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Jia S, Cheung DST, Ho MH, Takemura N, Feng Y, Lin CC. A Systematic Review of Interventions Targeting Cancer-Related Financial Hardship: Current Evidence and Implications. Cancer Nurs 2024:00002820-990000000-00287. [PMID: 39190807 DOI: 10.1097/ncc.0000000000001393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
BACKGROUND Despite an increasing emphasis on alleviating financial hardship in cancer care delivery, limited knowledge of evidence-based and effective interventions is available. OBJECTIVE This systematic review aimed to identify gaps in the literature and provide insights for future evidence-based interventions targeting financial hardship from both micro and macro perspectives. METHODS We comprehensively searched the PubMed, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and PsycINFO databases from inception to October 2022. Studies examining the effect of an intervention on mitigating cancer-related financial hardship were included. RESULTS A total of 24 studies were included. Findings indicate that the most significant positive changes were in the material conditions domain from the micro perspective of financial hardship. From the macro perspective, positive effects were shown for improving access to care, affordability of care, healthcare utilization, and healthcare equity of interventions at the provider or care team level, the community healthcare environment level, and the healthcare system and policy level. Notably, significant heterogeneity was observed among interventions and outcome measurements. CONCLUSIONS This is the first comprehensive systematic review of interventions targeting cancer-related financial hardship from both micro and macro perspectives. No consistently positive effect of the interventions on all domains was reported. Multidisciplinary approaches and higher-level hierarchical and evidence-based interventions are needed to address financial hardship. IMPLICATIONS FOR PRACTICE Health practitioners should screen and manage financial hardship using a standard and comprehensive measurement at the dyadic level of cancer survivors and caregivers.
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Affiliation(s)
- Shumin Jia
- Author Affiliations: School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
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Fiala MA. Financial Toxicity and Willingness-to-Pay for Cancer Treatment Among People With Multiple Myeloma. JCO Oncol Pract 2024; 20:1263-1271. [PMID: 38885465 DOI: 10.1200/op.24.00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/08/2024] [Accepted: 05/07/2024] [Indexed: 06/20/2024] Open
Abstract
PURPOSE This study used willingness-to-pay (WTP) exercises to explore the relationships between race, financial toxicity, and treatment decision making among people with cancer. METHODS A convenience sample of people with multiple myeloma who attended an academic medical center in 2022 was surveyed. Financial toxicity was assessed by the Comprehensive Score for financial Toxicity, with scores <26 indicating financial toxicity. WTP was assessed with (1) a discrete choice experiment (DCE), (2) fixed-choice tasks, and (3) a bidding game. RESULTS In total, 156 people were approached, and 130 completed the survey. The majority of the sample was White (n = 99), whereas 24% (n = 31) was African American or Black. Forty-six percent (n = 60) of the sample were experiencing financial toxicity. In the DCE, the relative importance of cost was twice as high for those with financial toxicity (30% compared with 14%; P < .001). In the fixed-choice tasks, they were twice as likely to accept a treatment with shorter progression-free survival but lower costs (adjusted odds ratio [aOR], 2.47; P = .049). In the bidding game, the median monthly WTP of those with financial toxicity was half that of those without ($100 in US dollars [USD] compared with $200 USD; P < .001). Only in the bidding game was race statistically associated with WTP; after controlling for financial toxicity, African American or Black participants were three times as likely (aOR, 3.06; P = .007) to report a lower WTP. CONCLUSION Across all three exercises, participants with financial toxicity reported lower WTP than those without. As financial toxicity disproportionally affects some segments of patients, it is possible that financial toxicity contributes to cancer disparities.
