The Implications of Insurance Benefit Design for Health and Disability Among Low Income Adults with Diabetes.

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Project Summary/Abstract This career development award will establish Dr. Kimberly Narain, MD, PhD, MPH, as an independent investigator focused on evaluating the health, aging and healthcare costs implications of social, economic and health policies/programs, among adults with low socioeconomic status (SES), using both quasi-experimental and microsimulation approaches. This KO8 award will provide her the support she needs to develop expertise in 3 areas 1) analysis of administrative claims and longitudinal data; 2) aging epidemiology and SES disparities in aging; and 3) microsimulation and cost-benefit analysis. Non-adherence to medications and treatment recommendations due to costs is an important driver of the SES gradient in health and disability among adults with diabetes.1 Value Based Insurance Design (VBID) strategies that reduce out-of-pocket (OOP) costs for medications to treat diabetes and associated conditions (hyperlipidemia and hypertension) as well as disease management appointments (primary care and endocrinologist visits) have been shown to improve medication adherence and cardiovascular risk factor control, among privately insured individuals. However, little is known about the effects of VBID among low income adults with Type 2 diabetes. 2,3 Understanding the effect of VBID among low income adults is important because they face the highest disease burden associated with Type 2 diabetes and they may be particularly responsive to VBID given their higher level of price sensitivity, relative to higher income individuals.4 However, they may also face barriers outside of costs such as low health literacy, making the effects of VBID among this population uncertain. Additionally, it is important to know if there is any heterogeneity in response to VBID, across baseline medication adherence levels, given that prior studies have shown the largest effect magnitudes among subgroups with the lowest baseline medication adherence levels. Lastly, the long-term impacts of VBID on the health, disability and healthcare costs of low income adults with diabetes remains uninvestigated. Dr. Narain will clarify the impact of VBID among this population by examining the impact of the Diabetes Health Plan (DHP), an employer-sponsored VBID, offered by Unitedhealthcare, among low income (salaries < $30,000), adults with Type 2 diabetes. This project will leverage an existing data set of more than 200 employers, housed at UCLA, to estimate both the short and long-term impacts of the DHP, using quasi-experimental methods and a microsimulation modeling approach, respectively. The specific aims of the proposed project are to 1) Estimate the impact of the DHP on (A) medication adherence, (B) cardiovascular risk factors (HbA1c and LDL) and (C) healthcare utilization among low income adults with Type 2 diabetes; 2) Compare DHP treatment effects across baseline levels of medication adherence and 3) Estimate the long-term impact of the DHP, relative to standard health insurance plans, on disability-free life expectancy and healthcare costs among aging low income adults with Type 2 diabetes. The project will provide key insight for informing health insurance benefit design and improving health equity.