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Objective: To evaluate the association between employer-mandated enrollment into high-deductible health plans (HDHPs) and contraception and birth rates among reproductive-age women.Data Sources/study Setting: Using data from 2002 to 2008, we examined 1,559 women continuously enrolled in a Massachusetts health plan for 1 year before and after an employer-mandated switch from an HMO to a HDHP, compared with 2,793 matched women contemporaneously enrolled in an HMO.Study Design: We used an individual-level interrupted time series with comparison series design to examine level and trend changes in clinician-provided contraceptives and a differences-in-differences design to assess annual birth rates.Data Collection/extraction Methods: Employer, plan, and member characteristics were obtained from enrollment files. Contraception and childbirth information were extracted from pharmacy and medical claims.Principal Findings: Monthly contraception rates were 19.0-24.0 percent at baseline. Level and trend changes did not differ between groups (p = .92 and p = .36, respectively). Annual birth rates declined from 57.1/1,000 to 32.7/1,000 among HDHP members and from 61.9/1,000 to 56.2/1,000 among HMO controls, a 40 percent relative reduction in odds of childbirth (odds ratio = 0.60; p = .02).Conclusions: Women who switched to HDHPs experienced a lower birth rate, which might reflect strategies to avoid childbirth-related out-of-pocket costs under HDHPs. [ABSTRACT FROM AUTHOR]

One-third of US workers now have high-deductible health plans, and those numbers are expected to grow in 2014 as implementation of the Affordable Care Act continues. There is concern that high-deductible health plans might cause enrollees of low socioeconomic status to forgo emergency care as a result of burdensome out-of-pocket costs. We analyzed emergency department (ED) visits and hospitalizations over two years among enrollees insured in high- deductible plans through small employers in Massachusetts. We found that plan members of low socioeconomic status experienced 25-30 percent reductions in high-severity ED visits over both years, while hospitalizations declined by 23 percent in year 1 but rose again in year 2. Similar trends were not found among high-deductible plan members of high socioeconomic status. Our findings suggest that plan members of low socioeconomic status at small firms responded inappropriately to high-deductible plans and that initial reductions in high-severity ED visits might have increased the need for subsequent hospitalizations. Policy makers and employers should consider proactive strategies to educate high-deductible plan members about their benefit structures or identify members at higher risk of avoiding needed care. They should also consider implementing means-based deductibles. [ABSTRACT FROM AUTHOR]

Background: Health plans with high deductibles could lead patients to avoid preventive care, such as cancer screening. Objective: To determine the effect of membership in a high-deductible health plan on cervical, breast, and colorectal cancer screening. Design: Before-after comparison between groups. Setting: A high-deductible health plan and an HMO in Massachusetts. The high-deductible health plan fully covered mammography, Papanicolaou tests, and fecal occult blood testing (FOBT) but not colonoscopy, flexible sigmoidoscopy, or double-contrast barium enema (DCBE). Participants: 3169 high-deductible health plan members and 27 022 HMO members (who served as controls). Measurements: Change in the proportions of patients undergoing breast, cervical, and colorectal cancer screening. Results: Cancer screening in the high-deductible health plan group was unchanged from baseline to follow-up (adjusted ratios of change, 1.04 [95% CI, 0.91 to 1.19] for breast cancer, 1.04 [CI, 0.92 to 1.17] for cervical cancer, and 1.02 [CI, 0.89 to 1.16] for colorectal cancer). High-deductible health plan members had colonoscopy, flexible sigmoidoscopy, and DCBE less often (ratio of change, 0.73 [CI, 0.56 to 0.95]) and FOBT more often (ratio of change, 1.16 [CI, 1.01 to 1.33]) than HMO members. Limitations: Population screening frequency was probably underestimated because the study could not assess screening before the baseline year. The study may have included people ineligible for screening because of previous colectomy, mastectomy, or hysterectomy. The findings are limited to a population with relatively high socioeconomic status, which is typical of employed, commercially insured populations. Conclusion: Members of a high-deductible health plan did not seem to change their use of breast, cervical, and colorectal cancer screening when tests were fully covered. However, members may have substituted a fully covered screening test (FOBT) for tests subject to the deductible (colonoscopy, flexible sigmoidoscopy, and DCBE). [ABSTRACT FROM AUTHOR]

