Evaluation of High-Deductible Health Plans and Acute Glycemic Complications among Adults with Diabetes

Abstract

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 42326 patients who switched to an HDHP (mean [SD] age: 52 [10] years, 19752 [46.7%] women, 7375 [17.4%] Black, 5740 [13.6%] Hispanic, 26572 [62.8%] non-Hispanic White) and 202729 patients who did not switch (mean [SD] age, 53 [10] years, 89828 [44.3%] women, 29551 [14.6%] Black, 26689 [13.2%] Hispanic, 130843 [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