Association of health insurance types and out-of-pocket expenses with clinical outcomes among patients with head and neck cancer.

8 Background: Patients with head and neck cancer often receive multimodality treatments and experience substantial financial burden. However, it is unclear whether health insurance types and out-of-pocket expenses translate to heterogeneous clinical outcomes. To address this knowledge gap, we performed an observational cohort study to evaluate the association of health insurance types and out-of-pocket expenses with such outcomes. Methods: Our single institution database was queried for patients with non-metastatic head and neck cancer diagnosed between October 2011 and December 2023 who received definitive radiation, chemoradiation, or induction chemotherapy followed by chemoradiation. Primary health insurance and total out-of-pocket expenses for radiation treatment services were collected. Cox multivariable analysis (MVA) and Fine-Gray MVA were performed for survival and tumor recurrence outcomes. Logistic MVA was used to identify variables associated with certain health insurances. Bonferroni correction was performed for multiple comparisons with p < 0.016 for statistical significance. Results: A total of 752 patients met our criteria (n = 304 [40.4%] with private insurance, n = 268 [35.6%] with Medicare, n = 119 [15.8%] with Medicaid, and n = 61 [8.1%] with other governmental insurance). Median out-of-pocket cost was $0 (interquartile range 0-81). The majority of these patients (n = 540, [71.8%]) had no out-of-pocket expenses, while 103 [13.7%] and 18 [2.4%] patients paid over $1,000 and $5,000 out of pocket, respectively. Median follow up was 46.7 months (95% confidence interval [CI] 45.1-48.6). When compared to private insurance, Medicaid was associated with worse overall survival (OS; adjusted hazards ratio [aHR] 2.03, 95% CI 1.30-3.17, p = 0.002) and progression-free survival (PFS; aHR 1.83, 95% CI 1.22-2.75, p = 0.003), but not locoregional failure (LRF; aHR 1.38, 95% CI 0.68-2.81, p = 0.37) and distant failure (DF; aHR 1.58, 95% CI 0.68-3.64, p = 0.29). Similar findings were noted among those with p16-positive tumors, but not with p16-negative tumors. In the entire cohort, other governmental insurance was also associated with worse PFS than private insurance, but otherwise other types of insurance and out-of-pocket expenses were not associated with survival and cancer control outcomes. Compared to patients with private insurance, those with Medicaid were more likely to be non-Caucasian and current smokers, while they were less likely to be male and have high out-of-pocket expenses and p16-positive tumors. Conclusions: Our study suggested that although the vast majority of patients had no or minimal out-of-pocket expenses, a handful of patients paid substantial expenses. It also suggested that when compared to those with private insurance, patients with Medicaid had worse survival outcomes, driven by those with p16-positive tumors.