The Diabetes Health Plan and Healthcare Utilization Among Beneficiaries with Low Incomes

Abstract

Background: The socioeconomic status (SES) gradient in hospital and emergency room utilization among adults with type 2 diabetes (T2DM) is partially driven by cost-related non-adherence.

Objective: To test the impact of the Diabetes Health Plan (DHP), a diabetes-specific health plan incorporating value-based insurance design principles on healthcare utilization among low-income adults with T2DM.

Design: To examine the impact of the DHP on healthcare utilization, we employed a difference-in-differences (DID) study design with a propensity-matched comparison group. We modeled count and dichotomous outcomes using Poisson and logit models, respectively.

Participants: Cohort of adults (18-64) with T2DM, with an annual household income <$ 30,000, and who were continuously enrolled in an employer-sponsored UnitedHealthcare plan for at least 2 years between 2009 and 2014.

Interventions: The DHP reduces or eliminates out-of-pocket costs for disease management visits, diabetes-related medicines, and diabetes self-monitoring supplies. The DHP also provides access to diabetes-specific telephone case management as well as other online resources.

Main measures: Number of disease management visits (N = 1732), any emergency room utilization (N = 1758), and any hospitalization (N = 1733), within the year.

Key results: DID models predicting disease management visits suggested that DHP-exposed beneficiaries had 1.7 fewer in-person disease management visits per year (- 1.70 [95% CI: - 2.19, - 1.20], p < 0.001), on average, than comparison beneficiaries. Models for emergency room (0.00 [95% CI: - 0.06, 0.06], p = 0.966) and hospital utilization (- 0.03 [95% CI: - 0.08, - 0.01], p = 0.164) did not demonstrate statistically significant changes associated with DHP exposure.

Conclusions: While no relationship between DHP exposure and high-cost utilization was observed in the short term, fewer in-person disease management visits were observed. Future studies are needed to determine the clinical implications of these findings.

Keywords: diabetes; healthcare utilization; low income; value-based insurance design.