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Switching to high-deductible health plans (HDHPs) spelled trouble when it came to diabetes complications, a retrospective cohort study found.

In a group of over 40,000 patients whose employers forced a switch to an HDHP from a non-HDHP, the health plan pivot initially wasn't linked with an overall increased odds for a hypoglycemia-related emergency department (ED) visit or hospitalization (OR 1.01, 95% CI 0.95-1.06, P=0.85), reported Rozalina McCoy, MD, MS, of the Mayo Clinic in Rochester, Minnesota, and colleagues.

But this risk didn't exactly remain flat, the researchers reported in .

Each year that patients stayed enrolled in an HDHP, there was a small but significant 2% increase in the odds for at least one hypoglycemia-related ED visit or hospitalization (OR 1.02, 95% CI 1.00-1.04, P=0.04). On top of that, people enrolled in an HDHP had 11% higher odds for a severe hypoglycemic event (OR 1.11, 95% CI 1.08-1.14, P<0.001), which subsequently increased by 5% for each year of enrollment.

The proportion of HDHP enrollees experiencing hypoglycemia during an office visit was also 14% higher and subsequently increased another 6% with each additional year of enrollment.

This equated to 311 HDHP enrollees out of every 1,000 having any coded hypoglycemia each year compared with 282 per 1,000 non-HDHP enrollees per year.

Not surprisingly, this increased risk for hypoglycemia appeared to intersect with the patient's income level. The researchers found that enrollees with an annual household income of more than $40,000 were significantly less impacted by hypoglycemia-related emergency department and hospital visits (interaction OR 0.76, 95% CI 0.67-0.87, P<0.001). About 16% of the HDHP enrollees had annual incomes below this threshold.

"There was no interaction between income and hypoglycemia-related office visits, raising concerns about rationing of what patients may perceive to be elective care if patients with low income experience severe hypoglycemia requiring ED and hospital care but then forego ambulatory care to improve their glycemic control," McCoy and co-authors wrote.

Pivoting to an HDHP appeared even worse when it came to hyperglycemic episodes. The switch was associated with a 25% higher risk for at least one hyperglycemia-related ED visit or hospitalization (OR 1.25, 95% CI 1.11-1.42, P<0.001), marked by a steady 5% increase in the odds each year of HDHP enrollment.

McCoy's group explained that "although all patients may need to seek urgent medical care for severe hyperglycemia, patients with low income are more likely to forego ambulatory care to discuss these events, resulting in missed opportunities to improve glycemic control."

"Although HDHPs were created to lower insurance premiums and promote cost savings by limiting low value care, their implementation has adversely affected health outcomes in patients with diabetes," the researchers pointed out, adding that "HDHP enrollees may be rationing or foregoing necessary care, which is detrimental to their health and ultimately increases the morbidity, mortality, and costs associated with diabetes."

Data for the study were pulled from deidentified administrative claims data from a single private insurance carrier. Among the 42,326 patients who were switched to an HDHP, 46.7% were women, average age was 52, and 62.8% were white. More than half resided in the South.

The most common baseline deductible amount for the HDHP enrollees was $501-$1,350, compared with $251-$500 for the non-HDHP group.

There wasn't a significant difference between the groups in regard to which glucose-lowering medications were prescribed, the researchers noted. More than half of the patients in both groups were on metformin and about a quarter were on sulfonylureas. Less than 10% were on a GLP-1 receptor agonist, and less than 5% were on an SGLT2 inhibitor.

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