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Affiliation(s)
- Mark A Fiala
- Department of Medicine, Washington University School of Medicine, St Louis, MO
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Nogueira LDA, Ribeiro CDO, Silva LDS, dos Santos YH, Kalinke LP. Impact of financial toxicity on adults with cancer during the COVID-19 pandemic: an integrative review. Rev Bras Enferm 2024; 77Suppl 1:e20240078. [PMID: 39230125 PMCID: PMC11368384 DOI: 10.1590/0034-7167-2024-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/05/2024] [Indexed: 09/05/2024] Open
Abstract
OBJECTIVES to identify the repercussions of financial toxicity on the lives of adult cancer patients during the COVID-19 pandemic. METHODS an integrative review was conducted using the PubMed, Web of Science, Scopus, and Embase databases, as well as the Virtual Health Library portal, in March 2023. RESULTS out of 62 studies found, 13 were included for analysis. The primary repercussions of financial toxicity included difficulties in covering basic expenses such as food, housing, medication, transportation, and internet access; increased anxiety and concerns related to health and financial situations; reduction or absence of income; challenges in obtaining treatment or accessing healthcare services; rising expenses; and telemedicine as a less burdensome alternative. CONCLUSIONS the pandemic has exacerbated financial toxicity; therefore, healthcare teams must recognize it as an adverse event of oncological treatment and understand its potential to affect various aspects of patients' lives.
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Olateju OA, Shen C, Thornton JD. The Affordable Care Act and income-based disparities in health care coverage and spending among nonelderly adults with cancer. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae050. [PMID: 38812986 PMCID: PMC11135644 DOI: 10.1093/haschl/qxae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/12/2024] [Accepted: 04/23/2024] [Indexed: 05/31/2024]
Abstract
The Patient Protection and Affordable Care Act (ACA) significantly reduced uninsured individuals and improved financial protection; however, escalating costs of cancer treatment has led to substantial out-of-pocket expenses, causing severe financial and mental health distress for individuals with cancer. Mixed evidence on the ACA's ongoing impact highlights the necessity of assessing health-spending changes across income groups for informed policy interventions. In our nationally representative survey evaluating the early- and long-term effects of the ACA on nonelderly adult patients with cancer, we categorized individuals-based income subgroups defined by the ACA for eligibility. We found that ACA implementation increased insurance coverage, which was particularly evident after 2 years of implementation. Early post-ACA (within two years of implementation), there were declines in out-of-pocket spending for the lowest and low-income groups by 26.52% and 38.31%, respectively, persisting long-term only for the lowest-income group. High-income groups experienced continuously increased out-of-pocket and premium spending by 25.39% and 34.28%, respectively, with a notable 122% increase in the risk of high-burden spending. This study provides robust evidence of income-based disparities in financial burden for cancer care, emphasizing the need for health care policies promoting equitable care and addressing spending disparities across income brackets.
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Affiliation(s)
- Olajumoke A Olateju
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, TX 77204-5000, United States
| | - Chan Shen
- Departments of Surgery and Public Health Sciences, Penn State Cancer Institute, Hershey, PA 17033, United States
| | - James Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, TX 77204-5000, United States
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Barnes JM, Johnson KJ, Osazuwa-Peters N, Yabroff KR, Chino F. Changes in cancer mortality after Medicaid expansion and the role of stage at diagnosis. J Natl Cancer Inst 2023; 115:962-970. [PMID: 37202350 PMCID: PMC10407703 DOI: 10.1093/jnci/djad094] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Medicaid expansion is associated with improved survival following cancer diagnosis. However, little research has assessed how changes in cancer stage may mediate improved cancer mortality or how expansion may have decreased population-level cancer mortality rates. METHODS Nationwide state-level cancer data from 2001 to 2019 for individuals ages 20-64 years were obtained from the combined Surveillance, Epidemiology, and End Results National Program of Cancer Registries (incidence) and the National Center for Health Statistics (mortality) databases. We estimated changes in distant stage cancer incidence and cancer mortality rates from pre- to post-2014 in expansion vs nonexpansion states using generalized estimating equations with robust standard errors. Mediation analyses were used to assess whether distant stage cancer incidence mediated changes in cancer mortality. RESULTS There were 17 370 state-level observations. For all cancers combined, there were Medicaid expansion-associated decreases in distant stage cancer incidence (adjusted odds ratio = 0.967, 95% confidence interval = 0.943 to 0.992; P = .01) and cancer mortality (adjusted odds ratio = 0.965, 95% confidence interval = 0.936 to 0.995; P = .022). This translates to 2591 averted distant stage cancer diagnoses and 1616 averted cancer deaths in the Medicaid expansion states. Distant stage cancer incidence mediated 58.4% of expansion-associated changes in cancer mortality overall (P = .008). By cancer site subgroups, there were expansion-associated decreases in breast, cervix, and liver cancer mortality. CONCLUSIONS Medicaid expansion was associated with decreased distant stage cancer incidence and cancer mortality. Approximately 60% of the expansion-associated changes in cancer mortality overall were mediated by distant stage diagnoses.
