Because of the growing prevalence of cancer survivorship, the financial burden of cancer is becoming increasingly overwhelming for patients not only immediately after a cancer diagnosis, but often many years after treatment, according to K. Robin Yabroff, PhD, MBA, Strategic Director, Economic Burden of Cancer, American Cancer Society.
Cancer survivors often experience lasting effects of their disease or treatment. Compared with individuals without a history of cancer, survivors face an increased risk for new cancers and chronic conditions, devastating healthcare expenditures, work limitations and loss of health insurance, and foregone or delayed care because of insurmountable costs, she told the audience at the 2018 Cancer Survivorship Symposium.
US Health Insurance Trends
Employers are increasingly offering high-deductible health insurance plans, adding to the out-of-pocket burden for patients. Among the insured, cost-sharing has also increased through coinsurance and copayments. With a common 30% to 40% coinsurance rate for specialty cancer drugs, a drug costing $100,000 would cost a patient $30,000 to $40,000 out of pocket annually. “And that’s not uncommon,” she noted.
The number of uninsured Americans has also recently increased, and according to Dr Yabroff, that number may skyrocket even higher in the near future. Changes in treatment patterns have led to more patients getting treatment for longer periods of time, often with combination instead of single-agent treatments, and as a result, increasing the unit cost of treatment.
The Reality of Bankruptcy
A 2013 study by Ramsey and colleagues linked cancer registry data to bankruptcy claim files and showed that in every single year between 1995 and 2009, the risk of bankruptcy was higher for survivors compared to those without a history of cancer.
A 2016 follow-up study by the same authors restricted the analysis to survivors who filed for bankruptcy compared with those who did not and showed significantly increased mortality risk among those who filed for bankruptcy. The hypothesized mechanisms for this effect include lower quality of life and lower overall well-being, increased stress, and decreased treatment adherence or access to care. “This finding was very compelling,” she said.
The Financial Hardship Framework
The framework for describing financial hardship includes 3 distinct but overlapping components, according to Dr Yabroff. These components include material conditions (ie, medical debt, high out-of-pocket costs); psychological response (ie, stress and distress about high costs); and coping behaviors (ie, delaying filling a prescription, taking less medication, or skipping doses).
A 2016 analysis using the 2011 Medical Expenditure Panel Survey: Experiences with Cancer Survivorship Supplement estimated that 7% of cancer survivors had to borrow money or go into debt and 12% were unable to cover their share of medical care costs. Overall, 20% of cancer survivors had some type of material financial hardship and 23% experienced some type of psychological financial hardship. A stratified analysis of the data revealed that patients aged ≤64 years faced more financial hardship, because of ineligibility for Medicare coverage. Approximately 40% of survivors aged 18 to 64 years had at least some form of financial hardship, compared with 20% of those aged ≥65 years.
For material financial hardship specifically, only about 12% of patients aged ≥65 years reported some hardship, whereas approximately 50% among the uninsured and publicly insured people in the younger cohort reported material financial hardship. Rates were lower for those with private insurance, but almost 25% of patients in this group still reported some form of material financial hardship. Findings were similar for psychological financial hardship when stratified by age-group and type of insurance.
“I want to emphasize the types of things survivors are spending money on,” Dr Yabroff said. “It’s not just medical care.” A 2012 LiveSTRONG survey on out-of-pocket spending among cancer survivors who reported borrowing money or having medical debt revealed that 60% cited the high cost of transportation, although lodging, child care, and home or respite care were also major concerns.
Patient characteristics associated with a high risk for financial hardship include younger age, minority race or ethnicity, lower household income, being unemployed, and being uninsured or underinsured.
“The populations that have the highest risk of financial hardship are the same populations we’ve seen have much poorer outcomes for cancer,” she said. “So there is a risk that with increasing financial hardship, we’ll see greater health disparities in the future.”
Strategies to Address Financial Hardship
“When we’re thinking about different strategies to address the financial hardship of cancer, interventions need to happen at multiple levels,” Dr Yabroff asserted.
Financial navigators can be invaluable at the patient level. At the provider level, more enhanced discussions about the expected costs and benefits of treatment can prepare patients for what’s ahead. At the organizational level, one strategy would be the implementation of a value-based insurance design.
State policy decisions can affect Medicaid eligibility expansion, and in the current national policy environment, influencers can work on closing the Medicare Part D donut hole.
“Many cancer survivors blow through that donut hole very quickly,” she said. “It’s important to consider multiple levels in understanding financial hardship and opportunities for intervention.”