Women in High-Deductible Health Plans Delay Breast Cancer Diagnosis, Treatment

Researchers looked at the time to first breast cancer diagnostic testing, diagnosis, and chemotherapy among a group of women whose employers switched from low-deductible to high-deductible health plans.

Low-income women enrolled in high-deductible health plans delay chemotherapy treatments for breast cancer by nearly nine months, compared with low-income women enrolled in low-deductible plans, a new study shows.

Delays also occurred at the diagnosis and testing stages, including a 1.6 months delay to initial breast imaging, a 2.7 months delay to first biopsy, and a 6.6 months delay to early-stage breast cancer diagnosis, according to the research published this week in Health Affairs.

"The most likely reason that women delay these events along the path towards breast cancer diagnosis and treatment would be the barrier of high out-of-pocket costs that women face when they join high-deductible health plans," said study chief author J. Frank Wharam, MD, with the Harvard Pilgrim Health Care Institute.

Wharam says that cancer screenings, diagnosis, and treatment often go through stages, and this is where the delays mount.

"What we found was that in between the stages—from screenings to diagnostic tests to a biopsy to a diagnosis of cancer to chemotherapy—there were some delays and those delays added up to be quite substantial by the time you compared time to chemotherapy," he says.

"And again, this is likely related to fear of out-of-pocket costs," he says. "We do know that people tend to put off care towards the end of the year when there's a high-deductible health plan because their cost sharing goes down once they hit the deductible, so that's possibly another factor."

The researchers looked at the 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.

The research group included 54,403 low-income and 76,776 high-income women who were continuously enrolled in low-deductible plans for a year and then up to four years in HDHPs.

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.

The researchers recommend developing policies to reduce out-of-pocket spending obligations to encourage prompt screening and treatment.

Wharam says further study is needed to determine if the treatment delays were detrimental.

"There's not great evidence about whether longer delays are associated with worse outcomes," he says. "There have been a few studies that indicate that delays of three to four months between diagnosis and surgery are associated with worse outcomes such as survival. But those studies are a bit challenging in the sense that the delays might be related to other illnesses."

"We're not completely sure, but if it was a two- or three-month delay to chemotherapy, I don't think there'd be as much great concern as if it were, say, a two-year delay," Wharam says. "We're in this in-between area where I'm not sure of the downstream impact on health outcomes like death and survival and progression to metastatic disease."