Insurance Network Status and 1-Year Health Care Utilization and Outpatient Costs Among Commercially Insured Patients...

Cancer care in the U.S. exceeds $200B, with patients paying over $16B out-of-pocket. We examined whether insurance network status (in-network [IN] vs. out-of-network [OON]) at prostate cancer diagnosis was associated with subsequent OON care use and patient spending within 1 year of diagnosis.

Using the MarketScan database (2010-2021), we identified patients aged 40-64 with a new outpatient prostate cancer diagnosis. Patients who received definitive local treatment (radical prostatectomy or radiotherapy) were excluded. The exposure was network status at diagnosis. Outcomes were the proportion of OON claims and patient spending for prostate cancer-related care and/or non-definitive treatments during 1 year of follow-up. Results were stratified by insurance type.

Among 67,271 patients, 5% were diagnosed OON. Compared with IN diagnosis, OON diagnosis was associated with greater OON follow-up claims (aIRR 29.0, 95% CI 25.0, 33.5), lower odds of prostate cancer-related spending (aOR 0.55, 95% CI 0.49, 0.61), and lower outpatient costs (% difference = -8.6, 95% CI -13.4, -3.6). In stratified analyses, patients with HMO (aOR 0.54, 95% CI 0.44, 0.67) and PPO (aOR 0.47, 95% CI 0.41, 0.54) plans had lower odds of any spending. Patients with HMO (% difference = -22.3, 95% CI -30.9, -12.5) and CDHP (% difference = -26.5, 95% CI -43.6, -4.3) plans had lower costs.

OON diagnosis was associated with continued OON care. Some patients diagnosed OON had lower liability, likely reflecting differences in plan design and adjudicated claims. Claims-based estimates may underestimate the financial impact of OON non-definitive prostate cancer care.