Article: High health insurance deductibles can interfere with breast cancer treatment decisions

Contents

ARTICLE AT A GLANCE

Financial barriers that delay health care decisions and treatment can affect cancer outcomes. In her piece for the NY Times, “Women with Breast Cancer Delay Care When Faced with High Deductibles” Reed Abelson writes about how high insurance deductibles can lead to delays in pursuing or obtaining health care for breast cancer.

High-deductible health plans are common

Many people pay high health insurance deductibles. According to a Kaiser Family Foundation survey, as of 2017, 51% of U.S. workers with health insurance were enrolled in plans with annual deductibles of $1,000 or more for single coverage; about 11% had deductibles of at least $3,000.

High deductibles discourage necessary and unnecessary tests and/or procedures

Employers are increasingly shifting from no-deductible or low-deductible health plans (LDHPs) to worker-paid, high-deductible health plans (HDHPs). HDHPs are designed to lower insurers’ costs by discouraging testing and treatments that are not medically warranted. The unintended impact of HDHPs, however, is that they also discourage people from pursuing necessary medical care. “It’s also frankly to impede their use of these services,” said Dr. Peter Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center. The plans are reducing the use of care. “The question is, at what cost?” Dr. Bach said.

The landmark RAND Health Insurance Experiment randomly assigned families to health insurance plans with varying levels of cost sharing, ranging from 0 to 95% coinsurance. It showed that cost sharing reduces health care costs by lowering utilization, but it also reduces patients’ use of both appropriate and inappropriate services. Demand for health care was particularly reduced in low income and vulnerable populations.

A study published April 2018 in the Journal of Clinical Oncology by Harvard researcher James Wharam and colleagues followed women who were on LDHPs for 1 year and either stayed on an LDHP or switched to an HDHP. This study showed that compared to women with LDHPs, women with HDHPs had statistically significant delays in diagnostic procedures and treatment: “Slight delays added up to long delays,” Dr. Wharam said. Newly diagnosed breast cancer patients with high deductibles were more likely to defer diagnostic imaging, biopsies and treatment; they also postponed chemotherapy by an average of seven months.

Paying for medical care is a common concern of many breast cancer patients

1. High deductibles and other health plan cost sharing creates unintended financial burdens for many patients
   
   Another recent Harvard study of out-of-pocket health care spending by metastatic breast cancer patients found that women with HDHPs paid 55% more than those with LDHPs.
   
   Quoted in the NYT article, Dr. Bach said, “We treat health care as a luxury good.” And that is the underlying problem. Although some employers offer medical savings accounts for employees, too many people live paycheck to paycheck and don’t have extra income to put aside. The result is that high-deductible healthcare plans end up costing the most for those who can least afford it. 
    
2. Fear for how people will pay for medical services can drive their medical decisions
   
   Indiana University health policy professor Dr. Nir Menachemi and colleagues conducted a meta-analysis of how health care plans impact cancer care. They concluded that high-deductible plans reduce health care costs by decreasing the use of both appropriate (such as cancer screening) and inappropriate (such as low-severity ED visits) health services. Researchers say that patients don’t always distinguish between the care they should get and what they can do without. Dr. Menachemi has found that people are more likely to forgo preventive care when they have a high deductible, even if that care is free.
   
   “What we see here is an unintended consequence of sharing costs,” according to oncologist Ethan Basch, MD. He said in the NYT article that patients often make decisions based on financial issues. Facing high out-of-pockets costs, “they’re of a mindset to avoid visits, expensive treatments.”
   
   The NYT article uses the stories of two breast cancer patients to illustrate how financial concerns can limit the ability of some individuals to pursue treatment. Pam Leonard found a lump in her breast but delayed seeing a doctor because she needed to pay $8,300 above and beyond what her health policy covered. A mammogram and ultrasound eventually confirmed her diagnosis, followed by lumpectomy and chemotherapy. Leonard, who is a teacher, took on a second job at night to pay for her treatment.
   
   Rochelle Ness’ experience is a striking example of how health care costs can escalate, even when you have health insurance. With an annual health plan out-of-pocket expense of $11,500, two years after diagnosis, she faces medical bills of $25,000 while fighting for her insurer to pay for injections needed to help prevent infection during chemotherapy. “We have maxed out our credit cards trying to pay medical expenses," she said.

The impact of delaying breast cancer treatment

Delaying treatment, no matter the reason, can adversely impact cancer progression and survival. Lars Eriksson, Ph.D. and colleagues in Sweden recently showed that even short delays (3 weeks versus 6 weeks) between diagnosis and surgery modestly decreased survival. In a meta-study of 3,390 women from 3 clinical trials, delays between surgery and the start of chemotherapy were associated with poorer outcomes, while delays between surgery and radiation while patients had chemotherapy did not impact disease-free survival.

Smith and colleagues found that for adolescent and young adult (AYA) women with breast cancer, delays in treatment were associated with decreased survival rates. At 5 years post-surgery, AYA women who had treatment delays of more than 6 weeks had 80% survival compared to a 90% among those who were treated in less than 2 weeks. Delays in treatment also affect ethnic minorities disproportionally: 15% of Hispanic and African American women surveyed experienced treatment delays of more than 6 weeks compared to 8.1% of non-Hispanic white women. Treatment delays of more than 6 weeks were also experienced by 18% of women with no health insurance or public insurance, compared to 8% of women with private insurance.

What does this mean for me?

Here are some important takeaway messages from the article: 

• Know your healthcare coverage.
  • When you consider health care plans, be aware of the cost of deductibles and consider a health savings plan or other financial reserves to cover deductible expenses.
• Given a choice of plans with differing deductibles, weigh the short- and long-term benefits of a higher deductible and longer-term cost.
• Consulting with a financial advocate can help to navigate health care expenses. However, medical staff sometimes assume that patients with health insurance do not need the help of a financial advocate. Ms. Leonard, for example, said, “Because I had insurance, I was told I didn’t need a financial advocate.”
• If you face health care decisions, be aware that delays in care may have significant, detrimental impacts on treatment outcome.

Posted 7/12/18

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References

Kaiser Family Foundation. “2017 Employer Health Benefits Survey.” 

Reed Abelson. “Women with Breast Cancer Delay Care When Faced with High Deductibles.” New York Times. 

Wharam JF, Zhang F, Lu CY, et al. “Breast Cancer Diagnosis and Treatment After High-Deductible Insurance Enrollment.” Journal of Clinical Oncology. 2018 Apr 10;36(11):1121-1127.

Leopold C, Wagner AK, Zhang F, et al. “Total and out-of-pocket expenditures among women with metastatic breast cancer in low-deductible versus high-deductible health plans.” Breast Cancer Research and Treatment. 2018 June 1. doi: 10.1007/s10549-018-4819-6.

Eriksson L, Bergh J, Humphreys K, et al. “Time from breast cancer diagnosis to therapeutic surgery and breast cancer prognosis: A population-based cohort study.” International Journal of Cancer. 2018 Mar 31. doi: 10.1002/ijc.31411. [Epub ahead of print.]

Smith EC, Ziogas A, Anton-Culver H. “Delay in surgical treatment and survival after breast cancer diagnosis in young women by race/ethnicity.” JAMA Surgery. 2013 Jun;148(6):516-23. doi: 10.1001/jamasurg.2013.1680.
 

Disclosure

FORCE receives funding from industry sponsors, including companies that manufacture cancer drugs, tests and devices. All XRAYS articles are written independently of any sponsor and are reviewed by members of our Scientific Advisory Board prior to publication to assure scientific integrity.