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Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Nosayaba Osazuwa-Peters
- Department of Otolaryngology-Head and Neck Surgery, Duke University, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Barnes JM, Graboyes EM, Adjei Boakye E, Schootman M, Chino JP, Moss HA, Mowery YM, Osazuwa-Peters N. Insurance Coverage and Forgoing Medical Appointments Because of Cost Among Cancer Survivors After 2016. JCO Oncol Pract 2023; 19:e589-e599. [PMID: 36649493 PMCID: PMC10530391 DOI: 10.1200/op.22.00587] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/19/2022] [Accepted: 12/01/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE The uninsured rate began rising after 2016, which some have attributed to health policies undermining aspects of the Affordable Care Act. Our primary objectives were to assess the changes in insurance coverage and forgoing medical care because of cost in cancer survivors from pre-enactment (2016) through postenactment of those policies (2019) and determine whether there were subgroups that were disproportionately affected. METHODS The 2016-2019 Behavioral Risk Factor Surveillance System surveys were queried for 18- to 64-year-old cancer survivors. Survey-weighted logistic regression was used to assess temporal changes in (1) insurance coverage and (2) forgoing medical appointments because of cost in the preceding 12 months. RESULTS A total of 62,669 cancer survivors were identified. The percentage of insured cancer survivors decreased from 92.4% in 2016 to 90.4% in 2019 (odds ratio for change in insurance coverage or affordability per one-year increase [ORyear], 0.92; 95% CI, 0.86 to 0.98; P = .01), translating to 161,000 fewer cancer survivors in the United States with insurance coverage. There were decreases in employer-sponsored insurance coverage (ORyear, 0.89) but increases in Medicaid coverage (ORyear, 1.17) from 2016 to 2019. Forgoing medical appointments because of cost increased from 17.9% in 2016 to 20.0% in 2019 (ORyear, 1.05; 95% CI, 1.01 to 1.1; P = .025), affecting an estimated 169,000 cancer survivors. The greatest changes were observed among individuals with low income, particularly those residing in nonexpansion states. CONCLUSION Between 2016 and 2019, there were 161,000 fewer cancer survivors in the United States with insurance coverage, and 169,000 forwent medical care because of cost.
