High-Deductible Insurance Linked to More Complex Hernias

Patients with a groin or ventral hernia were more likely to present with complex cases if they had a high-deductible health insurance plan (HDHP), suggesting delays in seeking care, a retrospective study found.

In a claims database analysis involving over 83,000 patients, having a HDHP was associated with a greater odds of presenting with an incarcerated or strangulated hernia of the abdominal wall or groin, compared with having a traditional healthcare plan (adjusted OR 1.07, 95% CI 1.03-1.11, P<0.001), reported Arden Morris, MD, of Stanford University School of Medicine in California, and colleagues in JAMA Surgery.

HDHP patients who did not have a health savings account (HSA) were also more likely to present with complicated hernias (aOR 1.10, 95% CI 1.05-1.15, P<0.001), which served as a “proxy for delay” in those seeking care as time durations between patients’ diagnosis and repair dates were unavailable.

“While expectant management is appropriate for most asymptomatic hernias, repair is indicated for all groin hernias in women and for symptomatic hernias in surgically fit patients to reduce the risk of incarceration or strangulation,” the authors noted. “The results suggest that cost-related delay in care may have deleterious effects on hernia presentation.”

For surgical conditions, waiting it out due to concerns about out-of-pocket costs frequently results in patients requiring emergency surgery, which “does not allow for preoperative medical optimization or procedural planning,” Morris’s group noted.

The findings were also presented at the annual meeting of the Pacific Coast Surgical Association.

For their study, Morris and colleagues examined insurance claims data from the Optum Clinformatics Data Mart on 83,281 patients who had ventral or groin surgery from January 2016 to June 2019. The study included adults up to age 63 (72% males) who were privately insured and enrolled in a traditional health care plan with a low deductible (n=55,804) or in a HDHP (n=27,477), as defined by the Internal Revenue Service. HDHPs were stratified by three tier levels based on annual deductible, with tier three having the largest deductible.

Hernias were classified as “incarcerated” if they were obstructed, while “strangulated” hernias had impending or frank gangrene. The proportion with incarcerated or strangulated hernia was slightly higher for HDHP versus traditional plan patients (26.7% vs 26.0%).

Multivariate logistic regression adjusted for covariates such as demographics, hernia type, Charlson Comorbidity Index score, and residential state. Full sample analysis controlled for individual versus family coverage.

Compared with traditional plan patients, HDHP patients were more likely to be enrolled in individual coverage plans (61% vs 39%), were younger (mean age 48 vs 49), and had fewer comorbidities (Charlson score of ≥3, 40% vs 50%).

HDHP patients enrolled in individual coverage were even more likely to present with a complicated hernia compared to those with a traditional plan (aOR 1.09, 95% CI 1.04-1.15, P<0.001). No significant differences were observed among groups who were enrolled in family coverage.

While nearly all participants (98%) had costs that exceeded their deductibles, HDHP patients were paying a significantly higher mean annual deductible versus those with a traditional plan ($3,635 vs $705, P<0.001).

“HDHPs may be beneficial for individuals who can afford to self-insure with the HSA mechanism but not for those unable to set aside money for unexpected health expenses,” the group wrote.

The authors acknowledged several limitations to the data, including the use of administrative claims data, which is subjected to selection bias, misclassification, and lacks information on symptom duration and more. Data on the amount of HSA funds were also unavailable.