“It's just not easy to understand”: A mixed methods study of health insurance literacy and insurance plan decision‐making in cancer survivors

• Published in: Cancer medicine (Malden, MA) MA), 2023-07, Vol.12 (14), p.15424-15434
• Main Authors: Williams, Courtney P., Platter, Heather N., Davidoff, Amy J., Vanderpool, Robin C., Pisu, Maria, Moor, Janet S.
• Format: Article
• Language: English
• Subjects: Breast cancer; cancer survivorship; Cancer therapies; Decision making; Ethnicity; Eye movements; Generalized linear models; Health care expenditures; Health care policy; Health insurance; health insurance literacy; Health maintenance organizations; Hispanic Americans; HMOs; Insurance coverage; Interviews; Literacy; Medical diagnosis; mixed methods; Mixed methods research; out‐of‐pocket cost; Webcams
• ISSN: 2045-7634; 2045-7634
• DOI: 10.1002/cam4.6133

Background Understanding cancer survivors' health insurance decision‐making is needed to improve insurance choice, potentially resulting in reduced financial hardship. Methods This explanatory mixed methods study assessed health insurance decision‐making in cancer survivors. Health Insurance Literacy Measure (HILM) captured HIL. Quantitative eye‐tracking data collected from two simulated health insurance plan choice sets gauged dwell time (seconds), or interest, in benefits. Dwell time differences by HIL were estimated using adjusted linear models. Qualitative interviews explored survivors' insurance decision‐making choices. Results Cancer survivors (N = 80; 38% breast cancer) had a median age of 43 at diagnosis (IQR 34–52). When comparing traditional and high‐deductible health plans, survivors were most interested in drug costs (median dwell time 58 s, IQR 34–109). When comparing health maintenance organization and preferred provider organization plans, survivors were most interested in test/imaging costs (40s, IQR 14–67). Survivors with low versus high HIL had more interest in deductible (β = 19 s, 95% CI 2–38) and hospitalization costs (β = 14 s, 95% CI 1–27) in adjusted models. Survivors with low versus high HIL more often ranked out‐of‐pocket (OOP) maximums and coinsurance as the most important and confusing benefits, respectively. Interviews (n = 20) revealed survivors felt alone “to do their own research” about insurance choices. OOP maximums were cited as the deciding factor since it is “how much money is going to be taken out of my pocket.” Coinsurance was considered “rather than a benefit, it's a hindrance.” Conclusion Interventions to aid in health insurance understanding and choice are needed to optimize plan choice and potentially reduce cancer‐related financial hardship. Example choice task heat maps, including a choice between a traditional (Plan A) and high‐deductible healthcare plan (Plan B), and between a health maintenance organization plan (Plan C) and preferred provider organization plan (Plan D). Circles represent respondent areas of interest measured by eye fixations, with the warmer colored circles indicating longer duration of fixation (more dwell time; red, orange, yellow), and the cooler colored circles indicating shorter durations of fixation (less dwell time; blue).