J.M. Rook1,2,3,4,5, L.I. Kelley-Quon6,7,8, H.C. Jen1, R. Gidwani2,5,9 1UCLA David Geffen School Of Medicine, Department Of Surgery, Los Angeles, CA, USA 2RAND Health, Santa Monica, CA, USA 3UCLA National Clinician Scholars Program, Los Angeles, CA, USA 4Greater Los Angeles Veterans Administration Healthcare System, Los Angeles, CA, USA 5UCLA Fielding School of Public Health, Department Of Health Policy And Management, Los Angeles, CA, USA 6Children’s Hospital Los Angeles, Division Of Pediatric Surgery, Los Angeles, CA, USA 7USC Keck School of Medicine, Department Of Surgery, Los Angeles, CA, USA 8USC Keck School of Medicine, Department Of Preventative Medicine, Los Angeles, CA, USA 9University of Colorado School of Medicine, Department Of Medicine, Aurora, CO, USA
Introduction: Nearly 60% of families with employer-sponsored insurance are enrolled in high-deductible health plans (HDHPs). These plans use high levels of cost sharing to reduce unnecessary medical care. However, among adults, HDHPs have also been linked to delays in necessary care and greater disease severity on presentation. It is unknown how these plans affect children who require urgent surgical care. Using national data, we sought to determine how HDHPs affect rates of presentation with complicated vs uncomplicated disease and hospitalization costs and duration for children with appendicitis.
Methods: This retrospective cohort study used the 2016-2020 MarketScan database. We included children (5-17 years) with employer-sponsored insurance admitted for acute appendicitis. We assessed the exposure of HDHP enrollment and the outcomes of (1) complicated appendicitis; (2) costs of care; and (3) length of stay. We used machine learning-derived propensity score weighting and multivariable regression to assess the association between HDHP enrollment and outcomes. We converted β coefficients to average marginal effects. Covariates included age, sex, geographic region, comorbidities, healthcare utilization, and month and year treated. Analyses were further stratified by year and patient age.
Results: Of 10,741 children with appendicitis, 4,873 (45.4%) were enrolled in HDHPs. In the year prior to diagnosis, children enrolled in HDHPs more often had a pediatrician well-child visit (52.1% vs 49.0%; p=0.002) and less often utilized the ED (14.4% vs 17.2%; p=0.02). There were no differences between cohorts following propensity score weighting. When compared to children enrolled in non-HDHPs, HDHP enrollment was associated with an adjusted 3.3 percentage point (95%CI, 1.5-5.1; p<0.001) increase in the likelihood of presenting with complicated appendicitis (32.4% vs 29.1%); a $1,592 (CI, $1,524-$1,660; p<0.001) increase in out-of-pocket costs ($3,492 vs $1,900); an $858 (CI, $293-$1,422; p=0.003) increase in total costs ($20,236 vs $19,378); and a 0.2 day (CI, 0.1-0.3; p<0.001) increase in length of stay (1.8 vs 1.6 days; Table 1). In stratified analyses, the association of HDHPs with complicated disease decreased throughout the year as deductibles were met and out-of-pocket costs decreased. The association was diminished among older adolescents, particularly those aged 16 and 17.
Conclusion: Children in HDHPs are more likely to present with complicated appendicitis and require longer and more costly hospitalizations. High levels of cost sharing may not serve the needs of children with acute illnesses. Future research should identify policy solutions that encourage timely presentation for necessary surgical care.