AJMC: HDHPs cut SUD use 6.6%

Matthew D. Eisenberg and co-authors reported in The American Journal of Managed Care on October 5, 2022 that workers newly offered a high-deductible health plan were less likely to use substance-use-disorder treatment than comparable enrollees kept in traditional coverage. The study used deidentified OptumLabs commercial claims from 2007 through 2017 and examined 28.7 million person-years, with 2.2% of those person-years involving a diagnosed substance use disorder. The authors found lower treatment use after an HDHP offer and a shift in spending from insurers to patients. The paper appears in AJMC’s October 2022 issue. ### Who conducted the study and what exactly did they measure? Matthew D. Eisenberg, Alene Kennedy-Hendricks, Cameron Schilling and co-authors studied the effects of being newly offered an HDHP on the use of and spending on treatment for substance use disorders. The paper says the main independent measure was whether an enrollee was offered an HDHP, and the main outcomes were the probability of using SUD services and the spending tied to that care. (ajmc.com) The authors used difference-in-differences models to compare people newly offered an HDHP with enrollees who continued to have only traditional plan options during the study period. The data came from OptumLabs claims covering 2007 to 2017. ### How big was the drop in treatment use? (ajmc.com) The study found enrollees were 6.6% less likely to use SUD services after being offered an HDHP relative to the comparison group. The result was statistically significant at P below.001, according to the paper. The reductions were concentrated in inpatient care, intermediate care, ambulatory care and medication use, the authors wrote. (ajmc.com) That matters because the decline was not limited to one narrow treatment setting. ### What happened to the money patients and plans spent? The paper reported a 21% decrease in health-plan spending on SUD care and a 14% increase in out-of-pocket spending by enrollees after an HDHP offer. (ajmc.com) The authors described that pattern as a shift in spending from the plan to the enrollee. A 2020 JAMA Psychiatry research letter by Eisenberg and colleagues examined a related question and said HDHPs had proliferated in the United States, while warning that added financial strain from high deductibles could worsen outcomes for people with substance use and mental health disorders. That earlier paper used MarketScan data from 2011 to 2016 and focused on spending among people already enrolled in HDHPs versus traditional plans. (ajmc.com) ### Why are substance-use services especially sensitive to deductibles? The AJMC paper said substance use disorders are undertreated and often co-occur with other chronic conditions. The authors wrote that, in the context of the U.S. drug epidemic, the findings raised concern that the move toward HDHPs could worsen undertreatment of SUD. (jamanetwork.com) The American Medical Association’s Council on Medical Service said in a November 2020 report that even when services are covered, patients can still face large bills before meeting deductibles, and those costs can lead people — especially those with low incomes or chronic conditions — to forgo necessary care. The report recommended plan designs and employer practices aimed at helping enrollees understand benefits and spread out out-of-pocket costs over the year. (ajmc.com) ### What should readers watch for in the paper itself? The AJMC article says the sample covered commercially insured enrollees in OptumLabs data over a 10-year span, so the estimates reflect employer-sponsored insurance settings rather than all insurance markets. The paper’s core finding is about being offered an HDHP, not about every feature of every high-deductible plan. (ama-assn.org) The full article, titled “The Impact of HDHPs on Service Use and Spending for Substance Use Disorders,” is available through AJMC with the abstract, methods, estimates and author list. The DOI listed by the journal is 10.37765/ajmc.2022.89250. (ajmc.com)