Commercial High Deductible Plans May Not Impact Member Outcomes

Contrary to expectations, there may not be a correlation between deductible costs and member outcomes for commercial high deductible plans, according to a study published in JAMA Open Network.

The study looked at commercial and Medicare Advantage plans over a span of more than a decade. Researchers observed nearly 157,000 individuals with cardiovascular disease risk factors who also switched from a low deductible plan to a high deductible plan.

The study compared this group to nearly 1.5 million individuals who had similar risk factors but who remained in the low deductible health plan. For four years, the researchers followed up with individuals to track the healthcare spending patterns of these two groups.

The high deductible health plan members had a mean age of 53 years old and were fairly evenly split in gender representation and between those who lived in impoverished areas. A quarter had a high school education or lower.

Almost 30,500 in the high deductible health plan group had diabetes, over 127,600 had other cardiovascular risk factors, and more than 4,000 were high risk.

When the researchers compared the two groups, they found that there were no significant differences in healthcare spending, even for those with diabetes.

Enrollees with high deductible health plans saw cost-sharing levels increase by around 25 to 30 percent. However, researchers did not see a correlation between these cost increases and patient outcomes, such as amputations or strokes.

The results conflicted with expectations based on prior research.

In general, higher deductibles are associated with higher costs for members and negative health outcomes, such as premature birth and stillborn pregnancies when mothers delay care due to costs.

“High-deductible health plans were supposed to make us better healthcare consumers, but they have failed,” said Donald J. Palmisano, Jr., executive director and chief executive officer of the Medical Association of Georgia in a previous study conducted by the National Opinion Research Center (NORC) at the University of Chicago.

“They force people attracted by low premiums to choose between healthcare and housing, or food. They’re an idea that turned out to be bad for both patients and doctors.”

However, this latest JAMA Open Network study had a different outcome. According to the researchers, there were four possible explanations for this discrepancy.

First, they suggested that, since high deductible health plans cover preventive care and prescription drug spending, members may have reduced their overall healthcare spending through preventive care.

Second, since the study observed commercially insured individuals it did not account for the more vulnerable groups in Medicaid and other public payer plans that might see higher healthcare spending.

Third, the mean deductible for the high deductible health plans in the study was $2,000 which may exclude health plans with extremely high deductibles that may have a greater association between cost and patient outcomes. However, these health plans are less common.

Fourth, the association between high deductibles and poor patient outcomes in cardiovascular health may only be discernible after a much longer membership in a high deductible health plan. The study only followed the participants for four years.

Based on these unexpected findings, the researchers offered a couple of suggestions.

The study did not confirm or deny the tie between financially vulnerable populations in high deductible health plans and poor patient outcomes, so the researchers recommended discretion in pushing these plans for those populations.

Also, value-based care features of the studied health plans may have protected high deductible health plan enrollees from higher costs that would occur in plans without value-based features.

“Mandated enrollment in HDHPs was not associated with a significantly increased risk of major adverse cardiovascular events during 4 years of follow-up in the present study,” the researchers concluded.

“Future studies should include longer follow-up, rigorously examine effects of value-based medication cost-sharing arrangements within HDHPs and assess outcomes among low-income HDHP members.”

One factor that the study did not include was health savings accounts. Not many of the study participants had a health savings account, however.

A separate study recently published in JAMA Open Network found that members were largely unaware of their options when it came to health savings accounts (HSAs). Over a third of high deductible health plan members that were surveyed did not have an HSA and many of those who did were not using it.