Cancer patients face major financial hurdles

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Abstracts presented at this year’s annual meeting of the American Society of Clinical Oncology detailed the financial challenges faced by many cancer patients, including those related to high-deductible health plans and participation in clinical tests.

Two presentations at the 2022 American Society of Clinical Oncology (ASCO) Annual Meeting addressed different facets of the financial burden placed on patients with diagnosed cancers. Both were part of a session on health services research and quality improvement.

In his presentation, Nicolas K. Trad, a fourth-year medical student at Harvard Medical School in Boston, Massachusetts, and researcher in the Department of Population Medicine, discussed the findings on the potential impact of franchise health plans. high (HDHP) on delaying diagnosis of metastatic cancer.1

Financial burden of HDHPs1

In 2006, deductible relief day—the date when most people reach their annual medical deductible and insurance kicks in—usually occurred in late February. As recently as 2019, this milestone had been pushed back nearly 3 months by mid-May, indicating that it took patients an additional 3 months of out-of-pocket payments to reach their deductible. Along with this trend, research by Trad and his colleagues on workers enrolled in HDHPs shows a steady increase in enrollment between 2006 and 2019, to the point that HDHPs now cover more than half of American workers.

“Due to increased out-of-pocket expenses, patients may delay presentation of concerning symptoms or diagnostic tests, leading to delayed diagnosis,” wrote lead author Trad and team. “We therefore assessed the impacts of HDHPs on the timing of detection of metastatic cancer,” knowing that previous research already shows that the use of HDHPs has resulted in breast cancer-related delays in biopsy, imaging, diagnosis and initiation of chemotherapy.

HDHPs were originally intended to control healthcare costs, when they were introduced in 2003. Instead, they have led to decreased healthcare utilization due to increased spending patients to achieve their annual deductibles, even with plans. aims to “motivate” patients to seek lower prices and avoid unnecessary care. As a result, patients may be more likely to delay diagnostic visits and be diagnosed with cancer at a later stage, Trad noted.

The participants in this study were between the ages of 18 and 64 and had no history of cancer. They were matched 1:5 to a study group (n=345,401; employers mandated switching to an HDHP from a low-deductible health plan [LDHP]) and a control group (n=1,654,775; employers only offered LDHPs), with data from 2003 to 2017 taken from a national commercial database and Medicare Advantage. Matching criteria included demographics (age, gender, race/ethnicity, poverty level, region), morbidity measured by Adjusted Clinical Groups (ACG) score, and baseline medical and pharmaceutical costs. For this analysis, HDHPs had annual deductibles of at least $1,000, while LDHPs were $500 or less. The baseline period was one-year LDHP enrollment for all participants, who were followed for 13.5 years.

During an average follow-up period of 38 months, 1668 diagnoses of metastatic cancer were made. While no difference in time to metastatic diagnosis was observed in the baseline period (HR, 0.96; P= 0.67), participants were shown to have a longer time to first metastatic diagnosis if they were to switch from LDHP to HDHP (HR, 0.88; P= .01). This was “indicative of delayed detection relative to the control group,” the authors wrote, for a total of 4.6 months relative to the control group with continued enrollment in the LDHPs.

These delayed diagnoses could further translate into delayed palliative care and limited treatment options, Trad pointed out, all due to exposure to high cost sharing.

“The policy relevance of these findings is that they highlight a great need for innovative insurance models that do not deter patients from seeking care,” Trad concluded, “as well as plans that align rather than contradict the goal of improving population-level cancer survival.

Areas of interest for future research include how HDHPs affect quality of life and treatment utilization among this patient population.

Impact of Medicaid expansion on clinical trial participation2

In the second presentation, Joseph M. Unger, PhD, MS, associate professor in the Cancer Prevention Program, Division of Public Health Sciences at Fred Hutchinson Cancer Center in Seattle, Washington, and biostatistician for the SWOG Cancer Research Network, explained how the passage of the Affordable Care Act (ACA) and the expansion of Medicaid influenced enrollment and participation in cancer clinical trials.2

Unger and colleagues’ study of 51,751 participants, which represented the peaks and troughs of cancer clinical trial enrollment, compared the total number of patients using Medicaid coverage who enrolled before and after the initial implementation of ACA. Unger and his team found that the ACA improved access to clinical trials for patients using Medicaid coverage between 2014 and 2015.

Overall in 2020, following the expansion of the law, the number of patients using Medicaid in clinical trials increased to 17.8% from 6.9% before the expansion. When investigators compared states that expanded coverage to states that did not, the odds of patients using Medicaid in clinical trials were nearly 4 times higher in states with expanded coverage.

Unger and his team used data from the SWOG Cancer Research Network. All patients aged 18 to 64 who participated in therapeutic trials between April 1, 1992 and February 28, 2020 were included in the analysis. Data on patients who enrolled in trials from March 2020, when the COVID-19 pandemic was just beginning, were excluded because “this time period was considered unrepresentative of previously demonstrated temporal associations between unemployment and use of Medicaid insurance”. Adjustments were made for the monthly unemployment rate using data from the Bureau of Labor Statistics.

“Our analysis is based on the idea that the proportion of patients using Medicaid for their medical insurance generally parallels national economic trends,” Unger said, “particularly the unemployment rate.” He pointed to the fact that trends in Medicaid use among trial participants generally follow unemployment trends – for example, coverage increases as unemployment increases, as was the case during the recession of 2007-2009 – with a lag of about 1 year, but reversed after implementation. of the ACA.

Study co-authors found an overall 19% increase in annual odds of clinical trial enrollment among patients using Medicaid coverage following the expansion of the law (odds ratio [OR], 1.19; 95% CI, 1.11-1.28; PPP= 0.21) more likely.

Of their predominantly female population (67.3%), under the age of 50 (40.4%), 62.6% lived in the 32 states that expanded Medicaid coverage between 2014 and 2015. Most participants were neither black (91.6%) nor Hispanic (95.5%). .

Among the policy implications of these findings is that improving access to clinical trials for Medicaid patients means those who are socioeconomically vulnerable have better access to newer treatments. , underlined Unger.

“Improving access to clinical trials for the most vulnerable patients is key to improving confidence that trial results also apply to the general cancer population,” he concluded. “And one might reasonably assume from these findings that the recently enacted law [Clinical] Treatment Act, which requires state-level Medicaid programs to cover routine care through clinical trials for Medicaid patients may, in fact, improve access to clinical trials for socioeconomically underserved populations.

References

1. Trad NK, Hassett MJ, Zhang F, Wharam JF. Impact of high-deductible health plans on delays in diagnosis of metastatic cancer. Abstract presented at the ASCO Annual Meeting 2022; June 3-7, 2022; Chicago, IL. Abstract 6503. Accessed June 4, 2022. https://meetings.asco.org/2022-asco-annual-meeting/14377?presentation=206347#206347

2. Unger JM, Xiao H, Vaidya R, Hershman DL. Medicaid expansion of the Affordable Care Act and patient participation with Medicaid in cancer clinical trials. Abstract presented at the ASCO Annual Meeting 2022; June 3-7, 2022; Chicago, IL. Abstract 6505. Accessed June 4, 2022. https://meetings.asco.org/2022-asco-annual-meeting/14377?presentation=206536#206536

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