Two common cost-containment strategies — high-deductible health plans and stringent prior authorization requirements — can significantly hinder the survival and well-being of patients with cancer, according to two studies presented at the American Society of Clinical Oncology (ASCO) 2024 Annual Meeting.
In the first study, Justin Barnes, MD, with Washington University in St. Louis, and colleagues used data from the National Health Interview Survey (2011-2018) to analyze the impact of high-deductible health plans — which often result in higher out-of-pocket expenses for patients before insurance coverage kicks in — on overall and cancer-specific survival.
High-deductible health plans were defined as a yearly deductible of $1200 to $1350 or more for an individual, and $2400 to $2700 for a family. A total of 147,254 respondents were identified, 5.9% of whom were cancer survivors.
Barnes and colleagues found, that compared with cancer survivors who had standard health plans, peers with high-deductible plans had a significantly greater risk of death from any cause (hazard ratio [HR], 1.46) and risk of death from cancer (HR, 1.34).
For individuals in the general population without a history of cancer, however, high-deductible health plans appeared to have "minimal impact on survival, with hazard ratios approaching 1," Barnes reported.
In addition to the results for all cancer survivors, high-deductible health plans were associated with worse overall survival in several subgroups, most notably non-Hispanic White patients (HR, 1.45), individuals with higher incomes (more than 400% of the federal poverty level, HR, 1.65), a college (HR, 1.47) or high school education (HR, 1.59) and those with multiple cancers (HR, 1.58).
Although the subgroups affected are "those with historically better access to care," Barnes noted that high-deductible health plans may "financially disincentivize cancer survivors from utilizing necessary medical care that's needed to optimize their survivorship, thereby compromising survival."
Alexi Wright, MD, MPH, the ASCO discussant for the study, noted that 30% of working-age adults receiving healthcare through their employer have a high-deductible health plan — up from 15% in 2007 — and cancer survivors enrolled in these plans are more likely to delay or forgo care because of costs.
"This study shows, for the first time to my knowledge, that high-deductible health care plans are associated with an increased risk of overall and cancer-specific mortality in cancer survivors," said Wright, with Harvard Medical School and Dana-Farber Cancer Institute, Boston.
High Human Toll of Prior Authorization Denials
The other study presented at the meeting demonstrated how denying prior authorization requests for pain medication can lead to uncontrolled pain and more expensive healthcare utilization.
The researchers identified 1752 prior authorization requests for new outpatient long-acting opioid prescriptions for 982 unique patients with cancer from Memorial Sloan Kettering Cancer Center in New York City.
These requests were for buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone, oxymorphone, and tapentadol.
The vast majority of these requests — 1567 (89%) — were ultimately approved, which "means the process may be unnecessary and it could just be delaying care," Fumiko Chino, MD, with Memorial Sloan Kettering Monmouth in Middletown, New Jersey, told attendees.
However, 99 prior authorizations (5.6%) in 62 unique patients were denied; 1 patient had seven different denials. A chart review of these 62 patients during the 2 weeks after denial revealed some "heartbreaking" results, Chino said.
Fourteen patients (22.6%) ended up in the emergency department or were admitted to the hospital for either pain crisis or failure to thrive and 7 (11.3%) ended up paying out of pocket for pain medications.
Four patients (6.5%) transitioned to hospice care, including three who died within 2 weeks of being denied. "This number is pretty compelling because it means that it's possible that some of those patients actually ended up dying in pain due to prior authorization denial," Chino said.
Wright, who was not involved in the research, put it bluntly: "Prior authorizations are a colossal waste of time. In this study, most were ultimately approved but with high human costs," she told attendees.
She also noted that these estimates, derived from one well-resourced cancer center, are likely a "gross underestimate of the human impact" of prior authorization denials.
Considering the results of these two studies together, "I would say the time is up," said Wright.
"We need to increase awareness and advocacy for all of our patients, but particularly minoritized and disadvantaged patients, while we wait for a better understanding of mechanisms, interventions, and ultimately policy reform."
The studies had no specific funding. Barnes has received honoraria from Elsevier. Chino and Wright report no relevant financial relationships.
