Association of county-level medical debt and timely treatment initiation among individuals newly diagnosed with cancer.

Abstract

11077 Background: Medical debt is associated with adverse cancer outcomes, including poor survival. However, it is unknown if living in a county with high medical debt is associated with treatment initiation. We examined the association of county-level medical debt and timely treatment initiation among individuals newly diagnosed with cancer. Methods: We identified adults aged ≥19 newly diagnosed with cancer from the 2012-2021 Colorado Central Cancer Registry linked to the Colorado All-Payer Claims Database, which were combined with data on county-level share of adults with medical debt in collections. We used Cox proportional hazard models to examine the associations of county-level medical debt and receipt of any treatment within 90 days after cancer diagnosis overall and by selected cancer sites (acute leukemias, lymphomas, breast, colorectal, and lung cancers) and health insurance coverage, adjusting for individual sociodemographic characteristics. P-trend was calculated using medical debt quartile as a continuous variable in the models to examine dose-response associations. Results: Among 35,789 individuals newly diagnosed with cancer, individuals living in counties with the highest share of adults with medical debt in collections (Quartile 4 (Q4)) had lower likelihood of initiating treatment within 90 days after diagnosis compared to those living in counties with the lowest share of adults with medical debt (Q1), adjusting for covariates (HR: Q4 vs Q1: 0.93, 95% confidence interval: 0.90-0.97, P-trend < 0.001). When stratified by cancer site, higher county-level medical debt was associated with lower likelihood of timely treatment initiation among individuals diagnosed with lymphoma (HR: Q4 vs Q1: 0.82 (0.69-0.98), P-trend = 0.022) and female breast cancer (HR: Q4 vs Q1: 0.90 (0.85-0.94), P-trend < 0.001). When stratified by insurance, higher county-level medical debt was associated with lower likelihood of timely treatment initiation among individuals aged 19-64 years with private fee-for-service (FFS) plans (HR: Q4 vs Q1: 0.88 (0.78-0.98), P-trend = 0.011) and individuals aged ≥65 years with Medicare FFS plans (HR: Q4 vs Q1: 0.90 (0.82-0.98), P-trend = 0.007). Conclusions: County-level medical debt in collections was associated with delays in treatment initiation among individuals newly diagnosed with cancer. Policies aimed at preventing and alleviating medical debt could be effective strategies for improving access to timely cancer treatment.