Quantifying Changes to Healthcare Utilization After a Reduction in Cost-sharing Among Deductible Plan Enrollees

Health plan deductibles are a form of cost-sharing that require patients to pay out-of-pocket before insurance pays for benefits. Deductible plans have become increasingly common in the United Sates to mitigate escalating healthcare costs. Quantifying the impact of increased cost-sharing from deductibles on utilization is a challenging empirical question because individuals and employers self-select into plans with deductibles. We evaluated the impact of cost-sharing in plans with deductibles by leveraging an accidental injury to a family member as an instrumental variable that strongly predicted the non-injured family member reaching their deductible maximum, which resulted in a reduction in cost-sharing. Our outcome measures examined utilization subject to cost-sharing as compared to utilization exempt from cost-sharing. Using data from the same healthcare system to control for quality and provider network, we found that reaching the deductible increased emergency department (ED) utilization by 10.0 percentage points (pp). Nearly one-quarter of the increased ED utilization was potentially avoidable. Wellness visits not subject to cost-sharing decreased by 5.7 pp. Results were similar for high-deductible plans and for families meeting their maximum out-of-pocket amount. These findings provide causal evidence that individuals enrolled in plans with deductibles change utilization patterns after an exogenous reduction in cost-sharing.