By J. Frank Wharam, Fang Zhang, Jamie Wallace, Christine Lu, Craig Earle, Stephen B. Soumerai, Larissa Nekhlyudov, and Dennis Ross-Degnan
Health Affairs, March 2019
The effects of high-deductible health plans (HDHPs) on breast cancer diagnosis and treatment among vulnerable populations are unknown. We examined time to first breast cancer diagnostic testing, diagnosis, and chemotherapy among a group of women whose employers switched their insurance coverage from health plans with low deductibles ($500 or less) to plans with high deductibles ($1,000 or more) between 2004 and 2014. Primary subgroups of interest comprised 54,403 low-income and 76,776 high-income women continuously enrolled in low-deductible plans for a year and then up to four years in HDHPs. Matched controls had contemporaneous low-deductible enrollment. Low-income women in HDHPs experienced relative delays of 1.6 months to first breast imaging, 2.7 months to first biopsy, 6.6 months to incident early-stage breast cancer diagnosis, and 8.7 months to first chemotherapy. High-income HDHP members had shorter delays that did not differ significantly from those of their low-income counterparts. HDHP members living in metropolitan, nonmetropolitan, predominantly white, and predominantly nonwhite areas also experienced delayed breast cancer care. Policies may be needed to reduce out-of-pocket spending obligations for breast cancer care.
From the Discussion
This study found that both vulnerable and less vulnerable women experienced delays in breast cancer diagnostic testing, early-stage diagnosis, and chemotherapy initiation following an employer-mandated switch to high-deductible health plans. Although magnitudes of delays among women in the three income categories were not statistically different at a 95 percent level of certainty, the graduated duration of the delays in the expected direction suggests true differences. For example, HDHP enrollment was associated with delays in chemotherapy initiation of 8.7 months among low-income women, 8.1 months among middle-income women, and 5.7 months among high-income women. We also detected delayed breast cancer care among HDHP members living in metropolitan, nonmetropolitan, predominantly white, and predominantly nonwhite areas.
These results suggest that HDHP-associated delays in breast cancer care are only partially related to patients’ sociodemographic characteristics and that women across the income spectrum might experience high out-of-pocket spending obligations as a barrier to breast cancer care. The delay of approximately five to seven months in early-stage breast cancer diagnosis among women across the sociodemographic spectrum could imply suboptimal breast cancer outcomes.
High-income women have greater ability to afford out-of-pocket expenses than low-income women do, so our finding that high-income women experienced substantial delays in breast cancer care was unexpected.
Our findings raise concerns that in coming years a majority of commercially insured women of all sociodemographic levels could experience delayed breast cancer care.
Both vulnerable and less vulnerable women who were switched to high-deductible health plans experienced delays in breast cancer diagnostic testing, early-stage diagnosis, and chemotherapy initiation, compared to women remaining in low-deductible health plans. Such delays could lead to adverse long-term breast cancer outcomes affecting a substantial proportion of commercially insured women who develop breast cancer. Policy makers, health insurers, and employers should consider implementing value-based features in HDHPs to encourage successful transitions through key stages of the cancer care pathway. This could take the form of increased HSA contributions or “population-tailored” exclusions of essential care so that women would pay minimal amounts for services such as breast diagnostic testing.
By Don McCanne, M.D.
We have serious problems with our health care financing system – a system that costs twice the average per capita of other wealthy nations yet falls miserably short in performance. In the meantime, the policy community busies itself with fixes that have clearly failed to bring our expensive system up to the standards of other nations. One of those fixes is high-deductible health plans.
Deductibles have fallen short as a policy tool, yet the policy community still insists that they have to be of benefit since they would make patients better health care shoppers by exposing them to more of the costs of their care. Their policy diagnosis is that, for deductibles to work, patients are going to have to feel more financial pain. Thus they have been increasing the deductibles to reach that threshold where pain occurs.
The policy community is quite smug now because moving to higher deductibles is working, according to their terms. People are limiting or delaying care because of these deductibles, thus meeting the goal of reducing health care spending. Or, in our terms, is it really working? Is it smart health care shopping if the financial exposure causes patients to delay diagnosis and treatment of breast cancer? Should women be waiting to be sure that they really need this care by seeing if they develop further invasive or metastatic disease? Just asking that question depresses and even nauseates me. Yet this study confirms through a “natural experiment” that women are delaying breast cancer care when they are shifted to plans with high deductibles.
As an individual obsessed with the study of health policy as it applies to our health care system, I am disappointed to see that the authors suggest implementing “value-based” features – perhaps increasing contributions to health savings accounts – as a means to reduce the stress of out-of-pocket spending for breast cancer. Not only is this a feeble response, it ignores the fact that these consumer-driven policies negatively impact the care of all serious medical problems, not just breast cancer.
We need a fundamental restructuring of our health care financing system. Right now with all of the talk about single payer Medicare for All it is almost impossible to avoid knowing what form that restructuring should take. A well-designed, single payer Medicare for All program, free at the point of service, would make essential health care accessible and affordable for absolutely everyone. And yet too many of today’s politicians and many in the policy community seem to think that an extreme measure would be to allow individuals to buy a Medicare plan as they exist today that would cover on the average only about half of health care costs, but don’t dare take away our private insurance (that relies on high deductibles and other perversities). Or rather, many say, we should just limit ourselves to building on the highly deficient Affordable Care Act.
Excuse me, but I have to barf.
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