'Financial Toxicity' of CVD Catastrophic for Low-Income Families

Marlene Busko

May 07, 2018

For one in four low-income patients with chronic atherosclerotic cardiovascular disease (ASCVD), out-of-pocket medical expenses were a "high financial burden," defined as claiming more than 20% of a family's annual income.  

But for 1 in 10 such patients, these expenses were a "catastrophic financial burden," taking more than 40% of a family's annual income, in a study based on a representative survey of medical expenses for Americans during 2006 to 2015.

"High out-of-pocket costs were mainly seen in those with private insurance, and seem to be driven by high insurance premiums," followed by cost of medications, Rohan Khera, MD, lead author of the study and a cardiology research fellow at the University of Texas Southwestern Medical Center in Dallas, told theheart.org | Medscape Cardiology in an email.

He presented these findings in a session for young investigator award finalists at the American Heart Association's Quality of Care and Outcomes Research Scientific Sessions 2018, in a presentation titled "Financial Toxicity From Out-of-Pocket Annual Health Expenditures in Low-Income Adults With Atherosclerotic Cardiovascular Disease in the United States."

This research shows that high out-of-pocket spending for chronic ASCVD "continues to pose substantial financial hardship and disproportionately affects low-income families, even in recent years," said Khera.

Clinicians should ask patients about whether their medical expenses are a financial hardship and consider low-cost medication alternatives and generic medications, he said, because "'financial catastrophe' itself can have negative health consequences."

The data "clearly demonstrate that for patients with atherosclerotic cardiovascular disease (and by extrapolation likely heart disease in general), the burden of healthcare costs is significant, especially for those patients (and their families) at the lower end of the socioeconomic strata," said Paul Hauptman, MD, professor of medicine and assistant dean for clinical and translational research at Saint Louis University School of Medicine in Missouri, who was not involved in the study.

"Remarkably," out-of-pocket costs exceeded 20% of annual income in almost one in four families, he told theheart.org | Medscape Cardiology.

It would be useful to know the breakdown of the costs, but "nevertheless, the implications for policy are clear: the economic burden associated with health care is uneven and lower-income patients remain vulnerable to severe economic pressure if they develop ASCVD," Hauptman said.

"Whether or not this situation can be fixed in the short term is unclear," he added. "As a consequence, providers must be sensitive to cost implications of care as experienced by the patient and add this aspect to discussions involving shared decision-making."

High, Even Catastrophic Financial Burden

Health insurance can prevent financial hardship that arises from unexpected medical crises, but it is unclear how patients with long-term ASCVD, especially those from low-income families, are insured and how they manage their medical expenses, the researchers note.

For this report, Khera and colleagues analyzed data from 2006 to 2015 national Medical Expenditure Panel surveys to determine annual inflation-adjusted out-of-pocket medical costs for patients with ASCVD. ASCVD diagnoses included one or more of the following: coronary artery disease (angina or prior myocardial infarction), prior stroke, and peripheral vascular disease. Most common were coronary artery disease, in 75%, and prior stroke, in 37%. 

Out-of-pocket medical costs comprised emergency department visits; outpatient clinic visits; hospitalization; medication; insurance premiums (if any); cardiac rehabilitation; behavior counseling about nutrition, smoking, or exercise; and home care.

The researchers identified 22,521 adults aged 18 years or older with ASCVD in 20,600 families. This sample represents about 10% of 23 million US adults and 15% of 21 million families.

The 39% of families that were low-income families had a mean annual family income of $19,012 and mean annual family out-of-pocket medical expenses of $2288.

The middle-to-high-income families had a mean annual family income of $83,304 and mean family annual out-of-pocket medical expenses of $4895.

Insurance coverage went from 90% at the beginning of the study to 93%. However, out-of-pocket expenses in low-income patients were largest for those with private insurance and were sometimes larger than for patients with no insurance. 

Among patients with ASCVD who were from middle- to high-income families, out-of-pocket medical expenses were a high financial burden for 1 in 15 patients (7%) and a catastrophic financial burden for 1 in 100 patients (1%) throughout the study period.     

However, in low-income families, out-of-pocket medical expenses were a high financial burden in 34% and a catastrophic financial burden in 21% of families in 2006-2007.

The rates dropped but were still high in 2014-2015: Out-of-pocket medical expenses were a high financial burden in 21% of families and a catastrophic financial burden in 10% of families.

"In order to more fully understand the components of the financial burden," said Hauptman, "additional data are needed to break down expenditures by type of health plan and by category (eg, out-patient vs in-patient care, drug costs, et cetera)."

The researchers are continuing this line of study and investigating the costs of medications, said Khera.

The study was funded by grants from the National Institutes of Health. Khera has disclosed no relevant financial relationships. Hauptman reports serving as a consultant to St Jude Medical, Sensible Medical, Relypsa, and Corvia; participating in speaker bureaus for Relypsa and Otsuka; and receiving research grants from Alnylam, BMS, Boehringer Ingelheim, and the National Heart, Lung, and Blood Institute.

American Heart Association's Quality of Care and Outcomes Research Scientific Sessions 2018. Presentation 2. Session AOS.01. Presented April 6, 2018. Abstract

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