Evaluating two novel, population-tailored health insurance designs: impact on diabetes outcomes

Duke University, Durham NC

Investigators

Abstract

PROJECT SUMMARY/ABSTRACT Low-income people with diabetes are struggling with the high costs of health care. Among working age adults, this is often caused by high-deductible health plans (HDHP) that require annual out-of-pocket payments of up to $16,000 per family. HDHPs are attractive to employers and some workers because of their low monthly pre- miums that have the potential to increase real wages. However, after 2010-15, as HDHP prevalence exceeded 30-40%, rates of acute and chronic diabetes complications began rising among younger adults. Experts are concerned that the cost barriers under HDHPs are partially contributing. In an attempt to avoid such harms among low-income workers while providing affordable premiums, an in- creasing number of employers are adopting a novel approach. In recent years, approximately 11-18% of firms have selectively provided more generous health benefits to only their low-income workers. For example, em- ployers might provide free diabetes medicines (“preventive drug lists”) or low deductibles to hourly workers while executives receive HDHPs. Such “population-tailored” designs represent a potentially major advance in decades-long efforts to improve both equity and cost efficiency in the private U.S. health system. Population-tailored designs could especially improve outcomes in diabetes given its disproportionate impact on low-income people. Nevertheless, health and financial effects of such designs are unknown. The overarching goal of this project is therefore to assess whether population-tailored insurance designs improve dia- betes care, outcomes, and spending. Analyses will leverage a large, national health insurance claims data- base from 2019-2028 to study approximately 1.75 million working age adults at risk for adverse diabetes-re- lated outcomes. The Specific Aims are: 1. Assess 10-year trends in the adoption of population-tailored health insurance designs. 2. Evaluate impacts of low-deductible-based population-tailored designs on diabetes screening and diagnosis. 3. Examine effects of employer switches to low-deductible-based population-tailored designs on secondary preventive diabetes care, acute preventable diabetes complications, and diabetes-related spending. 4. Determine effects of employer switches to $0 preventive drug list-based population-tailored designs on sec- ondary preventive diabetes care, acute preventable diabetes complications, and diabetes-related spending. The research will use the most rigorous observational study designs including controlled interrupted time series and segmented survival. Results could demonstrate that population-tailored plans increase diabetes secondary prevention, improve health outcomes, and reduce employer spending versus HDHP-only employers. In a health system dominated by cost-prohibitive HDHPs and cost-related disparities, such evidence could enhance employer adoption and inform national policymaking efforts to encourage uptake of population-tailored plans. These efforts could move the U.S. toward being a more equitable, efficient, and affordable health system.