Objective: To determine whether Massachusetts Health Reform improved health outcomes in uninsured patients with hyperlipidemia, diabetes, or hypertension., Data Source: Partners HealthCare Research Patient Data Registry (RPDR)., Study Design: We examined 1,463 patients with hyperlipidemia, diabetes, or hypertension who were uninsured in the 3 years before the 2006 Massachusetts Health Reform implementation. We assessed mean quarterly total cholesterol, glycosylated hemoglobin, and systolic blood pressure in the respective cohorts for five follow-up years compared with 3,448 propensity score-matched controls who remained insured for the full 8-year study period. We used person-level interrupted time series analysis to estimate changes in outcomes adjusting for sex, age, race, estimated household income, and comorbidity. We also analyzed the subgroups of uninsured patients with poorly controlled disease at baseline, no evidence of established primary care in the baseline period, and those who received insurance in the first follow-up year., Principal Findings: In 5 years after Massachusetts Health Reform, patients who were uninsured at baseline did not experience detectable trend changes in total cholesterol (-0.39 mg/dl per quarter, 95 percent confidence interval [-1.11 to 0.33]), glycosylated hemoglobin (-0.02 percent per quarter [-0.06 to 0.03]), or systolic blood pressure (-0.06 mmHg per quarter [-0.29 to 0.18]). Analyses of uninsured patients with poorly controlled disease, no evidence of established primary care in the baseline period, and those who received insurance in the first follow-up year yielded similar findings., Conclusions: Massachusetts Health Reform was not associated with improvements in hyperlipidemia, diabetes, or hypertension control after 5 years. Interventions beyond insurance coverage might be needed to improve the health of chronically ill uninsured persons., (© Health Research and Educational Trust.)

Objective: To examine whether high-deductible health plans (HDHPs) that exempt prescription drugs from full cost sharing preserve medication use for major chronic illness, compared with traditional HMOs with similar drug cost sharing., Data Sources/study Setting: We examined 2001-2008 pharmacy claims data of 3,348 continuously enrolled adults in a Massachusetts health plan for 9 months before and 24 months after an employer-mandated switch from a traditional HMO plan to a HDHP, compared with 20,534 contemporaneous matched HMO members. Both study groups faced similar three-tiered drug copayments. We calculated daily medication availability for all prescription drugs and four chronic medication classes: hypoglycemics, lipid-lowering agents, antihypertensives, and chronic obstructive pulmonary disease (COPD)/asthma controllers., Study Design: Interrupted time-series with comparison group study design examining monthly level and trend changes in prescription drug utilization., Principal Findings: The HDHP and control groups had comparable changes in the level and trend of all drugs after the index date; we detected similar patterns in the use of lipid-lowering agents, antihypertensives, and COPD/asthma controllers. Some evidence suggested a small relative decline in hypoglycemic use among diabetic patients in HDHPs., Conclusions: Switching to an HDHP that included modest drug copayments did not change medication availability or reduce use of essential medications for three common chronic illnesses., (© Health Research and Educational Trust.)

Objective: To evaluate the impact of switching from an HMO to a high-deductible health plan on the costs and utilization of maternity care., Study Design: Pre–post design, with a control group., Methods: We compared 229 women who delivered babies before or after their employers mandated a switch from HMO coverage to a high-deductible health plan, with a control group of 2180 matched women who delivered babies while their employers remained in an HMO plan. Administrative claims from a large Massachusetts-based health insurance program were used in a difference-in-differences regression analysis., Results: Mean out-of-pocket maternity care costs for high-deductible group members increased from $356 for women who delivered before the insurance transition (n = 86) to $942 for women who delivered after the transition (n = 143), compared with a change from $262 (n = 711) to $282 (n = 1569) for HMO members, a relative increase of 106% (P <.001) for high-deductible members. Delivery after transition to a high-deductible plan was not associated with changes in the odds of receiving early prenatal care (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.32-3.19), recommended prenatal visits (OR, 1.64; 95% CI, 0.89-3.02), or postpartum care (OR, 0.74; 95% CI, 0.42-1.32)., Conclusions: Switching from an HMO to a high-deductible plan with exemptions for routine care increased out-of-pocket member costs for maternity care, but had no apparent adverse impacts on receipt of recommended prenatal and postpartum care.

