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April 9, 2003


Uninsured Patients Pay More but Get Less in Cancer Treatment

ATLANTA ≠ Uninsured cancer patients receive only about half the health services of insured cancer patients, but pay nearly twice as much in out-of-pocket expenses, according to a study by Emory University health policy professors Kenneth E. Thorpe, PhD and David Howard, PhD in the April issue of Health Affairs. Moreover, uninsured patients are less likely to be treated in accordance with accepted clinical guidelines, and experience worse outcomes. Dr. Thorpe says the results are "disturbing, but place an interesting face on the uninsured issue."

In the study, a sample of 1,383 cancer patients were tracked over a six-month period. Patients with private insurance consumed an average of $6,550 for health care compared to $3,606 by uninsured patients. But despite the lower overall spending by uninsured patients, they paid more out-of-pocket costs than did insured patients.

The data were obtained from the household component of the Medical Expenditure Panel Survey (MEPS) for the years 1996 to 1999. MEPS is a nationally-representative survey used to collect information on insurance status and the use of and spending on health care services. For the study, the measure of health care spending included the total of all expenditures incurred by individuals and their insurers from the time of the first cancer visit recorded in the MEPS to six months after the first visit. There was no differentiation between spending for cancer services and spending for care for other diseases or conditions. However, tabulations of MEPS revealed that cancer expenditures were, on average, 70% of total expenditures over the six months.

When comparing the use of health care services of insured and uninsured cancer patients, it was found that uninsured patients had fewer overall provider encounters, inpatient admissions and physician office visits. They also had fewer hospital outpatient visits and fewer emergency room visits. And compared to the 56% of cancer patients covered by Medicaid, uninsured patients spent substantially less overall, but more on outpatient hospital services.

The researchers also concluded that ten percent of cancer patients under age 65 were uninsured (compared to 5% of overall cancer patients) and used about 45% fewer health care services compared to insured patients of the same age.

"The numbers reflect patients whose employers donít offer health insurance, are too sick to work, or simply canít afford it," Dr. Thorpe says. "They utilize fewer health services because they are not tied into the primary health care structure and canít afford to pay."

Cancer patients under age 65 showed large differences in health care expenditure spending. The privately insured patients averaged $8,419 in spending compared to $4,806 among uninsured patients. The differences, Dr. Thorpe says, can be attributed to the increased hospital spending among the insured. Out-of-pocket expenditures totaled $1,343 for uninsured patients under 65, $576 for the entire sample and $165 for Medicaid patients.

"Differences between uninsured and insured cancer patients largely reflect the age at which various cancers are typically diagnosed," the researchers wrote. "Many breast cancer patients are diagnosed before age 65, and, not surprisingly, rates of uninsurance are higher among breast and cervical cancer patients and female cancer patients. Conversely, prostate cancer is typically detected after age 65, and only seven percent of prostate cancer patients lack insurance."

The researchers also found substantial differences in insurance coverage by race and ethnicity, especially in the Hispanic population. Twenty percent of Hispanic cancer patients under age 65 were uninsured and 12% of total Hispanic patients were uninsured. Hispanic cancer patients with private health insurance totaled 51% compared to 73% of overall cancer patients.

"A high number of the Hispanic population tends to work in places where health insurance is not offered," Dr. Thorpe said.

The researchers noted that the analysis was limited by the sample size and because the health spending of patients with all types of cancers were analyzed together.

"Studies of patients with specific types of cancer would help shed light on the reasons for spending differences, for example, whether they are due to differences in the intensity of treatment or use of ancillary services ≠ and the implications of those differences in patients outcomes," they wrote.

"We need to find ways to extend health insurance to all chronically ill people first and eventually to all uninsured," Dr. Thorpe concluded.

Dr. Thorpe is the Robert W. Woodruff Professor and Chair of the department of health policy and management at the Rollins School of Public Health of Emory University. Dr. Thorpe carries a reputation for critically and constructively evaluating the U.S. health care system, particularly in regards to its financing strategies and provisions for the uninsured. He is widely sought after as a policy resource for government and private entities.

Dr. Howard is an assistant professor and health economist in the department of health policy and management at the Rollins School of Public Health of Emory University. His research focuses on medical decision making, with applications to organ allocation and transplantation, antibiotic resistance, and cancer treatment. Currently Dr. Howard is examining the use of cancer treatments at the end of life and the relationship between comorbidities and outcomes in prostate cancer patients.

The study was sponsored by the Commonwealth Fund.

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