Current guidelines recommend that patients with asthma use controller medications, including inhaled corticosteroids (ICS), leukotriene inhibitors (LTIs), or combination ICS and long-acting β2-agonists (ICS-LABAs), to manage their disease. Unfortunately, studies suggest adherence to these recommendations is suboptimal, which in turn increases risks for exacerbations. High out-of-pocket costs have been linked with decreased controller medication use and adverse outcomes. These costs can be especially high for patients enrolled in high-deductible health plans (HDHPs).

Research suggests that about one-half of all people with employer health insurance coverage and most with individual coverage have HDHPs. “HDHPs are increasingly common and associated with decreased medication use in some adult populations,” says Alison A. Galbraith, MD, MPH. “However, little is known about how children and people with asthma are affected, and it’s important to better understand the effects.”

Are There Consequences to HDHP Enrollment in Asthma?

For a study published in JAMA Pediatrics, Dr. Galbraith and colleagues examined the association between HDHP enrollment and asthma controller medication fills, adherence, and exacerbations in a national, commercially insured population of children and adults in which most HDHPs exempted medications from the deductible. They assessed data from a large claims database between 2002 and 2014 in children and adults with persistent asthma who switched from traditional plans to HDHPs or remained in traditional plans (control group) during a 24-month period. In most HDHPs, asthma medications were exempt from the deductible and subject to copayments.

Specifically, the authors reviewed 30-day fill rates and adherence for asthma controller medications, which included ICS, LTIs, and ICS-LABAs. Asthma exacerbations were measured by rates of oral corticosteroid bursts and asthma-related ED visits among controller medication users. Modest Decreases in Controller Medication Use

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According to the results, children switching to HDHPs experienced significant absolute decreases in annual 30-day fills only for ICS-LABA medications when compared with the control group, but no significant decreases in other controller medication fills or adherence were seen (Table).

“When compared with those staying in traditional plans, we found modest decreases in the use of some controller medications for adults and children with asthma enrolling in HDHPs, with which the large majority of high-deductible plans did not subject medications to the deductible,” Dr. Galbraith says. “We also found no impact on asthma outcomes as measured by the number of oral steroid bursts and asthma-related ED visits. Findings for adults were similar to those seen in children.”

Health Plans Need Value-Based Designs

As the prevalence of HDHPs continues to increase, the study findings suggest that HDHP enrollment may not be associated with negative outcomes in some situations. However, it is important for clinicians to be aware that patients with asthma in HDHPs may be cutting back on their use of controller medications, according to Dr. Galbraith. “While this doesn’t appear to lead to greater exacerbations, there may be increased financial burden to obtain asthma medications in these types of plans,” she says.

The protective effect of exempting certain healthcare services from the deductible is the premise that drives value-based insurance. “Value-based designs—in which high-deductible plans exempt important medications from the deductible—may be helpful in maintaining medication adherence at levels that reduce the potential for adverse health outcomes,” says Dr. Galbraith. “In future research, we should evaluate the impact of different value-based insurance designs on adherence, health outcomes, and financial burden for patients in high-deductible plans. It’s also important to understand how the out-of-pocket costs in high-deductible plans create tradeoffs with other medical and non-medical needs and how this affects a family’s financial well-being.”