Oral Targeted Anticancer Medication Use Following High-Deductible Health Plan Enrollment

ABSTRACT

Out-of-pocket (OOP) spending obligations associated with high-deductible health plans (HDHPs) may reduce health care utilization, but evidence on how enrollment in HDHPs affects use of oral targeted anticancer medications (OTAMs) is limited. We used difference-in-differences regression analyses to examine the associations among employer-mandated enrollment in an HDHP, OOP spending, and use of OTAMs in a commercially insured population between 2007 and 2021. Among users of OTAMs, we found that HDHP enrollment may have increased OOP spending but was not associated with reductions in the use of these anticancer agents over a 1-year follow-up period. Research should continue to examine the links among patient cost sharing, cancer care utilization, and spending trade-offs, particularly for low-income patients with cancer.

Am J Manag Care. 2026;32(10):545-547

doi:10.37765/ajmc.2026.90025

Takeaway Points

• Employer-mandated high-deductible health plan enrollment was not associated with reduced use of oral targeted anticancer medications.
• The findings suggest that members of commercial health plans prioritize anticancer treatments.
• Our results raise questions about the trade-offs that patients may make to afford their cancer treatments, particularly among low-income populations.

Oral targeted anticancer medications (OTAMs) offer clinical benefits for many patients with cancer when used appropriately.¹ High-deductible health plans (HDHPs), which are increasingly prevalent and impose substantial out-of-pocket (OOP) cost responsibility on patients,² have been associated with reductions in the use of certain pharmaceutical and medical treatments.^3-5 We examined whether an employer-mandated switch to an HDHP was associated with increased OOP spending and/or reduced use of OTAMs.

METHODS

We used Optum’s deidentified Clinformatics Data Mart database and extracted information from commercial health plan members who were younger than 65 years and insured between January 2007 and September 2021. We examined members enrolled for at least 1 year before and 1 year after either (1) an employer-mandated switch from a low-deductible plan (annual deductible ≤ $500) to an HDHP (annual deductible ≥ $1000) or (2) renewal of a low-deductible plan (control group), following validated methods to define mutually exclusive groups.³ Study members were required to have used an OTAM⁶ in the 1-year baseline period. We excluded patients whose only OTAM use was a hormonal treatment for breast cancer, given prior literature on this topic.⁴

First, we estimated and plotted monthly OOP spending on OTAMs and the quantity supplied of OTAMs, as well as OOP spending on other medical and pharmaceutical care, which might indirectly affect OTAM use. OOP spending included deductibles, co-pays, and coinsurance; it was adjusted to 2021 dollars using the Consumer Price Index. Second, we estimated the effect of switching to an HDHP on the same outcomes using stacked difference-in-differences regressions, which accounted for the specific month of switch and controlled for baseline age, sex, cancer type, OTAMs used, and mean zip code household income. We assessed average effects over the 12 months following the HDHP switch. Standard errors were clustered at the
patient level.

RESULTS

The study included 124 members with an employer-mandated switch to an HDHP and 1662 members who remained in low-deductible plans. HDHP enrolleesdiffered in year of index date, zip code household income, and OTAMs used (Table).

In the early months following the switch, HDHP enrollees showed transient increases in unadjusted OOP spending on OTAMs and other pharmaceutical and medical care (Figure A-B), followed by similar or lower spending thereafter. HDHP enrollees did not reduce OTAM use relative to members who remained in low-deductible plans (Figure C).

The difference-in-differences regressions estimated that HDHP enrollment was associated with a modest increase in OOP spending for OTAMs in the year following enrollment, which was not statistically significant ($22.70 per month increase; 95% CI, −$2.50 to $47.90). In contrast to unadjusted data showing early temporary rises (Figure, B), switches to HDHPs were not associated with significantly increased OOP spending on other pharmaceutical and medical care (−$17.00 per month change; 95% CI, −$68.20 to $34.20) when estimating the 12-month average relative to a contemporaneous control group and accounting for baseline characteristics and index month. HDHP enrollment did not significantly affect days supplied of OTAMs (0.1-day increase in quantity supplied per month; 95% CI, −3.8 to 4.1).

DISCUSSION

Employer-mandated HDHP enrollment may increase member OOP spending but does not appear to impede use of OTAMs. Prior observational research has found associations between higher cost sharing and poorer adherence to 1 class of OTAM—tyrosine kinase inhibitors—for chronic myeloid leukemia,⁷ but has not examined the effects of plan-level switches to HDHPs using quasi-experimental designs. Our results provide quasi-experimental evidence on the effects of employer-mandated HDHP enrollment on the use of OTAMs. Although patients face high deductibles in these plans, expensive cancer care may cause them to exceed their deductibles early in the year, thereby reducing OOP costs for OTAMs over the remainder of the benefit year. Although HDHPs may not deter OTAM use, patients may still experience financial toxicity—broad financial hardship associated with cancer care—through trade-offs not captured in claims data, such as reduced spending on noncancer care or household necessities.⁸ We used a large national claims database, but the subgroup of patients with cancer who had employer-mandated HDHP switches and who were using OTAMs in the baseline period was small, limiting precision and generalizability. Future research should examine whether these results hold in other populations, particularly low-income patients with cancer at high risk of financial toxicity.

Author Affiliations: Department of Population Medicine, Harvard Medical School (MRE, MS, FZ, JFW, DRD, AKW), Boston, MA; Harvard Pilgrim Health Care Institute (MRE, RC, SA, MS, FZ, JFW, DRD, AKW), Boston, MA; Department of Resource Economics, University of Massachusetts Amherst (MRE), Amherst, MA; Harvard Center for Health Decision Sciences (MRE), Boston, MA; Department of Medicine, Duke University (JFW), Durham, NC; Duke-Margolis Institute for Health Policy (JFW), Durham, NC.

Source of Funding: American Cancer Society (RSGI-20-030-01-CPPB).

Author Disclosures: Dr Wagner reports employment as the director of the ethics program at Point32Health. The remaining authors report no relationships or financial interests with any entity that would pose a conflict of interest regarding the subject matter of this article.

Authorship Information: Concept and design (MRE, RC, SA, MS, JFW, AKW); acquisition of data (SA, JFW, DRD, AKW); analysis and interpretation of data (MRE, RC, MS, FZ, JFW, DRD, AKW); drafting of the manuscript (MRE); critical revision of the manuscript for important intellectual content (MRE, RC, SA, MS, FZ, JFW, DRD, AKW); statistical analysis (MRE, RC, MS, FZ); obtaining funding (JFW, AKW); administrative, technical, or logistic support (MRE, SA); and supervision (JFW, DRD, AKW).

Address Correspondence to: Michael R. Eber, PhD, University of Massachusetts Amherst, Stockbridge Hall, 80 Campus Center Way, Amherst, MA 01003. Email: meber@umass.edu.

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