Women who recently learned they had or might have breast cancer were more likely to delay receiving care if they were enrolled in high-deductible health plans (HDHPs), according to a study published last month in the Journal of Clinical Oncology.
While research has shown people with HDHPs are more likely to delay potentially needed care, the new study is among the first to examine how people behave when they are diagnosed with a life-threatening disease and the recommended treatments are less subjective, Frank Wharam, one of the study authors and a Harvard Medical School researcher, said.
For the study, researchers assessed patient data between 2003 and 2012 to determine whether HDHPs might cause delays in breast cancer treatment. The researchers compared women with low-deductible health plans (LDHPs), those with deductibles ranging from $0 to $500, with women enrolled in HDHPs, those with deductibles of at least 1,000, including:
- 2.4 million women whose employers only provided LDHPs; and
- 273,499 women who were enrolled continuously in LDHPs for a year and then enrolled in HDHPs for up to four years after an employer-mandated switch.
The researchers did not examine the health outcomes of women after they received breast cancer treatment.
According to the study, women enrolled in HDHPs experienced delays in care when compared with women in LDHPs. In particular, the researchers found women enrolled in HDHPs delayed when they received:
- Breast biopsies;
- Breast cancer chemotherapy;
- Diagnostic breast imaging; and
- Incident early-stage breast cancer diagnosis.
The researchers found women with HDHPs delayed when they started chemotherapy by an average of seven months. According to the researchers, even short delays in diagnosis and treatment can have an effect on a woman's health outcomes.
The researchers concluded that additional research is needed to "determine whether such delays cause adverse health outcomes and policymakers should consider selectively reducing out-of-pocket costs for key breast cancer services."
Ethan Basch—director of cancer outcomes research at UNC Lineberger Comprehensive Cancer Center, who was not involved in the study—said, "What we see here is an unintended consequence of sharing costs." Basch said he often has seen patients make decisions concerning their care based on their financial circumstances. When they have high out-of-pocket costs, "they're of a mind-set to avoid visits, expensive treatments," he said, adding, "They have a fear."
Susan Brown, senior director of education and patient support at Susan G. Komen, said more than 50% of the questions the group's helpline receives are related to financial assistance. Susan G. Komen and the organization's affiliates offer modest grants to help cover certain costs for breast cancer patients. Brown said people often talk about discontinuing or delaying their treatment, even in cases when they have an abnormal screening.
According to the New York Times, HDHPs pose a particular problem for patients because such plans do not always distinguish between medically unnecessary and necessary care.
Peter Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center, said HDHPs are designed to encourage patients to think about whether the tests or treatment are medically necessary, but "frankly [such plans] ... impede [patient's use of these services." Bach said such plans might be reducing the use of tests and treatments, but "the question is, at what cost?" (Abelson, New York Times, 5/4; Wharam et al., Journal of Clinical Oncology, April 2018).
Advisory Board's take
By Deirdre Saulet, Practice Manager, Oncology Roundtable
Experts have long worried that the rise in high-deductible health plans would lead to delays in cancer care. This study provides alarming evidence the problem is real and that health systems cannot afford to wait to address it.
Many systems have taken first steps by hiring financial advocates to help patients access financial assistance once treatment is prescribed. However, providers have focused less on helping patients navigate, evaluate, and optimize their insurance coverage at the moment of diagnosis, before treatment begins.
Providers can use these five tactics to get started:
- Screen patients for coverage eligibility. Providers need to ensure that all uninsured and underinsured patients are identified upfront and screened for eligible coverage options as quickly as possible.
- Build partnerships with external Medicaid assistance agencies. Many health systems contract with external agencies that specialize in signing patients up for Medicaid, but these agencies rarely have expertise in managing cancer patients' unique needs. For instance, Lehigh Valley Health Network has secured upfront coverage for more than 20 cancer patient per month by integrating an agency representative into the cancer program and financial advocacy team.
- Coordinate treatment start with the clinical team. If programs secure improved insurance coverage for patients, financial advocates should work with the clinical team to understand opportunities to safely and appropriately coordinate treatment start with insurance coverage.
- Hardwire monthly insurance checks. Implement processes to regularly re-verify insurance. This is particularly important for patients on Medicaid or federal exchange plans.
- Normalize conversations about costs. It's critical to treat patients' concerns about cost as a normal, expected part of their treatment. To help ease patient concerns, these conversations should be solution-oriented, highlighting the various financial assistance programs that may be available to patients and families.
To learn more, check out our full study on ways to ease patients' financial journey, "Cancer patient financial navigation."