Cost-Sharing Sticker Shock for Many Cancer Patients

The "financial toxicity" of cancer can adversely affect patients mental and physical state, particularly if they decide against recommended treatment, according to a research letter published online in JAMA Oncology.

This article first appeared August 10, 2017 on Medpage Today.

By Charles Bankhead

Out-of-pocket costs for cancer care that came in higher than expected had a significant association with patient-reported financial distress and increased reluctance to pay for recommended care, a survey of 300 patients showed.

Patients who reported "high or overwhelming" financial distress were almost five times as likely to say that the personal financial burden for their care exceeded expectations. On average, the cancer-related care consumed 11% of the patients' household income. The bite out of income increased to more than 30% among the individuals who reported feeling most burdened by finances. Two-thirds of patients who felt the most stress had private health insurance.

The findings emphasize how the "financial toxicity" of cancer can adversely affect patients mental and physical state, particularly if they decide against recommended treatment, Fumiko Chino, MD, of Duke University Medical Center in Durham, N.C., and co-authors reported in a research letter published online in JAMA Oncology.

"I think these findings suggest that, more and more, patients are taking cost into consideration as they make decisions about their cancer care," senior author Yousuf Zafar, MD, also of Duke, told MedPage Today.

Noting that a majority of the patients in the study had private insurance, Zafar said the findings imply that healthcare providers "can't rely on a patient's insurance status to determine whether or not they can afford care."

The findings also reinforced the need for clinicians to be proactive in addressing the cost of care they recommend to patients. Acknowledging that he does not discuss financial aspects of cancer care as often as he should, Zafar continued, "One easy thing for a provider to do is to ask very simply, 'Are you able to afford this treatment?' For patients who say no, we can refer them to financial counselors, or social workers or pharmacists to get them resources in a timely fashion."

The study added to a growing body of literature on the financial toll of cancer. One recent study showed that an increasing number of patients with cancer spend 10% or more of household income on healthcare costs.

Studies to date have provided little insight into patient expectations regarding the cost of cancer care and how those expectations might influence decision making. With that in mind, Chino, Zafar, and colleagues conducted a cross-sectional survey of patients identified by electronic medical records. Investigators collected standard demographic information, as well as data related to cancer diagnosis, stage, and the type and duration of treatment the patients received.

Estimated out-of-pocket expenditures for healthcare were derived from patients' self-reported estimates of recent monthly costs. Each study participant was asked how actual costs for care compared with their expectations and about how much they were willing to spend out of pocket to pay for cancer treatment, not including the cost of insurance premiums.

Investigators used a validated survey instrument to determine the patients' perceived financial stress. They calculated the median relative cost of care and assessed the impact of unexpected costs and high financial distress, taking into account patients' expected financial burden, willingness to pay for care, and subjective financial distress.

The 300 patients had a median age of 60, and 68% were married, 75% were white, 56% had private insurance, and most of the rest were covered by Medicare or Medicaid. The most common cancer diagnoses were colorectal cancer (27.0%), breast and lung cancers (17% each), and pancreas/biliary (13%).

About 40% (118/300) of the patients said their cancer care posed an "unexpected financial burden," and 49 patients (16%) reported "high or overwhelming" financial distress (score >7). Patients who reported unexpected financial burden were younger (57 versus 61), less likely to be married (62% versus 74%), more likely to be unemployed (41% versus 17%), had higher monthly out-of-pocket costs ($703 versus $553), and spent more of their income on care (17% versus 10%).

The subgroup reporting high or overwhelming financial distress had a median age of 54. They were more likely to have private insurance as compared with those who reported average financial stress or less (67% versus 54%), and they had a lower annual income (60% earned <$40,000 versus 26% for others). On average, they paid $728 a month for healthcare and spent 31% of their income on their care (versus $565 and 10% for others). They had a median financial distress score of 8.1 compared with 3.3 for other patients reporting less financial stress.

By multivariable analysis, a higher-than-expected financial burden boosted the odds ratio for high or overwhelming distress to 4.78 (95% CI 2.02-11.32, P<0.01) and decreased patients' willingness to pay for care by more than 50% (OR 0.48, 95% CI 0.25-0.95, P=0.03).

"Those who spend more than 10% of their income on healthcare costs are considered underinsured," Chino said in a statement. "Learning about the cost-sharing burden on some insured patients is important right now, given the uncertainty in health insurance."