Delay in Diabetes Diagnosis After High-Deductible Health Plan Enrollment: A Pre-Post Study with Control.

BACKGROUND: High-deductible health plan (HDHP) members face relatively high out-of-pocket (OOP) costs for urgent care, high-acuity care, and secondary prevention. These costs could affect the timing of cardiometabolic disease diagnosis. OBJECTIVE: To determine whether HDHPs are associated with delays in diabetes diagnosis and increases in health care costs in the period surrounding new diagnoses. DESIGN: Segmented survival with control group and pre-post with control group. PARTICIPANTS: Members aged 18 to 64 years without diabetes at the beginning of the pre-index period. Characteristics of interest for stratified analyses comprised sex, income, and race/ethnicity. INTERVENTION: Employer-mandated transition from low-deductible health plan to HDHP. MAIN MEASUREMENTS: Time to first diabetes diagnosis; and total and OOP medical costs in the peri-diagnosis period (from 30 days before to 90 days after first diabetes diagnosis). KEY RESULTS: In this sample of 346,492 HDHP members and 346,492 matched and weighted controls, the mean (SD) age was 42.3 (13.0) years, and 48.5% were women. The overall and female HDHP groups experienced delays in diabetes diagnosis in the post- versus pre-index period (adjusted hazard ratio, aHR: 0.93 [95% CI 0.88, 0.99] and 0.91 [0.83, 0.99], respectively), compared with controls. These hazard ratios corresponded to delays of 1.7 and 2.1 months compared with median diagnosed control patients. Other HDHP subgroups did not have statistically significant delays. HDHP group members newly diagnosed with diabetes had relative post- versus pre-index increases in total and OOP peri-diagnosis medical costs of 20% (95% CI 1%, 39%) and 51% (95% CI 33%, 60%), respectively, versus controls. CONCLUSIONS: HDHP enrollment was associated with delayed diabetes diagnosis and substantially increased peri-diagnosis total and OOP medical costs. Female HDHP members might be especially at risk. Policymakers should consider reducing OOP costs for key health care services associated with diagnosing diabetes.

Duke Scholars

Author J. Franklin Wharam Medicine, General Internal Medicine