Out-of-pocket costs for many cancer patients higher than expected

By Liz Meszaros, MDLinx
Published August 16, 2017

Key Takeaways

Over one-third of cancer patients with insurance who are undergoing cancer treatments have out-of-pocket costs that are greater than they expected, according to researchers from the Duke Cancer Institute, Durham, NC, who also found that patients in the most financial distress—paying almost one-third of their income to health care costs—were those who were underinsured. Their results are published in JAMA Oncology.

Many cancer patients undergoing treatment are sorely affected by ‘financial toxicity,’ which can have deleterious effects on not only their mental health, but their physical health as well, particularly if they stop treatments because they feel they can’t afford it.

“This study adds to the growing evidence that we need to intervene,” said senior author Yousuf Zafar, MD, medical oncologist, Duke University. “We know there are a lot of barriers that prevent patients from talking about cost with their providers. We need to create tools for patients at risk of financial toxicity and connect them with resources in a timely fashion so they can afford their care.”

Dr. Zafar and fellow researchers conducted this cross-sectional survey to assess financial distress and cost expectations in 349 consecutive patients with cancer presenting for anti-cancer therapy. A convenience sample of adult patients at from a comprehensive cancer center and from three affiliated rural oncology clinics were included, who were all compensated $10 for completing the survey. Surveys were administered by trained interviewers and conducted in person.

They abstracted EHRs for cancer diagnosis, stage, type of treatment, and duration at the time of enrollment. Patient out-of-pocket expenses were based on each patient’s estimates of recent, average monthly costs.

Patients were asked whether their actual costs met their expectations and how much they were willing to pay out-of-pocket for cancer treatment, not including insurance premiums.

Dr. Zafar and colleagues measured financial stress, median relative cost of care, which they defined as monthly out-of-pocket costs divided by income. To determine the impact of unexpected costs and high financial distress, they dichotomized expected financial burden, willingness to pay, and subjective financial distress.

They had an 86% response rate of 300 patients (52% male), of whom 3 withdrew. The median relative cost of care was 11%, and 16% reported high or overwhelming financial distress (score greater than 7). For these patients reporting high or overwhelming distress, the relative cost of care was 31% compared with 10% in those with no, low, or average financial distress.

In all, 39% of patients had higher than expected financial burden caused by their cancer care.

Upon unadjusted analysis, Dr. Zafar and fellow researchers found that younger age, unmarried, nonwhite, unemployed/not retired, lower household income, higher costs, colorectal or breast cancers, lower quality of life, and higher financial distress were associated with unexpected burden.

Upon adjusted analysis, unexpected financial burden was associated with high or overwhelming financial distress (OR: 4.78; 95% CI: 2.02, 11.32; P < 0.01), and with a decreased willingness to pay for cancer care (OR: 0.48; 95% CI: 0.25, 0.95; P=0.03).

“Overall, the patients in the study were paying an average of 11 percent on out-of-pocket costs for their cancer treatment,” said lead author Fumiko Chino, MD, radiation oncology resident, Duke Health. “Those who spend more than 10% of their income on health care costs are considered underinsured. Learning about the cost-sharing burden on some insured patients is important right now, given the uncertainty in health insurance.”

This research was supported by the American Cancer Society and Duke Cancer Institute. 

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