Men cut back on needed health care after switching to high-deductible insurance plans

(Press-News.org) Philadelphia, Pa. (July 16, 2013) – After switching to high-deductible health plans (HDHPs) in the US, men make fewer emergency department visits for even severe problems—which may lead to a later increase in hospitalization rates, suggests a study in the August issue of Medical Care, published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

In contrast, women respond to HDHPs more appropriately, reducing emergency visits only for less-severe problems. The gender differences raise concerns that "[M]en who transition to HDHPs may forego needed care in the immediate term, resulting in delays or increased severity of illness when care is later sought and received," according to the study by Katy B. Kozhimannil, PhD, MPA, of University of Minnesota School of Public Health, Minneapolis, and colleagues.

When Deductibles Rise, Men Avoid the Emergency Room… The researchers analyzed data from a large insurance plan on members whose employers had mandated a switch to an HDHP. These increasingly popular plans feature lower premiums—but also have higher annual deductibles, which members must typically pay out of pocket. Members in the HDHPs had individual deductibles ranging from US$500 to $2,000, with family deductibles of US$1,000 to $4,000.

For the study, changes in health care use in the first two years were assessed for approximately 6,000 men and 6,500 women in the US who switched to an HDHP. Trends were compared with men and women who remained in a traditional HMO plan.

In the year after transition to an HDHP, men made significantly fewer emergency department visits. Visits for low- and intermediate-severity problems decreased by 21 percent, while high-severity visits decreased by 34 percent, compared to men who remained in HMOs.

Women also made fewer emergency visits after switching to an HDHP, including a 27 percent reduction in low-severity visits. However, for women there was no decrease in visits for more severe problems.

…Leading to Higher Hospitalization Rates Later On Men also had a dramatic 24 percent reduction in hospitalizations during their first year in an HDHP. However, this trend was completely reversed the following year, when hospital admissions increased by 30 percent. The trends suggest that men might have put off needed care after their deductible went up—leading to more severe illness requiring hospital care later on.

High-deductible plans are an increasingly popular way to "incentivize members to reduce inappropriate health care"—such as going to the emergency room for less-severe problems—"while maintaining appropriate use of preventive and necessary services." The new study is one of the first to look at possible gender differences in responses to HDHPs.

"In our study, the HDHP seemed to act as a 'blunt instrument' among men, reducing care across the board—emergency visits across all severity levels and hospital care— in the year following transition to an HDHP," according to Dr Kozhimannil. "In contrast, women seemed to respond to the HDHP largely as intended, maintaining stable rates of intermediate and high severity care and limiting reductions in ED utilization to low severity visits."

The study raises concerns about some possible unintended consequences of HDHPs—especially among men, who may delay or reduce necessary care when out-of-pocket costs go up. Dr Kozhimannil and coauthors suggest that health plans and employers may want to develop educational programs to inform HDHP members about their benefits, and the risks of avoiding needed care because of costs. They add, "Employers that primarily hire men might want to carefully consider whether HDHPs are the optimal choice of coverage."

"As a clinician, our results weren't highly surprising because I often see men hesitant to come to the doctor for a variety of reasons," adds Dr Frank Wharam of Harvard Pilgrim Health Care Institute, senior author of the new study. "But from a research perspective, we don't usually think of men as vulnerable to health policies.

"The study points to a general lack of understanding of how modern high-deductible plans affect important patient subgroups," Dr Wharam adds. "The Affordable Care Act will greatly expand high-deductible insurance, and research on potentially vulnerable populations is urgently needed."

### About Medical Care Rated as one of the top ten journals in health care administration, Medical Care is devoted to all aspects of the administration and delivery of health care. This scholarly journal publishes original, peer-reviewed papers documenting the most current developments in the rapidly changing field of health care. Medical Care provides timely reports on the findings of original investigations into issues related to the research, planning, organization, financing, provision, and evaluation of health services. In addition, numerous special supplementary issues that focus on specialized topics are produced with each volume. Medical Care is the official journal of the Medical Care Section of the American Public Health Association

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