Enrollment in high-deductible health plans (HDHPs) is associated with delays in the diagnosis of metastatic cancer, according to research presented at the 2022 ASCO Annual Meeting.1
The researchers defined HDHPs as plans in which patients are responsible for all costs until they have spent at least $1000 annually, said study presenter Nicolas Trad, of Harvard Medical School in Boston.
Trad cited data suggesting that the percentage of American workers enrolled in HDHPs increased from approximately 10% in 2006 to nearly 60% in 2021.2 He also cited data suggesting that HDHP enrollees experience delays with diagnostic biopsies and imaging for breast cancer, as well as initiation of chemotherapy.3
For the current study, Trad and colleagues investigated whether participants in HDHPs experience a delay in the diagnosis of metastatic cancers as well.1
Study Details and Results
The researchers examined insurance claims from 2003-2017 for 345,401 individuals, ages 18-64, whose employers mandated a switch from a low-deductible plan ($500 or less annually for individual coverage) to a HDHP.
The researchers compared the HDHP group to a matched control group of 1,654,775 individuals whose employers offered only low-deductible plans.
Both groups had a 1-year baseline period when everyone was enrolled in a low-deductible plan. The groups were matched for a variety of demographic, clinical, financial, and other parameters, so there was no difference in baseline characteristics between the groups.
Through claims data, the researchers assessed the time to metastatic cancer diagnosis in the baseline (pre-HDHP switch) and follow-up periods (post-HDHP switch). Patients with a prior diagnosis of metastatic cancer were not included in the analysis.
At a mean follow-up of 38 months, patients had a total of 1668 metastatic events.
During the year when all patients had low-deductible plans, there was no significant difference between the groups in the time to metastatic diagnosis (hazard ratio [HR], 0.96; P =.67).
However, after some patients switched to HDHPs, those with HDHPs had lower odds of metastatic cancer diagnosis than patients who kept their low-deductible plans (HR, 0.88, P =.01). This is indicative of significantly delayed detection in the HDHP group compared with the control group, Trad said.
He noted that, on average, metastatic disease was detected 4.6 months later in patients with HDHPs than in patients who kept their low-deductible plans.
Diagnostic delays could delay the start of palliative care and symptom-relieving therapies, Trad noted. Delays could also lead to greater dissemination of disease, which limits therapeutic options.
Trad acknowledged, however, that the impact of diagnostic delays on treatment, quality of life, and survival could not be ascertained with the current study.
Value From the Patient’s Perspective
Learning about a metastatic cancer diagnosis sooner could mean a lower disease burden at the start of treatment, which could lead to improved outcomes, said study discussant Oluwadamilola Fayanju, MD, of the University of Pennsylvania in Philadelphia.4
She noted that an earlier diagnosis gives patients more time to receive treatment, get their personal affairs in order, grieve, and perhaps die how and where they want.
On the other hand, some patients might choose a HDHP despite the prospect of a later diagnosis, Dr Fayanju said. She pointed out that having money in hand might be more important than a possible delay in diagnosis. Furthermore, getting an earlier diagnosis might not help patients physically, and it could result in longer unemployment, make patients feel like a burden to their loved ones, and prolong psychological suffering.
Dr Fayanju emphasized that additional research should distinguish metastatic recurrences from de novo diagnoses. The trajectory up to that moment may impact which outcomes are prioritized, she said.
She also noted that some employers may mandate the choice of a HDHP for their employees. Additional research about clinical outcomes could have an influence on efforts toward collective advocacy.
Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.
- Trad N, Hassett M, Zhang F, Wharam JF. Impact of high-deductible health plans on delays in metastatic cancer diagnosis. Presented at ASCO 2022; June 3-7, 2022. Abstract 6503.
- 2021 Employer Health Benefits Survey. Kaiser Family Foundation. Published November 10, 2021. Accessed June 24, 2022. https://www.kff.org/report-section/ehbs-2021-summary-of-findings/
- Wharam JF, Zhang F, Lu CY, et al. Breast cancer diagnosis and treatment after high-deductible insurance enrollment. J Clin Oncol. 2018;36 (11):1121-1127. doi:10.1200/JCO.2017.75.2501
- Fayanju OM. Evaluating the real value: Impact of health insurance on cancer care delivery. Presented at ASCO 2022; June 3-7, 2022.