High-deductible health plans linked to shorter survival for cancer survivors
CHICAGO — High-deductible health plans appeared associated with shorter survival among cancer survivors, according to results of a nationwide population-based analysis presented at ASCO Annual Meeting.
The findings suggest high-deductible health plans may create a financial disincentive for cancer survivors that prevents them from seeking necessary medical care, according to Justin Barnes, MD, MS, radiation oncology resident at Washington University School of Medicine in St. Louis.
“Our main findings — that cancer survivors enrolled in high-deductible health plans are at increased risk for death compared with other cancer survivors — are not surprising,” Barnes told Healio. “We were initially intrigued by our subgroup analyses, which demonstrated that several subgroups typically associated with higher socioeconomic status and relatively good access to care — non-Hispanic white individuals, and individuals with higher income or educational attainment — appeared to have the greatest survival detriment associated with high-deductible health plans; however, these findings may, too, make sense if we assume that the high-deductible health plans are counteracting what otherwise might have been good access to care in these individuals.”
Background and methods
Individuals with high-deductible health plans pay lower premiums but could face considerably high out-of-pocket costs.
Prior research has shown people with these plans are more likely to be diagnosed with cancer at an advanced stage, and that cancer survivors with these plans often delay or forego care due to costs, according to study background.
However, the effect of high-deductible health plans on survival among cancer survivors had not been established.
Barnes and colleagues used the 2018 National Health Interview Survey and linked mortality files from the National Death Index to identify individuals aged 18 to 84 years with non-Medicaid insurance.
National Health Interview Survey classification defined high-deductible status as $1,200 to $1,350 per year for an individual or $2,400 to $2,700 for a family, with amounts increasing each survey year.
The analysis included 147,254 respondents, 5.9% of whom were cancer survivors.
A comparable percentage of cancer survivors (25.6%) and individuals with no cancer history (28.5%) reported having a high-deductible insurance plan at the time of survey participation.
Results
Adjusted analyses showed cancer survivors with coverage through a high-deductible plan had shorter OS (HR = 1.46; 95% CI, 1.19-1.79) and cancer survival (HR = 1.34; 95% CI, 1.01-1.77), defined as freedom from cancer death.
Coverage through high-deductible health plans appeared linked to shorter OS among several subgroups of cancer survivors, including those with income greater than 400% of the federal poverty level (HR = 1.65; 95% CI, 1.16-2.36), those with college education (HR = 1.47, 95% CI; 1.07-2) or high school education (HR = 1.59; 95% CI, 1.19-2.12), non-Hispanic white individuals (HR = 1.45; 95% CI, 1.16-1.82) and those who had multiple cancers (HR = 1.58; 95% CI, 1.06-2.36).
Researchers identified no clear patterns based on sex, cancer site or comorbidities.
Participation in a high-deductible health plan had minimal effect on survival among individuals with no cancer history, Barnes said.
“Although the reasons for this aren’t totally clear, we suspect that one contributing factor is that cancer survivors are at increased risk for cancer recurrence and development of medical issues related to toxicities from their cancer treatment, which make them relatively more likely to require more health care and increase their baseline risk for mortality,” Barnes said. “With that in mind, while I think patients with cancer need to consider whether a high-deductible health plan is their best option given these data, I wouldn’t have the same concerns about a younger and healthier individual without a cancer history considering enrolling in a high-deductible health plan.”
Next steps
There are two types of potential solutions to the findings from the cancer survivor cohort, Barnes said.
“The first involves education – which can be done on a larger scale for the U.S. population as a whole or in one-on-one counseling with our patients to inform them of potential implications and risks of insurance plans such as high-deductible health plans that may impair access to care,” Barnes told Healio. “The second involves advocacy for policies that promote optimal health care access, which in this case may be policies that limit the proliferation of high-deductible health plans.”
Barnes and colleagues hope to better understand the mechanism by which high-deductible health plans may lead to worse survival.
They are conducting mediation analyses to test the hypothesis that delaying or forgoing care because of costs is an important mediator of the relationship between high-deductible plans and survival, Barnes said.
“Additionally, we would like to study how the use of health savings accounts — which can accompany high-deductible health plans — impact our results,” Barnes said. “My colleagues from the American Cancer Society have shown that the use of health savings accounts may mitigate — though not eliminate — high-deductible health plans’ impact on health care utilization.”
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Barnes JM, et al. Abstract 11005. Presented at: ASCO Annual Meeting; May 31-June 4, 2024.