Breast Cancer Research and Treatment

, Volume 171, Issue 1, pp 235–242 | Cite as

Impact of high-deductible insurance on adjuvant hormonal therapy use in breast cancer

  • Christine Y. LuEmail author
  • Fang Zhang
  • Anita K. Wagner
  • Larissa Nekhlyudov
  • Craig C. Earle
  • Matthew Callahan
  • Robert LeCates
  • Xin Xu
  • Dennis Ross-Degnan
  • J. Frank Wharam
Brief Report



High-deductible health plans (HDHPs) have become the predominant commercial health insurance arrangement in the US. HDHPs require substantial out-of-pocket (OOP) costs for most services but often exempt medications from high cost sharing. We examined effects of HDHPs on OOP costs and utilization of adjuvant hormonal therapy (AHT), which are fundamental care for patients with breast cancer.


This controlled quasi-experimental study used claims data (2003–2012) from a large national health insurer. We included 986 women with incident early-stage breast cancer, age 25–64 years, insured by employers that mandated a transition from low-deductible (≤ $500/year) to high-deductible (≥ $1000/year) coverage, and 3479 propensity score-matched controls whose employers offered only low-deductible plans. We examined AHT utilization and OOP costs per person-year before and after the HDHP switch.


At baseline, the OOP costs for AHT were $40.41 and $36.55 per person-year among the HDHP and control groups. After the HDHP switch, the OOP costs for AHT were $91.76 and $72.98 per person-year among the HDHP and control groups, respectively. AHT OOP costs increased among HDHP members relative to controls but the change was not significant (relative change 13.72% [95% CI − 9.25, 36.70%]). AHT use among HDHP members did not change compared to controls (relative change of 2.73% [95% CI − 14.01, 19.48%]); the change in aromatase inhibitor use was − 11.94% (95% CI − 32.76, 8.88%) and the change in tamoxifen use was 20.65% (95% CI − 8.01, 49.32%).


We did not detect significant changes in AHT use after the HDHP switch. Findings might be related to modest increases in overall AHT OOP costs, the availability of low-cost generic tamoxifen, and patient awareness that AHT can prolong life and health. Minimizing OOP cost increases for essential medications might represent a feasible approach for maintaining medication adherence among HDHP members with incident breast cancer.


Breast cancer care High-deductible health insurance Adjuvant hormonal therapy Tamoxifen Aromatase inhibitors 



This work was supported by a Grant from the National Cancer Institute and the National Institute of Health Office of the Director under Grant No. R01CA172639 (PI: Wharam). The Research Protocol was approved by the Harvard Pilgrim Health Care Institutional Review Board. Dr. Zhang and Mr. Xu primarily analyzed the data. We thank Ms. Jamie Wallace, BA, for data analysis and coordination, and Ms. Caitlin Lupton, MSc, for research assistance and administrative support. The statements in this publication are solely the responsibility of the authors and do not necessarily represent the views of the National Cancer Institute and its Board of Governors.

Author contributions

Drs. Lu and Zhang had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design all authors. Acquisition of data Wharam. Analysis and interpretation of the data all authors. Drafting of the manuscript Lu, Callahan. Critical revision of the manuscript for important intellectual content all authors. Statistical analysis Zhang, Xu. Obtained funding Wharam, Lu. Administrative, technical, or material support Wharam, Callahan, Zhang. Study supervision Wharam, Lu.

Compliance with ethical standards

Conflict of interest

The authors have no conflicts of interest or financial disclosures to report.

Supplementary material

10549_2018_4821_MOESM1_ESM.docx (32 kb)
Supplementary material 1 (DOCX 32 KB)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Christine Y. Lu
    • 1
    Email author
  • Fang Zhang
    • 1
  • Anita K. Wagner
    • 1
  • Larissa Nekhlyudov
    • 2
  • Craig C. Earle
    • 3
  • Matthew Callahan
    • 1
  • Robert LeCates
    • 1
  • Xin Xu
    • 1
  • Dennis Ross-Degnan
    • 1
  • J. Frank Wharam
    • 1
  1. 1.Division of Health Policy and Insurance Research, Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonUSA
  2. 2.Department of MedicineBrigham & Women’s HospitalBostonUSA
  3. 3.Ontario Institute for Cancer ResearchTorontoCanada

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