High-deductible Health Plans, Surgical Conditions, and a Different Moral Hazard.
High-deductible Health Plans, Surgical Conditions, and a Different Moral Hazard.
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高免赔额健康计划、手术条件和不同的道德风险。
DOI：
10.1097/sla.0000000000006010
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发表时间：
2023
影响因子：
9
通讯作者：
Loehrer,AndrewP
中科院分区：
文献类型：
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作者：
Loehrer,AndrewP
2010 年《患者保护和平价医疗法案》旨在解决美国医疗保健系统中的两大危机，即患者和公共部门获得医疗保健的机会和医疗费用。十多年后，未参保的美国人数量大幅减少，这主要是通过扩大医疗补助资格、扩大受抚养人覆盖范围以及建立非团体市场来实现的。然而，日益常见的高免赔额健康计划 (HDHP) 为 50% 至 60% 拥有雇主资助保险的美国人获得医疗服务的财务机会造成了新的障碍。最近的一份报告发现，超过一半的美国私营部门工人加入了 HDHP，单一保险计划的平均每年免赔额接近 3000 美元。 1 同时，公共调查发现，43% 的工作年龄成年人保险不足，49% 的人表示无法在 30 天内支付意外的 1000 美元医疗费用。 2 嗯，超过 50% 的接受调查的低收入非西班牙裔黑人和西班牙裔成年人表示，他们将无法支付如此意外的医疗费用。这些财务障碍不仅影响接受护理的整体负担能力，而且越来越多地影响患者寻求护理的延误，包括常见的急诊普通外科 (EGS) 情况。在本期《外科年鉴》中，Scott 及其同事评估了 HDHP 对就诊时 EGS 病情严重程度的影响，以及灾难性健康支出 (CHE) 的相关比率，其定义为自付费用超过年收入的 10%。 3 该研究使用了 2016 年至 2019 年入院的 18 岁至 64 岁商业保险患者的全国数据，这些患者患有急性阑尾炎、急性胆囊炎、肠梗阻或急性憩室炎。通过 HDHP 覆盖的患者与出现严重疾病的几率增加相关 [比值比 (OR)= 1.23]。即使作者控制了患者教育、收入和保险亚型，这种就诊时严重疾病风险增加的情况仍然成立。因 EGS 病症入院的 HDHP 患者中，超过 20% 的自付费用超过其收入的 10%，而拥有标准保险计划的患者中这一比例为 6.4%。即使在控制了混杂因素（包括严重疾病的表现）后，HDHP 的承保也与经历 CHE 的几率显着增加相关（OR = 3.93）。这种关联明显大于就诊时出现更严重、更复杂疾病的影响（OR = 1.20）。这项工作也很好地证明了 HDHP 作为结构性不平等的结果和驱动因素的作用。与非西班牙裔白人患者相比，研究人群的平均家庭年收入非西班牙裔黑人患者低近 50%，西班牙裔患者低 30%。与非西班牙裔白人患者相比，非西班牙裔黑人和西班牙裔患者发生 CHE 的几率也明显更高（OR 分别为 2.46 和 2.09）。此外，研究发现 HDHP 对低收入者（与中等收入和高收入者相比）以及非西班牙裔黑人和西班牙裔患者（与非西班牙裔白人患者相比）的 CHE 影响要大得多。政策效果的这种异质性是美国社会经济和种族不平等的一个关键驱动因素，但常常被忽视。 HDHP 越来越普遍，旨在降低保费……
The 2010 Patient Protection and Affordable Care Act aimed to address 2 crises in the US health care system, namely access to health care and cost of care to both patients and the public sector. More than 10 years later, there has been a considerable decrease in the number of uninsured Americans, largely through expansion of Medicaid eligibility, implementation of the dependent coverage expansion, and establishment of nongroup marketplaces. However, increasingly common high-deductible health plans (HDHP) create new barriers to financial access to care for the 50% to 60% of Americans with employer-sponsored insurance coverage. A recent report found that over half of American private-sector workers were enrolled in HDHP with an average annual deductible for single-coverage plans approaching $3000 USD. 1 At the same time, public surveys found that 43% of working-age adults were inadequately insured, and 49% of individuals reported being unable to pay an unexpected $1000 USD medical bill within 30 days. 2 Well, over 50% of low-income, non-Hispanic Black, and Hispanic adults surveyed shared that they would be unable to pay such an unexpected medical bill. These financial barriers are impacting not only the overall affordability of care received but are increasingly demonstrating an influence on patient delays in seeking care, including for common emergency general surgical (EGS) conditions. In this edition of Annals of Surgery, Scott and colleagues evaluate the influence of HDHP on severity of EGS conditions at the time of presentation as well as the associated rates of catastrophic health expenditures (CHE), defined as out-of-pocket expenses exceeding 10% of annual income. 3 The study used national data of commercially insured patients aged 18 to 64 years old admitted from 2016 to 2019 with acute appendicitis, acute cholecystitis, intestinal obstruction, or acute diverticulitis. Patient coverage through an HDHP was associated with increased odds of presentation with severe disease [odds ratio (OR)= 1.23]. This increased risk of severe disease at presentation held true even when authors controlled for patient education, income, and insurance subtype. More than 20% of patients with HDHPs who were admitted with these EGS conditions experienced out-of-pocket spending> 10% of their income compared with 6.4% of patients with standard insurance plans. Even after controlling for confounding factors, including a presentation with severe disease, coverage through an HDHP was associated with markedly increased odds of experiencing a CHE (OR= 3.93). This association is significantly greater than the impact of presenting with a more severe, complex disease at the time of presentation (OR= 1.20). The role of HDHPs as both a result and driver of structural inequities was also well demonstrated in this work. The study population had a mean annual household income that was nearly 50% lower for non-Hispanic Black patients and 30% lower for Hispanic compared with non-Hispanic White patients. Non-Hispanic Black and Hispanic patients both also had markedly higher odds of CHE as compared with non-Hispanic White patients (OR= 2.46 and 2.09, respectively). Further, the study found a disproportionately greater impact of HDHPs on CHE for low-income earners (compared with middle-income and high-income earners) and for non-Hispanic Black and Hispanic patients (compared with non-Hispanic White patients). Such heterogeneity of policy effects is a critical though often overlooked driver of socioeconomic and racial inequity in the United States. HDHPs are increasingly common, aiming to decrease premiums …