Cancer Leads to Financial Hardship Even Among Privately Insured

Roxanne Nelson, RN, BSN

March 22, 2022

Financial toxicity is now established as a "side effect" of cancer care, but new findings show that even patients who are privately insured and who are relatively well off run into financial problems because of the high costs of their treatment.

The study involved 380 patients who were newly diagnosed with metastatic colorectal cancer and were treated at community oncology practices across the United States. They answered questionnaires about finances every quarter over a 12-month period.

Nearly 3 of 4 patients reported major financial hardship (MFH) despite having health insurance. They reported accumulating debt and/or having to sell or refinance their home and/or experiencing a decline of more than 20% in their income and/or having to borrow money from family or friends.

"Our study findings draw attention to deficiencies in the US health-care system and economic safety nets that are unable to prevent the majority of cancer patients from experiencing financial hardship," write the authors, led by Veena Shankaran, MD, of the Fred Hutchinson Cancer Research Center, University of Washington, Seattle.

"Policy solutions that improve access to affordable health care and insurance benefit designs that minimize cost sharing for evidence-based cancer treatments are examples of strategies that can mitigate financial hardship," they suggest.

The study was published in the March issue of the Journal of the National Cancer Institute.

The study findings "underscore the likelihood of financial hardship, even among socioeconomically advantaged patients," comment Robin Yabroff, PhD, MBA, scientific vice president, health services research, American Cancer Society, and colleagues in an accompanying editorial.

They point out that most of the research evaluating financial hardship has been "cross-sectional and conducted in heterogeneous population-based samples of cancer survivors with different diagnoses, survival times, and treatments or among samples of patients receiving treatment within single institutions or geographic regions."

In contrast, for the current article, researchers evaluated a more clinically homogeneous cohort. All patients were diagnosed with metastatic colorectal cancer and underwent systemic treatment at National Cancer Institute Community Oncology Research Program (NCORP) sites across the United States.

At least 60% of these patients had annual incomes of $100,000 or more or had assets worth $100,000 or more, yet they reported major financial hardship within 12 months.

In addition, all study participants had health insurance, and yet the vast majority reported major financial hardship, the authors point out.

This counters the general assumption that comprehensive health insurance coverage is one of the strongest means of protecting against financial hardship, they comment. The findings suggest that having health insurance "may no longer be sufficient to protect patients and families from financial hardship and its adverse health sequelae."

Yabroff told Medscape Medical News that addressing medical financial hardship among patients with cancer requires multilevel efforts. These include screening patients for financial hardship and social needs and connecting them to resources, as well as enhancing partnerships with community safety net organizations, implementing caps on patient out-of-pocket costs, and incorporating assessment of financial hardship and social need in value-based payment models.

"These are examples, and multiple approaches at multiple levels will be necessary to mitigate adverse effects of medical financial hardship," she said.

Impact Felt at All Time Points

In the study, patients completed a self-administered 20-item financial questionnaire at baseline and quarterly for the next 12 months.

The median age of the patients was 60.2 years, 61.9% were men, 13.0% were Black, 56.5% had a total household income of $50,000 or less per year, and about 60% were employed prior to their cancer diagnosis. Almost half (47.3%) were from the Midwest (47.3%); the region with the fewest patients was the Northeast (9.2%).

At 12 months, the cumulative incidence of MFH was 71.3%. Regarding individual factors, the cumulative incidence at 12 months was 57.6% for new debt, 26.6% for a 20% or more decline in income, 26.0% for new loans from family or friends, 3.4% for refinancing of the home, and 2.6% for sale of a home.

About a quarter (24.9%) of patients experienced MFH at 3 months, 53.8% at 6 months, and 63.0% at 9 months.

In an exploratory post hoc analysis, income of less than $100,000 and total assets of less than $100,000 were adversely associated with MFH. Additionally, the 12-month cumulative incidence of MFH was very similar for homeowners (69.9%) and those who did not own a home (71.8%).

"At the clinic level, interventions that connect patients and caregivers with financial counseling, assistance, and navigation resources are critical," Shankaran and co-authors conclude. "Building on our initial insights from this study, we are actively analyzing credit data collected in this study to identify patient groups particularly vulnerable to MFH so that interventions can be targeted and tailored to their needs."

The study was supported by the ASCO Foundation Conquer Cancer Career Development Award 2013, the SWOG Hope Foundation Charles Coltman Jr Award (2010), and by grant awards from the National Cancer Institute of the National Institutes of Health. The authors have disclosed no relevant financial relationships. Yabroff serves on the advisory board of Flatiron Health Equity.

J Natl Cancer Inst. 2022 Mar 8;114:372-380. Full text, Editorial

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