Asthma Enrollment: Do High Insurance Deductibles Make a Difference?
You might think that when asthma patients unintentionally switched from regular insurance to high-deductible health plans (HDHP), a substantial number would cut back on their daily controller medications – but you’re usually wrong, researchers say.
In fact, in a study of some 185,000 pediatric and adult asthma patients from 2002 to 2014, average adherence (measured by prescription refills and days covered by filled prescriptions) did not change. markedly with such switches, reported Alison A. Galbraith, MD, PhD, of Harvard Medical School in Boston, and colleagues from Pediatrics JAMA.
A few comparisons showed minor but statistically significant differences. For example, adults switched to HDHP who used inhaled corticosteroids and long-acting beta-agonist controllers (ICS-LABA) showed a 1.4% greater decrease in days covered compared to patients remaining on the diets. conventional (95% CI 0.3% -2.5%), but not in other measures of adherence.
Additionally, people who switched to eligible HDHPs for Health Savings Accounts (HSAs), which typically submit controller medications to the deductible, had a 4.8% higher reduction in covered days (CI at 95% 1.9% -7.7%) compared to HSA HDHP registrants, for whom these drugs are generally exempt from the deductible. This was also the only major difference between the groups in this analysis.
In addition, these reductions in adherence do not appear to increase the risk of exacerbations. Claims data showed that neither asthma-related emergency room visits nor oral corticosteroid prescriptions (often used as rescue medication) differed between patient groups, whether stratified by HDHP versus conventional plans or by HSA versus non-HSA HDHP.
Previous studies of HDHP and asthma drug use had shown mixed results, said Galbraith and colleagues, although an adverse effect of high deductibles has long been suspected.
An accompanying editorial by two specialists at Lurie Children’s Hospital in Chicago, said the new findings “may be somewhat reassuring to skeptics of HDHP.”
But authors Jennifer Kusma, MD, MS and Matthew M. Davis, MD, MAPP, added that the study did not completely dispel suspicion.
For example, they wrote, it is not known how many children overall are enrolled in HDHP that does not exempt anti-asthmatic drugs from deductibles. And neither the current study nor others have addressed HDHP’s policies on medication for other chronic conditions, which might not be as generous as those of asthma controllers.
Galbraith and his colleagues noted other limitations as well. It is possible, they wrote, that the reductions in adherence were concentrated in patients at low baseline risk of exacerbations, who may have rightly believed they could safely skip doses. of their controller medications.
Taken at face value, however, the study findings support so-called value-based health policies that emphasize prevention and cost-effectiveness in determining what insurance should pay, according to the authors of study and editorial writers.
“Policymakers should consider adopting value-based designs and other policies that exempt drugs important for asthma and other chronic diseases from the franchise, which could prevent adverse clinical outcomes in HDHP.” , wrote Galbraith and colleagues.
For their part, Kusma and Davis said: “Policymakers need to think more about other elements of health care that should be exempt from deductibles in HDHP in order to minimize the risks and maximize the benefits for children enrolled in such. plans.
Galbraith’s group drew on data from a claims database spanning adults (up to 64 years old) and children (4 to 17 years old) enrolled in employer-sponsored commercial plans over a 13-year period starting in 2002. Patients included 7,275 children and 17,614 adults whose regimens were replaced by HDHP from more conventional low-deductible models, who were then compared to control groups comprising more 45,000 children and 114,000 adults remaining in conventional regimes.
HDHPs were defined as plans with deductibles of at least $ 1,000. They were then divided into those eligible for HSAs under federal regulations (which changes annually, currently at deductibles of $ 1,400 or more) and those not; 10% of the patients in the study had HDHP HSA. These plans generally do not exempt controlled drugs from the deductible, but assume that patients will pay for them on their HSA. (Non-HSA HDHPs may still impose medication control costs on registrants, in the form of co-payments, noted Galbraith and colleagues.)
Two related measures of adherence were monitored: the rate of 30-day refills of standard asthma control drugs, including ICS-LABA drugs, ICS alone, or leukotriene inhibitors such as montelukast (Singulair ); and the proportion of days covered by these agents.
For all three types of drugs, the latter measure showed substantial decreases over time in both groups, those who switched to HDHP and those who did not. But these declines were of similar magnitude in the two groups, suggesting that HDHP was not responsible. Both groups also showed decreases, not increases, in point estimates of adverse clinical outcomes, including oral corticosteroid use and asthma-related emergency visits.
Galbraith and his colleagues also looked at neighborhood wealth as a potential factor in patient responses to HDHP. About 40% of the people in the study lived in low-income neighborhoods. The adherence patterns in these patients were generally the same as in the study as a whole, with slightly larger reductions among those who switched to HDHP, but no higher rate of adverse clinical outcomes recorded in the data on claims.
The researchers noted that this data does not necessarily cover all side effects: days without work or school, for example, would be missed, as would an increase in symptoms that would not result in a new prescription or a visit to the doctors. emergency room. In addition, socioeconomic data was only available for neighborhoods and not for individuals.
Last updated on May 16, 2021
The study was funded by the Patient-Centered Outcomes Research Institute.
The study authors and editorial writers did not report any relationships with commercial entities.