Effects of Employer-Mandated Switches to High-Deductible Health Plans

shot of neon emergency sign
Employer mandated switches to high-deductible health plans reduce emergency department visits for nonspecific chest pain.

Seeking care at the emergency departments (ED) for nonspecific chest pain was linked to employer-mandated switches to higher-deductible health plans, according to results of a study published in Circulation.

Researchers from Harvard Pilgrim Health Care Institute analyzed commercial and Medicare Advantage claims between 2003 to 2014. Visits to ED for nonspecific chest pain, hospitalizations, and interventions were associated with insurance deductibles and demographic characteristics.

Individuals with high-deductible health plans (HDHP; ≥$1000; n=557,503) were matched with controls (n=5,861,955) employed by 52,857 and 171,078 entities, respectively. The study cohorts comprised individuals aged mean 42 years, between 48%-49% were women, 67% were White, ≥20% lived below the federal poverty line, and 26%-27% lived in areas with low educational attainment.

A total of 133,121 ED visits for nonspecific chest pain occurred. Employer-mandated switch to an HDHP associated with a decreased rate of ED visits for chest pain by 4.3% (95% CI, –6.3% to –2.8%) and for ED hospitalizations by 11.3% (95% CI, –14.0% to –8.6%).

After visit to the ED for chest pain, switch to HDHP associated with decreased rates of receiving invasive angiography (relative decrease, –8.2%; 95% CI, –12.0% to –4.5%) and nuclear stress testing (relative decrease, –15.2%; 95% CI, –21.5% to –8.9%).

Individuals who had cardiovascular comorbidities were even less likely to visit the ED for chest pain (relative decrease, –8.9%; 95% CI, –14.5% to –3.3%) or to be hospitalized (relative decrease, –18.1%; 95% CI, –26.3% to –10.0%).

A similar trend was observed among individuals living in higher poverty areas (relative decrease, chest pain ED: –7.3%; 95% CI, –8.3% to –6.3%; ED hospitalization: –15.7%; 95% CI, –19.2% to –12.3%).

Stratified by increase in deductibles, individuals with higher increases were less likely to visit the ED for chest pain (relative decrease, –37.1% vs –4.8%), undergo an invasive angiography (relative decrease, –33.3% vs –3.5%), or coronary revascularization (relative decrease, –41.5% vs 1.5%).

The study investigators were unable to determine whether there was a significant difference in severity of symptoms among patients seeking care for chest pain at the ED.

These findings suggested that after employer-mandated switch to an HDHP, fewer individuals sought care for nonspecific chest pain. The decline in seeking care was particularly prevalent among individuals with cardiovascular comorbidities, those living in high-poverty areas, and for those with higher increases in deductibles.


Chou S-C, Hong AS, Weiner SG, Wharam JF. Impact of high-deductible health plans on emergency department patients with nonspecific chest pain and their subsequent care. Circulation. June 28, 2021. doi:10.1161/circulationaha.120.052501