Association Between High-Deductible Health Plans and Hernia Acuity

Abstract

IMPORTANCE About half of people younger than 65 years with private insurance are enrolled in a high-deductible health plan (HDHP). While these plans entail substantially higher out-of-pocket costs for patients with chronic medical conditions who require ongoing care, their effect on patients undergoing surgery who require acute care is poorly understood. It is plausible that higher out-of-pocket costs may lead to delays in care and more complex surgical conditions. OBJECTIVE To determine the association between enrollment in HDHPs and presentation with incarcerated or strangulated hernia. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort analysis included privately insured patients aged 18 to 63 years from a large commercial insurance claims database who underwent a ventral or groin hernia operation from January 2016 through June 2019 and classified their coverage as either a traditional health plan or an HDHP per the Internal Revenue Service's definition. Multivariable regression, adjusting for demographic and clinical covariates, was used to examine the association between enrollment in an HDHP and the primary outcome of presentation with an incarcerated or strangulated hernia.EXPOSURES Traditional health plan vs HDHP. MAIN OUTCOMES AND MEASURES Presence of an incarcerated or strangulated hernia per International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes.RESULTS Among 83 281 patients (71.9% men and 28.1% women; mean [SD] age, 48.7 [10.9] years) who underwent hernia surgery, 27 477 (33.0%) were enrolled in an HDHP and 21 876 (26.2%) had a hernia that was coded as incarcerated or strangulated. The mean annual deductible was considerably higher for those in the HDHP group than their traditional health plan counterparts

Large Variations in the Prices of Urologic Procedures at Academic Medical Centers 1 Year After Implementation of the Price Transparency Final Rule

“…[2][3][4] High out-ofpocket costs represent a substantial financial burden for some patients, who may then forgo or delay necessary care. 5,6 To improve patient care and combat rising prices, the Centers for Medicare & Medicaid Services (CMS) passed the Hospital Price Transparency Final Rule, which requires that hospitals publish their standard charges in a publicly available, machine-readable file. 7 Price transparency is a prerequisite for price shopping, and according to standard economic theory, price shopping ensures that identical goods at different locations have the same price (the Law of One Price).…”

“…For the 31.6 million US individuals without health insurance and the 40% of privately insured US individuals with high-deductible health plans, these high prices can translate to high out-of-pocket costs . High out-of-pocket costs represent a substantial financial burden for some patients, who may then forgo or delay necessary care …”

High Deductibles are Associated With Severe Disease, Catastrophic Out-of-Pocket Payments for Emergency Surgical Conditions

“…[24][25][26][27][28][29] However, our findings add to more recent evidence that should increase caution about potential unintended and negative consequences of HDHPs. For instance, Yelorda et al 30 found that hernia patients enrolled in HDHPs were more like to have findings of incarceration or strangulation, and an analysis by Loehrer et al 31 identified an association between higher degrees of cost-sharing and early uncomplicated presentation for acute appendicitis and acute diverticulitis. However, neither of these studies had the ability to comment on rates of catastrophic health spending or on variations across race, ethnicity, or income.…”

High-deductible Health Plans, Surgical Conditions, and a Different Moral Hazard

“…Prior work has shown that increased cost-sharing is associated with decreased utilization of health services, including both indicated or beneficiary services and more discretionary or unneeded services 4–6 . The present study builds on growing evidence that increasing patient cost-sharing, here specifically through high-deductible plans, is associated with delays in presentation, more severe disease, and ultimately much higher rates of CHEs for patients with common surgical conditions 7,8 . In addition, Scott and colleagues were able to evaluate variation by patient race/ethnicity and income.…”

“…much higher rates of CHEs for patients with common surgical conditions. 7,8 In addition, Scott and colleagues were able to evaluate variation by patient race/ethnicity and income. Perhaps not surprisingly, these findings only further underscore the broader socioeconomic and racial inequity in the United States, especially via the wealth gap.…”