Financial Toxicity in Older Adult Surgical Patients: The Impact of Insurance Type

TL;DR

This study finds that older surgical patients with private or Medicare Advantage insurance face higher costs but not better financial protection compared to Medicare.

Contribution

The study reveals that higher total costs in private and Medicare Advantage plans do not reduce financial toxicity compared to Medicare.

Findings

21.9% of older surgical patients experience financial toxicity, with no significant difference between insurance types.

Private and Medicare Advantage patients had higher total costs but similar odds of financial toxicity compared to Medicare patients.

Despite subsidized insurance, financial toxicity remains common among older surgical patients.

Abstract

Surgical patients incur significant, harmful medical costs, termed financial toxicity (FT). After 65, most patients elect coverage through subsidized public insurance (Medicare), subsidized private insurance (Medicare Advantage [MA]), or unsubsidized private insurance. We investigated the financial impacts of insurance type in the older adult surgical population. Using the Medical Expenditure Panel Survey (2017-2022), we identified patients ≥65 years covered by Medicare, MA, or private insurance who underwent inpatient surgery. The primary outcome was FT, measured as reported difficulty paying medical bills or delays seeking care or filling prescriptions. Secondary outcomes were out-of-pocket (OOP) costs and total costs (OOP plus premium). Multivariable regression models estimated the risk-adjusted odds of FT, OOP costs, and total costs by insurance type. We identified 4,089 patients, weighted to 6,670,937. Insurance coverage was 24.4% Medicare, 35.3% MA, and 40.4% private. FT was present in 21.9% of patients (24.6% Medicare, 23.2% MA, 19.2% private; P-value< 0.05). Average OOP costs were $2395 ($2451 Medicare, $2291 MA, $2452 private; P-value=0.72). Average total costs were $9243 ($6071 Medicare, $7823 MA, $9975 private; P-value< 0.001). On multivariable analysis, relative to Medicare patients, private and MA patients had similar odds of FT (private OR: 0.89, 95%, CI: 0.64-1.23; MA OR: 1.07, 95% CI: 0.79-1.42), but higher total costs (private: +$3842, 95% CI $2170-$5513; MA: +$1823, 95% CI $114-$3533). Despite the availability of subsidized health insurance, FT remains prevalent in the older adult surgical population. Our data suggest that, relative to Medicare, private and MA plans cost more, but provide no additional benefit to FT.