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The Impact of High-deductible Health Plans on Men and Women: An Analysis of Emergency Department Care

Kozhimannil, Katy B. PhD, MPA*; Law, Michael R. PhD, MSc; Blauer-Peterson, Cori MPH*; Zhang, Fang PhD; Wharam, James Frank MB, BCh, BAO, MPH

doi: 10.1097/MLR.0b013e31829742d0
Original Articles

Background: Prior studies show that men are more likely than women to defer essential care. Enrollment in high-deductible health plans (HDHPs) could exacerbate this tendency, but sex-specific responses to HDHPs have not been assessed. We measured the impact of an HDHP separately for men and women.

Methods: Controlled longitudinal difference-in-differences analysis of low, intermediate, and high severity emergency department (ED) visits and hospitalizations among 6007 men and 6530 women for 1 year before and up to 2 years after their employers mandated a switch from a traditional health maintenance organization plan to an HDHP, compared with contemporaneous controls (18,433 men and 19,178 women) who remained in an health maintenance organization plan.

Results: In the year following transition to an HDHP, men substantially reduced ED visits at all severity levels relative to controls (changes in low, intermediate, and high severity visits of −21.5% [−37.9 to −5.2], −21.6% [−37.4 to −5.7], and −34.4% [−62.1 to −6.7], respectively). Female HDHP members selectively reduced low severity emergency visits (−26.9% [−40.8 to −13.0]) while preserving intermediate and high severity visits. Male HDHP members also experienced a 24.2% [−45.3 to −3.1] relative decline in hospitalizations in year 1, followed by a 30.1% [2.1 to 58.1] relative increase in hospitalizations between years 1 and 2.

Conclusions: Initial across-the-board reductions in ED and hospital care followed by increased hospitalizations imply that men may have foregone needed care following an HDHP transition. Clinicians caring for patients with HDHPs should be aware of sex differences in response to benefit design.

*Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN

Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada

Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA

Supported by the Building Interdisciplinary Research Careers in Women’s Health Grant (K12HD055887) from the Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD), the Office of Research on Women’s Health, and the National Institute on Aging, at the National Institutes of Health, administered by the University of Minnesota Deborah E. Powell Center for Women’s Health (K.B.K., C.B.-P.) and by a Harvard Pilgrim Health Care Foundation grant to J.F.W. M.R.L. receives salary support through a New Investigator Award from the Canadian Institutes of Health Research and a Career Investigator Award from the Michael Smith Foundation for Health Research. J.F.W. and F.Z. receive salary support from the Harvard Pilgrim Health Care Institute.

The authors declare no conflict of interest.

Reprints: Katy B. Kozhimannil, PhD, MPA, Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St. SE, MMC 729, Minneapolis, MN 55455. E-mail:

© 2013 by Lippincott Williams & Wilkins.