8%; P = .007). The high-deductible plan was not associated with a change in the rate of first visits occurring during the study period (−4.1% adjusted difference in difference; 95% CI, −11.8% to 4.3%). Repeat visits in the high-deductible group decreased from 334.6 to 255.3 visits per 1000 members and increased from 321.1 to 334.4 per 1000 members in controls (−24.9% difference in difference; 95% CI, −37.5% to −9.7%; P = .002). Low-severity repeat emergency department visits decreased in the high-deductible group from 142.5 to 92.1 per 1000 members and increased in controls from 128.0 to 132.5 visits per 1000 members (−36.4% adjusted difference in difference; 95% CI, −51.1% to −17.2%; P<.001), whereas a small decrease in high-severity visits in the high-deductible group could not be excluded. The percentage of patients admitted from the emergency department in the high-deductible group decreased from 11.8 % to 10.9% and increased from 11.9% to 13.6% among controls (−24.7% adjusted difference in difference; 95% CI, −41.0% to −3.9%; P = .02). Conclusions Traditional health plan members who switched to high-deductible coverage visited the emergency department less frequently than controls, with reductions occurring primarily in repeat visits for conditions that were not classified as high severity, and had decreases in the rate of hospitalizations from the emergency department. Further research is needed to determine long-term health care utilization patterns under high-deductible coverage and to assess risks and benefits related to clinical outcomes