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The Association Between Insurance Type and Financial Toxicity in Older Adult Surgical Patients
Ezra S Brooks1, Claire Morton2, Randall Bloch3
1Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Introduction:
Surgical patients often face significant financial strain, termed financial toxicity (FT). Among US adults aged ≥65 years, insurance options include public (Medicare), subsidized private (Medicare Advantage [MA]), and private insurance. We examined FT by insurance coverage in this population.
Methods:
We analyzed adults ≥65 years with Medicare, MA, or private insurance who underwent inpatient surgery in the Medical Expenditure Panel Survey (2017-2022). FT was defined as difficulty paying medical bills, delaying or skipping medications, or postponing care due to cost. Secondary outcomes included annual out-of-pocket (OOP) costs and total health-care expenditure (THE; OOP plus premiums). Logistic and linear regression models estimated adjusted odds of FT, OOP costs, and THE by insurance type.
Results:
Among 4089 patients (weighted n = 6.7 million), 21.9% reported FT: 24.6% Medicare, 23.2% MA, and 19.2% private (P = 0.047). The mean OOP costs were $2395 ($2451 Medicare, $2291 MA, and $2452 private; P = 0.72). THE averaged $9243 ($6071 Medicare, $7824 MA, $9975 private; P < 0.001). Compared with Medicare, adjusted odds of FT were similar for MA (odds ratio 1.07, 95% confidence interval [CI] 0.79-1.42) and private insurance (odds ratio 0.89, 95% CI 0.64-1.23). THE was higher for MA (+$1,823, 95% CI $114-$3533) and private insurance (+$3,842, 95% CI $2170-$5513).
Conclusions:
Despite subsidized insurance, FT remains prevalent among older adult surgical patients. Private and MA plans incur higher total costs than Medicare plans without lowering FT risk. As MA enrollment rises, we must work to understand the driving factors behind patient insurance plan selection and work to optimize it.