The 10th Annual Utah Health Services Research Conference: Gaps in Insurance Coverage for Pediatric Cancer Patients with Acute Lymphoblastic Leukemia. By: Rochelle Smits-Seemann, Ms; Aimee O. Hersh, MD; Mark N. Fluchel, MS; Kenneth M. Boucher, PhD; Anne C. Krichhoff, MPH, PhD Patient Centered Research Methods Core, University of Utah, CCTS

1. Gaps in Insurance Coverage for
Pediatric Cancer Patients with
Acute Lymphoblastic Leukemia
Rochelle Smits-Seemann, MS
Aimee O. Hersh, MD
Mark N. Fluchel, MS
Kenneth M. Boucher, PhD
Kent Korgenski, MS
Anne C. Kirchhoff, MPH, PhD

2. Background
• About 2,900 children are diagnosed with Acute
Lymphoblastic Leukemia (ALL) each year in the US
• Treatment lasts 2-3 years
• Financial burden of pediatric cancer
• A gap in health insurance coverage of any length of time
is associated with compromises in healthcare for
children.
• Gaps among children with cancer are unknown

3. Purpose and Objectives
1) Examine insurance coverage over the first two years
of therapy for patients with ALL.
2) Investigate patient predictors of experiencing a gap
in insurance.

4. Methods: Cohort

5. Methods: Data Access and Selection
• Location of service: Primary Children’s Hospital
• Service type: Oncology Clinic
• Date of service: Within 2 years post diagnosis

6. • Assign a primary payer for each encounter:
• Private
• Public
• Self-Pay (Uninsured)
• Outcome variable:
Methods: Insurance
Category Defined
Continuously Insured – Private All outpatient encounters had a private primary payer
Continuously Insured - Public All outpatient encounters had a public primary payer
Continuously Insured – Public and
Private
All outpatient encounters had a primary payer; either public or
private
Experienced a gap At least one outpatient encounter did not have a primary payer

7. • Chi-square, Fischer’s Exact or ANOVA to test differences across
insurance groups for demographic variables.
• Multivariate logistic regression to test for predictors of gaps in
insurance (0/1).
Methods: Statistical Analyses

8. Results
• The majority of patients
had insurance coverage at
all outpatient encounters
(n = 347; 88%).
• 47 (12%) patients
experienced a gap in
insurance.
• No differences in
demographic variables
across insurance categories
N = 394
%
Sex
Male 54
Female 46
Age at Diagnosis
1-5 56
6-10 21
10-17 19
18-26 4
County at Diagnosis
Urban 88
Rural 12
ALL Risk
Standard 65
High 34
Insurance at Diagnosis
Private 73
Public 25
Uninsured 2
Dead 12

9. Results
95% Confidence
Odds Ratio Interval p-value
Sex
Male Ref
Female 1.53 0.76 – 3.12 .23
Age at Diagnosis* 0.96 0.87 – 1.06 0.40
County at Diagnosis
Urban Ref
Rural 1.03 0.34 – 3.12 .95
ALL Risk
Standard Ref
High 1.54 0.62 – 3.81 0.35
Insurance at Diagnosis
Private Ref
Public 4.05 1.99 – 8.22 <.001
Diagnosis Year* 0.86 0.78 – 0.95 0.004
*Fit as a continuous variable.

10. Results
• Decreased proportion of patients experienced a gap
• Increased proportion of patients continuously enrolled in public insurance.

11. Limitations and conclusions
• Encounter based data
• Pediatric cancer regimens are very standardized and few patients miss
visits.
• No access to socioeconomic variables
• However, there were no differences when we included Census area
level household income.
• Insufficient numbers to evaluate healthcare outcomes

12. Conclusions and Implications
• 12% of patients experienced a gap in health insurance.
• Next steps: Understand the impact of this on adherence to visits and
patient outcomes.
• Patients who had public insurance at diagnosis were 4X more likely
to experience a gap in health insurance.
• More recently diagnosed patients were less likely to experience a
gap in insurance.
• There was an increasing proportion of patients continuously
enrolled on public insurance.

13. Acknowledgements
Collaborators
• Anne Kirchhoff, PhD, MPH
• Sapna Kaul, PhD, MA
• Richard Lemons, MD, PhD
• Kent Korgenski, MS
• Mark Fluchel, MD, MS
• Aimee Hersh, MD, MS
Funding
• Intermountain Healthcare
Foundation and the Primary
Children’s Hospital Foundation