Objective: To examine how enrollment in high-deductible health plans (HDHPs) affects use of well-child visits relative to traditional plans, when preventive care is exempt from the deductible., Study Design: Pre-post comparison between groups., Methods: We selected children aged <18 years enrolled in a large Massachusetts health plan through employers offering only 1 type of plan. Children were in traditional plans for a 12-month baseline period between 2001 and 2004, then were either switched by a decision of the parent's employer to an HDHP or kept in the traditional plan (controls) for a 12-month follow-up period. Preventive and other office visits were exempt from the deductible and subject to copayments, as in traditional plans. The primary outcome was whether the child received well-child visits recommended for the 12-month period. Using generalized linear mixed models, we compared the change in receipt of recommended well-child visits between baseline and follow-up for the HDHP group relative to controls., Results: We identified 1598 children who were switched to HDHPs and 10,093 controls. Between baseline and follow-up, the mean proportion of recommended well-child visits received by HDHP children decreased slightly from 0.846 to 0.841, and from 0.861 to 0.855 for controls. In adjusted models, there was no significant difference in the change in probability that recommended well-child visits were received by HDHP children compared with controls (P = .69)., Conclusions: Receipt of recommended well-child visits did not change for children switching from traditional plans to HDHPs that exempt preventive care from the deductible.

Objective: There is concern that high-deductible health plans may have negative effects on vulnerable groups. The objective of this study was to compare the characteristics of families who have children and switch to high-deductible health plans with those who stay in traditional plans., Methods: This double-cohort study included families who had children aged <18 years and were enrolled in a Massachusetts health plan through employers who did not offer a choice of health plans. We identified families who had traditional health maintenance organization plans for a 12-month baseline period between 2001 and 2004 and compared families whose coverage was then switched to a high-deductible health plan by their employers with similar families whose employer chose to remain in the traditional plan (controls). Data came from health plan enrollment and claims datasets and census data. We used multivariate logistic regression models to compare the characteristics of families who were switched to high-deductible health plans with controls., Results: We identified 839 families who had children and whose employer switched them to high-deductible health plans and 5133 controls. Among families with large employers, the adjusted odds of the employer switching to a high-deductible health plan were higher for families living in high-poverty neighborhoods. Among families with small employers, the adjusted odds of the employer switching to a high-deductible health plan were lower for families with more children, above-average family morbidity, and baseline total expenditures >$7000., Conclusions: Among families with large employers offering a single health plan, those from low-income neighborhoods are more likely to be switched to high-deductible health plans. In contrast, families with small employers offering a single plan are more likely to be switched to high-deductible health plans if they are healthier and have lower baseline costs. These findings suggest that families with children in high-deductible plans may represent two distinct groups, one with higher-risk characteristics and another with lower-risk characteristics compared with those in traditional plans.

Objectives: To demonstrate an important limitation of empirical tests of the proposition that medical care has contributed to long-term declines in mortality. Quasi-experiments cannot detect the effect of care that sustain, rather than change, a downward trajectory. We demonstrate this limitation by testing two hypotheses. One is that isolation of patients and antibiotic treatment coincided with declines in tuberculosis (TB) mortality in Massachusetts between 1850 and 1950. Another is that the introduction of Medicare in the 1960s increased life expectancy at age 65., Results: The first hypothesis is supported, for both patient isolation and streptomycin. The second is not. The circumstances that could yield such results are explored., Conclusions: Epidemiologists and historians should cooperate to devise methods that can resolve the issue of whether medical care has sustained the steady downward trend in mortality witnessed over the last century-and-a-half.