Employment Disruption and Insurance Instability Among Patients with Gastrointestinal Cancer Diagnosis.

Abstract

Background: Employment and insurance disruptions are common among working-age individuals diagnosed with gastrointestinal (GI) cancers, yet underlying mechanisms and consequences associated with insurance instability remain poorly defined. We sought to characterize the incidence and identify predictors of postdiagnosis insurance instability among patients with GI cancer and assess the mediating role of employment disruption.

Study design: The IBM MarketScan Commercial Claims database (2013 to 2020) was used to identify adults with newly diagnosed GI cancer who were employed and continuously insured for 12 months before diagnosis. Insurance instability was defined as any change in healthcare coverage within 12 months postdiagnosis. Generalized structural equation modeling estimated direct and indirect effects mediated by early (1 to 4 months), mid (5 to 8 months), and late (9 to 12 months) employment disruption.

Results: Within 12 months after GI cancer diagnosis, 1,163 patients (9.8%) experienced a change in insurance type vs 3,547 controls (8.8%; adjusted hazard ratio [HR] 1.18, 95% CI 1.10 to 1.26). Insurance instability was associated with delayed surgery (adjusted rate ratio 1.15, 95% CI 1.04 to 1.26), earlier chemotherapy (adjusted rate ratio 0.91, 95% CI 0.85 to 0.98), higher out-of-pocket costs ($3,675 vs $3,206, p ≤ 0.001), and total spending ($128,514 vs $116,939, p = 0.016). Insurance instability risk was highest among individuals with HMO (HR 2.60, 95% CI 2.32 to 2.91), exclusive provider organization (HR 1.82, 95% CI 1.52 to 2.17), and comprehensive plans (HR 2.66, 95% CI 2.13 to 3.32) vs preferred provider organizations (p < 0.001). Employment disruption mediated 97.2% (95% CI 93.8% to 100%) of the total effect of insurance instability, with 19.9%, 43.4%, and 34.0% attributed to early-phase, mid-phase, and late-phase employment disruptions, respectively.

Conclusions: Insurance instability after GI cancer diagnosis was largely mediated by mid- and late-phase employment disruption, highlighting the need for policies that protect employment and guarantee insurance continuity during cancer care.