J. Frank Wharam, MB, BCh, BAO, MPH; Christine Y. Lu, PhD; Fang Zhang, PhD; Matthew Callahan, MS; Xin Xu, MS; Jamie Wallace, BA; Stephen Soumerai, ScD; Dennis Ross-Degnan, ScD; Joseph P. Newhouse, PhD
Note: Drs. Wharam and Zhang primarily analyzed the data.
Acknowledgment: The authors thank Robert LeCates, MA; Beverly Adade, MBE; and Katherine Callaway, MPH, of Harvard Pilgrim Health Care Institute for valuable assistance with literature searches, computer programming, data processing, and algorithm development. They also thank Meda E. Pavkov, MD, PhD, and Edward W. Gregg, PhD, of the Division of Diabetes Translation at the Centers for Disease Control and Prevention and Ronald T. Ackermann, MD, MPH, of the Center for Diabetes and Metabolism at Northwestern University for consultation on development of macrovascular disease outcome measures. Finally, the authors thank an anonymous reviewer for suggesting many helpful edits.
Grant Support: By grants R01-DK100304 (principal investigator: Dr. Wharam) from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and 1P30-DK092924 from the NIDDK Health Delivery Systems Center for Diabetes Translational Research.
Disclosures: Dr. Ross-Degnan reports employment with Harvard Pilgrim Health Care. Dr. Newhouse reports personal fees from Aetna outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-3365.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Proctor & Gamble, Pfizer, and Johnson & Johnson.
Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Wharam (e-mail, email@example.com). Data set: Not available because of data use agreement restrictions.
Corresponding Author: J. Frank Wharam, MB, BCh, BAO, MPH, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401, Boston, MA 02215; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Wharam, Lu, Zhang, Soumerai, and Ross-Degnan; Mr. Callahan; Mr. Xu; and Ms. Wallace: Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401, Boston, MA 02215.
Dr. Newhouse: Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115.
Author Contributions: Conception and design: J.F. Wharam, C.Y. Lu, S. Soumerai.
Analysis and interpretation of the data: J.F. Wharam, F. Zhang, M. Callahan, X. Xu, J. Wallace, S. Soumerai, D. Ross-Degnan, J.P. Newhouse.
Drafting of the article: J.F. Wharam, C.Y. Lu, M. Callahan, J. Wallace, J.P. Newhouse.
Critical revision of the article for important intellectual content: J.F. Wharam, C.Y. Lu, F. Zhang, M. Callahan, S. Soumerai, D. Ross-Degnan, J.P. Newhouse.
Final approval of the article: J.F. Wharam, C.Y. Lu, F. Zhang, M. Callahan, X. Xu, J. Wallace, S. Soumerai, D. Ross-Degnan, J.P. Newhouse.
Statistical expertise: J.F. Wharam, F. Zhang, J.P. Newhouse.
Obtaining of funding: J.F. Wharam.
Administrative, technical, or logistic support: J.F. Wharam, M. Callahan, J. Wallace.
Collection and assembly of data: J.F. Wharam, X. Xu, J. Wallace, D. Ross-Degnan.
Little is known about the long-term effects of high-deductible insurance on care for chronic medical conditions.
To determine whether a transition from low-deductible to high-deductible insurance is associated with delayed medical care for macrovascular complications of diabetes.
Observational longitudinal comparison of matched groups.
A large national health insurer during 2003 to 2012.
The intervention group comprised 33 957 persons with diabetes who were continuously enrolled in low-deductible (≤$500) insurance plans during a baseline year followed by up to 4 years in high-deductible (≥$1000) plans. The control group included 294 942 persons with diabetes who were enrolled in low-deductible plans contemporaneously with matched intervention group members.
Employer-mandated transition to a high-deductible plan.
The number of months it took for persons in each study group to seek care for their first major macrovascular symptom, have their first major diagnostic test for macrovascular disease, and have their first major procedure-based treatment was determined. Between-group differences in time to reach a midpoint event rate were then calculated.
No baseline differences were found between groups. During follow-up, the delay for the high-deductible group was 1.5 months (95% CI, 0.8 to 2.3 months) for seeking care for the first major symptom, 1.9 months (CI, 1.4 to 2.3 months) for the first diagnostic test, and 3.1 months (CI, 0.5 to 5.8 months) for the first procedure-based treatment.
Health outcomes were not examined.
Among persons with diabetes, mandated enrollment in a high-deductible insurance plan was associated with delays in seeking care for the first major symptoms of macrovascular disease, the first diagnostic test, and the first procedure-based treatment.
National Institute of Diabetes and Digestive and Kidney Diseases.
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;169:845–854. [Epub ahead of print 20 November 2018]. doi: https://doi.org/10.7326/M17-3365
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Published: Ann Intern Med. 2018;169(12):845-854.
Published at www.annals.org on 20 November 2018
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism.
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