Consider High Deductibles as Risk Factor for Chest Pain

Patients with high deductible plans, lower incomes may delay care

Emergency room sign

Emergency department (ED) clinicians who evaluate patients with nonspecific chest pain should consider the possibility that previous delays in care adversely affected the presentations. This is particularly true among patients with both high deductible health plans (HDHP) and lower socioeconomic status.

This recommendation to ED clinicians was part of a broad analysis published in Circulation demonstrating that HDHPs that require large out-of-pocket payments were associated with increased 30-day acute myocardial infarction admission following ED diagnosis of nonspecific chest pain among low-income HDHP participants. The authors used U.S. Census tract data to identify patients living in low-income neighborhoods.

Senior author J. Franklin Wharam, MD, MPH, a Duke researcher in the Margolis Center for Health Policy, specializes in health policy and disparities research with an emphasis on the effects of health insurance on outcomes. A professor of medicine in the Duke General Internal Medicine Division, Wharam directed the Health Policy and Insurance Research Division at Harvard Medical School’s Department of Population Medicine before joining Duke, where he leads a center that studies how policy changes and economic forces shape health disparities.

Analysis shows that HDHP enrollment decreases ED visits

The analysis demonstrated that HDHP enrollment decreases ED visits and reduces the use of some cardiac tests after presentation, according to the comprehensive study of employer-mandated HDHPs. In a large-scale analysis, the authors used anonymized insurance data to review records of 557,501 members in the HDHP group. The control group totaled 5,861,990. Key findings from the analysis:

  • HDHPs reduced ED visits with a principal diagnosis of nonspecific chest pain (without acute cardiovascular findings or alternative explanations) as well as hospital admissions associated with these visits.
  • HDHP enrollment was not associated with significant changes in subsequent overall non-invasive cardiac testing but was associated with increased 30-day acute myocardial infarction rate after ED visits for nonspecific chest pain among patients living in higher poverty neighborhoods.

“ED clinicians should be aware that some lower income patients who have high out-of-pocket costs may have delayed or skipped care for a previous chest pain episode,” Wharam says. “We believe that reducing that cost barrier for lower income individuals who have high deductibles could produce better outcomes.”

While nonspecific chest pain is not generally dangerous, Wharam says, it does present significant risk to a small number of patients. “The ED teams usually disentangle the multiple possible causes of chest pain, but sometimes the reason is unclear. With such non-specific chest pain, we hope our results make clinicians aware of downstream consequences of possible care delays among certain populations.”

The researchers also identified another potential concern related to emergency treatment for patients living in low-income neighborhoods with HDHPs: reductions in certain additional tests to help stratify cardiac risk. “Tests such as stress ECG and echo that might be helpful declined among high-deductible members from lower income neighborhoods who presented with nonspecific chest pain” Wharam says. “But we were more concerned that rates of myocardial infarction increased.”