Impact of HSA Cost Sharing Reductions on High-deductible Members with Diabetes

 描述（由申请人提供）：高免赔额健康计划（HDHPs）的保费较低，但要求患者支付大多数医疗护理的全部费用，直到满足每年1000美元至6000美元的免赔额。在过去十年中，高人权高专办迅速增加。健康储蓄账户（HSA）合格的HDHP是增长最快的HDHP安排，现在覆盖了14%的商业保险美国人。这些计划使大多数医疗保健服务（包括药物）每年都有很高的免赔额，但允许向可用于医疗费用的账户提供税前捐款。倡导者认为，让患者承担更高的费用将创造“激活的消费者”，他们将寻求更高价值的医疗保健并采取健康的行为，而批评者担心这些经济障碍可能会减少获得所需医疗服务的机会。我们正在进行的糖尿病转化自然实验（NEXT-D）项目（5 U 58 DP 002719）已经确定，患有HSA-HDHPs的糖尿病患者在医院就诊和坚持慢性病关键药物治疗方面的减少幅度最大。尽管这些发现令人担忧，但联邦法规允许雇主通过两种机制来定制HSA-HDHPs，这两种机制可以改善获得护理的机会：（1）免除某些慢性药物的免赔额要求（即，通过“预防药物清单”（0美元-PD），患者的药物成本为0美元），以及（2）慷慨资助HSA，以便员工支付更少的自付费用。因此，HSA-HDHPs对糖尿病患者来说既是一种风险，也是雇主通过定制成本分担减少来改善护理的机会。在本申请中，我们将研究HDHP设计中这两种重要变化对糖尿病二级预防、高优先级护理、糖尿病并发症和成本的影响，包括总体和弱势亚组（男性、低社会经济地位、黑人或西班牙裔、重度糖尿病、高合并症）。我们将采用一种尖端的中断时间序列研究设计，近似于随机对照试验的估计。我们将从一个由大型国家健康计划承保的超过6000万成员的12年滚动队列（2005-2017）中抽取，其中有30，000名糖尿病患者经历了雇主强制的HSA-HDHP过渡。我们还将从雇主和成员的角度对零美元PD和慷慨资助的HSAs对总医疗保健和自付成本的影响进行经济分析。我们的研究结果将使政策制定者和雇主能够开发量身定制的下一代健康保险设计，优化HDHPs下最脆弱的糖尿病患者的质量和公平性。

 DESCRIPTION (provided by applicant): High deductible health plans (HDHPs) have lower premiums, but require patients to pay the full cost of most medical care until annual deductibles of $1000 to $6000 are met. HDHPs have proliferated rapidly over the last decade. Health Savings Account (HSA)-qualified HDHPs are the most rapidly growing HDHP arrangement, now covering 14% of commercially insured Americans. These plans subject most health care services (including medications) to high annual deductibles but allow pre-tax contributions to accounts that can be used for medical costs. Advocates believe that exposing patients to greater costs will create "activated consumers" who will seek higher-value health care and adopt healthy behaviors, while critics fear that these economic barriers may reduce access to needed care. Our ongoing project in the Natural Experiments in Diabetes Translation (NEXT-D) initiative (5U58DP002719) has determined that diabetes patients with HSA-HDHPs experience the largest reductions in hospital access and adherence to key medications for chronic illness. Although these findings are concerning, federal regulations allow employers to tailor HSA-HDHPs through two mechanisms that could improve access to care: (1) Exempting certain chronic medications from deductible requirements (i.e., medications cost $0 to patients) through "preventive drug lists" ($0-PDs), and (2) Generously funding HSAs so that employees pay less out-of-pocket. Thus, HSA-HDHPs represent both a risk to diabetes patients but also an opportunity for employers to improve care through tailored cost sharing reductions. In this application, we will examine effects of these two important variations in HDHP design on diabetes secondary prevention, high priority care, diabetes complications, and costs, both overall and among vulnerable subgroups (men, low socioeconomic status, Black or Hispanic, severe diabetes, high comorbidity). We will employ a cutting-edge interrupted time series study design that approximates the estimates of randomized controlled trials. We will draw from a 12-year rolling cohort (2005-2017) of >60 million members insured by a large national health plan, with 30,000 diabetes patients who experience employer-mandated transitions to HSA-HDHPs. We will also conduct economic analyses from the employer and member perspectives of the impacts of $0-PDs and generously funded HSAs on total health care and out-of-pocket costs. Our findings will allow policy makers and employers to develop tailored, next-generation health insurance designs that optimize quality and equity for diabetes patients who are most vulnerable under HDHPs.