Adding insult to injury: Effect of insurance benefit design on financial hardship among privately insured adults with colorectal cancer.

26 Background: Employer-sponsored private insurance often provides generous coverage. Mandates of out-of-pocket maximum (OOP max) under the Affordable Care Act (ACA) offers an extra layer of financial protection for adults with private insurance. The OOP max, however, only applies to in-network care. Two trends could erode protections of private insurance: a shift toward high-deductible plans (HDP) and narrowing insurance networks because of provider consolidation. We examined whether the compound effect of HDP and out-of-network care exacerbates financial hardship for privately insured non-elderly adults with colorectal cancer (CRC). Methods: Using MarketScan Commercial Claims and Encounters Data, we applied a claims-based algorithm to identify patients (pts) with incident CRC diagnosed 2015 - 2022, with 12-month continuous enrollment before and after index diagnosis. Total and OOP payments (sum of deductibles, copayments, and coinsurance) were calculated for 12 months post-diagnosis. Pts who received any portion of cancer treatment (surgery, radiation, or systemic therapy) from out-of-network providers were classified as receiving out-of-network care (ONET). We characterized insurance benefit by HDP enrollment (yes/no) and ONET status (yes/no). We used generalized linear models and quantile regressions (at median and 90 th percentile) to compare differences in costs at mean, median, and 90 th percentile, respectively, by benefit characteristics, adjusting for pre-diagnosis comorbidity, region, sex, year, and treatment received. All estimates are reported in 2024 US dollars. Results: Cohort included 10,839 pts with CRC. Overall, 27.3% were < 50 years, 53.6% were male, 23.0% enrolled in HDP, and 20.4% received a portion of cancer treatment from ONET providers. By benefit characteristics, the proportion in noHDP-noONET (Group00), noHDP-ONET (G01), HDP-noONET (G10), and HDP-ONET (G11) was 60.9%, 16.1%, 18.7%, and 4.3%, respectively. Total costs were positively associated with ONET but not with HDP. OOP costs were highest for G11, followed by G10, G01, and G00 (Table). Conclusions: Pts in HDP and received out-of-network care are at highest risk of financial hardship. Although the 2024 ACA OOP max is $9,450, many pts high spenders (top ten percentile) do not benefit from this financial protection. Narrowing network and expanding HDP may exacerbate cancer financial hardship, even among the well-insured. Group Mean P-value (vs. G00) Median P-value (vs. G00) 90 th percentile P-value (vs. G00) Total Costs G00 $111,794 - $90,686 - $190,230 - G01 136,393 <0.001 103,458 <0.001 220,452 <0.001 G10 109,280 0.364 90,261 0.794 192,715 0.671 G11 127,768 0.007 102,542 <0.001 217,326 0.013 OOP Costs G00 $4,087 - $3,491 - $7,856 - G01 5,007 <0.001 4,170 <0.001 9,576 <0.001 G10 5,937 <0.001 5,212 <0.001 10,033 <0.001 G11 6,779 <0.001 6,267 <0.001 12,260 <0.001