Up to 7 million people each year receive care in an emergency department (ED) for chest pain, a symptom of a potential heart condition. Over 80 percent of chest pain patients, however, ultimately have no evidence of cardiovascular disease or acute coronary syndrome. To disincentivize patients from over-utilizing costly care, insurers and employers are increasingly opting for high-deductible health plans (HDHPs) that require significant out-of-pocket spending before coverage begins. Researchers from Brigham and Women's Hospital and Harvard Pilgrim Health Care Institute investigated whether switching to an HDHP influenced the frequency of ED visits and hospitalizations for chest pain. Their findings, published in Circulation, report a 4.3 percent decrease in ED visits for chest pain and an 11.3 percent decrease in visits that led to inpatient hospitalization based on the initial ED evaluation. Low-income patients were particularly less likely to visit the ED for chest pain and subsequently more likely to be hospitalized with a serious heart condition.
"Our research, along with past studies, has shown that lower-income patients disproportionately suffer from delays in care and worse clinical outcomes," said corresponding author Shih-Chuan Chou, MD, MPH, SM, of the Department of Emergency Medicine at the Brigham. "Low-income patients need the most attention if employers or insurers are to expand the use of high-deductible plans."
In their study, the researchers used a national medical insurer database to identify more than a half a million patients aged 19-63 whose employers offered only low-deductible health plans (requiring less than $500/year of out-of-pocket spending) before mandating enrollment in an HDHP (greater than $1,000/year) the next year. A control group of nearly 6 million employees included those enrolled in a low-deductible health plan for two straight years.
The researchers did not observe significant differences in cardiac testing after ED admission between low- and high-deductible groups. However, HDHP patients living in neighborhoods with higher poverty rates had a 29.4 percent higher rate of heart attack hospitalization 30 days after their initial ED diagnosis of chest pain, compared to those with addresses in other neighborhoods.
"At the clinician level, our research certainly demonstrates that it is quite important for clinicians to be aware of patients' out-of-pocket costs, as high burdens may indicate that a patient has likely deferred care and may suffer worse outcomes," Chou said.
With 57 percent of U.S. employees enrolled in HDHPs for single coverage in 2020, the researchers emphasize that when evaluating ED patients with chest pain, particularly low-income patients with HDHPs, clinicians should account for possible delays in care preceding the patients' presentation. Going forward, the researchers hope to examine whether HDHPs are associated with patient outcomes for significant medical emergencies, such as heart attack, while also exploring on a deeper level how out-of-pocket spending influences patient-clinician interactions and discussions about testing or treatment.
"Potential solutions may be to ameliorate financial burden by funding health savings accounts, or to keep out-of-pocket costs proportional to patients' incomes," said Chou.
There was no external funding for this work.
Paper cited: Chou, SC et al., "The Impact of High-Deductible Health Plans on Emergency Department Patients with Non-Specific Chest Pain and Their Subsequent Care" Circulation DOI: https://doi.org/10.1161/CIRCULATIONAHA.120.052501