Impact of high-deductible health plans on delays in metastatic cancer diagnosis

Abstract

Background High-deductible health plans (HDHPs) have grown rapidly in recent years, and now cover more than half of U.S. workers. Patients in HDHPs are liable for the costs of all cancer-related care until their annual deductible is met, with the exception of screening tests such as colonoscopy and mammography. Due to higher out-of-pocket costs, patients may postpone presenting for concerning symptoms or diagnostic testing, leading to delayed diagnosis. We sought to assess the impacts of HDHPs on the timing of metastatic cancer detection in a nationally representative cohort of cancer patients. Methods Using a cohort of privately insured patients age 18-64 in a national commercial and Medicare Advantage database (2003-2017), we studied 2,703 individuals with cancer whose employers mandated a switch from a low-deductible (≤$500) plan to a high-deductible (≥$1,000) plan. Our control group consisted of 43,005 contemporaneous individuals with cancer whose employers offered only low-deductible plans. Both groups had a 1-year baseline period when all members were enrolled in low-deductible plans. Members were followed for a maximum of 4 years. To address potential confounding, HDHP and control participants were matched on demographic variables, morbidity score, baseline health care utilization, cancer type and timing, follow-up duration, and employer characteristics. We assessed time to metastatic cancer diagnosis in the baseline and follow-up periods using a weighted Cox proportional hazards model. Results The mean age of participants was 53; 59% were female. We detected 4,741 cases of metastatic progression. There were no differences in time to metastatic diagnosis in the baseline year, prior to the HDHP switch (HR 0.99, p = 0.93). After employer-mandated HDHP switch, cancer patients enrolled in HDHPs experienced later detection of metastatic cancer (HR 0.70, p = 0.04), equivalent to a delay of 8.5 months relative to the control group. Conclusion Compared with conventional insurance, HDHPs are associated with delayed detection of metastatic cancer. These findings imply that cancer patients postpone seeking care for concerning symptoms or defer diagnostic testing when exposed to high cost-sharing. Future policy efforts should aim to protect cancer patients from burdensome costs-sharing requirements to ensure timely detection and treatment of metastatic cancer.