Insurance-related differences in high-intensity care utilization among older patients with cancer

Health insurance is a key determinant of healthcare utilization, yet its influence on the allocation of high-intensity medical resources under varying levels of clinical need remains poorly understood.

We conducted a retrospective observational study using administrative data from a tertiary hospital in China. The study included 12,916 hospitalized patients aged 60 years or older with a primary diagnosis of cancer in 2024. High-intensity care departments were classified using a multi-dimensional department-level proxy approach, in which quantitative indicators served as initial screening references, final classification was determined by senior clinician adjudication, and the resulting classification was further validated using available hospitalization-level resource-use indicators. Multivariable logistic regression and modified Poisson regression were used to estimate the association between insurance type and admission to high-intensity care departments. Interaction tests and subgroup analyses explored potential heterogeneity by age and multimorbidity.

Overall, 83.0% of patients were admitted to high-intensity care departments. Employee-insured patients had lower odds of admission than resident-insured patients (OR = 0.84, 95% CI: 0.74-0.94; RR = 0.98, 95% CI: 0.96-0.99). Multimorbidity was associated with higher odds of admission (OR = 1.32, 95% CI: 1.06-1.64). The formal interaction between insurance type and age was not significant (p = 0.096). Exploratory subgroup analyses suggested a potentially weaker association among patients with greater clinical complexity.

Among older hospitalized patients with cancer, insurance type was associated with admission to high-intensity care departments. This association appeared to be weaker among patients with greater clinical complexity, suggesting that the influence of insurance-related factors may be attenuated when medical need becomes more pronounced. Exploratory analyses suggested a potentially weaker association among patients with greater clinical complexity; however, formal interaction tests did not provide statistically significant evidence of effect modification. These findings have implications for understanding equity in inpatient resource allocation within the context of ongoing health insurance payment reform and public hospital management in China.