Adults With Diabetes in High-Deductible Health Plans More Likely to Have Severe Hyperglycemia


Patients with diabetes who were forced to switch to a high-deductible health plan (HDHP) by their employer were more likely to experience acute diabetes complications that may have otherwise been preventable, possibly due to delayed or deferred care.

“These findings suggest that employers should be more judicious in their health plan offerings, and health plans and policy makers should consider allowing preventive and high-value services to be exempt from deductible requirements,” said the authors of the study, published in JAMA Network Open.

The retrospective cohort study included 42,326 patients with 1 baseline year of enrollment in a non-HDHP who were mandated to switch to an HDHP by their employer, and 202,729 patients who did not switch plans. The mean (SD) age was 52 (10) and 53 (10) in the HDHP and control group, respectively, and each group was 46.7% and 44.3% women. Racial diversity was comparable between both groups by percentage, though both groups were more than 60% non-Hispanic White.

Data were collected between January 2010 and December 2018 using deidentified administrative claims data for privately insured adults with diabetes from a single insurance carrier with multiple plans across the United States. Analyses were conducted between May 15, 2020, and November 3, 2022.

After adjusting for several factors, mixed-effects logistic regression models showed switching to an HDHP had differing associations with odds of severe hypoglycemia and hyperglycemia.

Switching to an HDHP was not associated with increased odds of experiencing an emergency department (ED) or hospital visit for severe hypoglycemia (OR, 1.01; 95% CI, 0.95-1.06; P = .85). However, each year of HDHP enrollment did increase these odds by 2% (OR, 1.02; 95% CI, 1.00-1.04; P = .04).

On the other hand, switching to an HDHP significantly increased these patients’ odds of an ED visit or hospitalization for hyperglycemia, with 25% higher odds during the study period (OR, 1.25; 95% CI, 1.11-1.42; P < .001) that increased 5% for each year of HDHP enrollment (OR, 1.05; 95% CI, 1.01-1.09; P = .02).

The study authors also looked at how trends differed based on income, race, and ethnicity. They also repeated models to include glucose-lowering medication classes as one of the adjustment covariates to assess if and how much an association between HDHP and patient outcome is mediated by the choice of glucose-lowering therapy.

After adding an interaction term between switching to HDHP and annual household income, the authors found that the associated change in hypoglycemia-related ED and hospital visits was smaller among patients with an income greater than $40,000 compared with patients with an income less than $40 000 (interaction OR, 0.76; 95% CI, 0.67-0.87; P < .001). However, the change in office visits for hypoglycemia was the same between patients with high and low income.

In contrast, there was no difference in the associated change in hypoglycemia-related ED or hospital visits based on race and ethnicity (interaction P = .22), but the change in office visits was smaller among patients who were part of minority racial and ethnic groups compared with White patients (interaction OR, 0.91; 95% CI, 0.86-0.96; P < .001).

For hyperglycemia, these results differed.

There was no significant interaction between switching to an HDHP and income with respect to hyperglycemia-related ED or hospital visits, but the switch was associated with a slightly bigger change in hyperglycemia-related office visits among patients in the higher income category compared with patients in the lower income category (interaction OR, 1.17; 95% CI, 1.00-1.37; P = .047).

The authors also found no significant interaction between switching to an HDHP and race and ethnicity regarding hyperglycemia-related ED, hospital, or office visits.

Results did not change when models were adjusted for glucose-lowering medications for both hypoglycemia and hyperglycemia.

“Although HDHPs were created to lower insurance premiums and promote cost savings by limiting low value care, their implementation has adversely affected health outcomes in patients with diabetes,” the authors wrote. “Individuals with low income and from minoritized racial and ethnic groups were especially susceptible to the detrimental outcomes of HDHP transition. Thus, HDHP enrollees may be rationing or foregoing necessary care, which is detrimental to their health and ultimately increases the morbidity, mortality, and costs associated with diabetes.”


Jiang DH, Herrin J, Van Houten HK, McCoy RG. Evaluation of high-deductible health plans and acute glycemic complications among adults with diabetes. JAMA Netw Open. 2023;6(1):e2250602. doi:10.1001/jamanetworkopen.2022.50602


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