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Affiliation(s)
- Justin M. Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO
| | - Evan M. Graboyes
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Eric Adjei Boakye
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
- Department of Otolaryngology Head and Neck Surgery, Henry Ford Health System, Detroit, MI
| | - Mario Schootman
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Junzo P. Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
- Duke Cancer Institute, Durham, NC
| | - Haley A. Moss
- Duke Cancer Institute, Durham, NC
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Yvonne M. Mowery
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
- Duke Cancer Institute, Durham, NC
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC
| | - Nosayaba Osazuwa-Peters
- Duke Cancer Institute, Durham, NC
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
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Barnes JM, Graboyes EM, Adjei Boakye E, Kent EE, Scherrer JF, Park EM, Rosenstein DL, Mowery YM, Chino JP, Brizel DM, Osazuwa-Peters N. The Affordable Care Act and suicide incidence among adults with cancer. J Cancer Surviv 2023; 17:449-459. [PMID: 35368225 DOI: 10.1007/s11764-022-01205-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/23/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with cancer are at an increased suicide risk, and socioeconomic deprivation may further exacerbate that risk. The Affordable Care Act (ACA) expanded insurance coverage options for low-income individuals and mandated coverage of mental health care. Our objective was to quantify associations of the ACA with suicide incidence among patients with cancer. METHODS We identified US patients with cancer aged 18-74 years diagnosed with cancer from 2011 to 2016 from the Surveillance, Epidemiology, and End Results database. The primary outcome was the 1-year incidence of suicide based on cumulative incidence analyses. Difference-in-differences (DID) analyses compared changes in suicide incidence from 2011-2013 (pre-ACA) to 2014-2016 (post-ACA) in Medicaid expansion relative to non-expansion states. We conducted falsification tests with 65-74-year-old patients with cancer, who are Medicare-eligible and not expected to benefit from ACA provisions. RESULTS We identified 1,263,717 patients with cancer, 812 of whom died by suicide. In DID analyses, there was no change in suicide incidence after 2014 in Medicaid expansion vs. non-expansion states for nonelderly (18-64 years) patients with cancer (p = .41), but there was a decrease in suicide incidence among young adults (18-39 years) (- 64.36 per 100,000, 95% CI = - 125.96 to - 2.76, p = .041). There were no ACA-associated changes in suicide incidence among 65-74-year-old patients with cancer. CONCLUSIONS We found an ACA-associated decrease in the incidence of suicide for some nonelderly patients with cancer, particularly young adults in Medicaid expansion vs. non-expansion states. Expanding access to health care may decrease the risk of suicide among cancer survivors.
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Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, USA
| | - Eric Adjei Boakye
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA
- Simmons Cancer Institute, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Erin E Kent
- Departments of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Eliza M Park
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Comprehensive Cancer Support Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Comprehensive Cancer Support Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yvonne M Mowery
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, USA
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Junzo P Chino
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - David M Brizel
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, USA
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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Olson RE, Smith A, Good P, Dudley M, Gurgenci T, Hardy J. 'What price do you put on your health?': Medical cannabis, financial toxicity and patient perspectives on medication access in advanced cancer. Health Expect 2023; 26:160-171. [PMID: 36335552 PMCID: PMC9854313 DOI: 10.1111/hex.13642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 09/29/2022] [Accepted: 10/16/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Following 2016 legislation permitting limited access to cannabis for research and medicinal purposes, the number of randomized clinical trials (RCTs) investigating the effectiveness of medicinal cannabis (MC) on symptom burden relief in cancer contexts has increased in Australia. This study aimed to understand the perceptions, hopes and concerns of people with advanced cancer regarding the future availability and regulation of MC in Australia. METHODS This qualitative study draws on semistructured interviews conducted between February 2019 and October 2020 in Brisbane, Australia, as part of an MC RCT substudy. Interviews were undertaken on 48 patients with advanced cancer in palliative care eligible to participate in an MC trial (n = 26 participated in an RCT; n = 2 participated in a pilot study; n = 20 declined). Interviews included a discussion of patients' decision-making regarding trial participation, concerns about MC and perceptions of future availability, including cost. Transcribed interviews were analysed inductively and abductively, informed by constructivist thematic analysis conventions. RESULTS Overall, participants supported making MC legally accessible as a prescription-only medication. Fear of financial toxicity, however, compromised this pathway. Steep posttrial costs of accessing MC prompted several people to decline trial participation, and others to predict-if found effective-that many would either access MC through alternative pathways or reduce their prescribed dosage to enable affordable access. CONCLUSIONS These findings suggest that-despite a relatively robust universal healthcare system-Australians are potentially vulnerable to and fearful of financial toxicity. Prevalent in the United States, financial toxicity occurs when disadvantaged cancer patients access necessary but expensive medications with lasting consequences: bankruptcy, ongoing anxiety and cancer worry. Interview transcripts indicate that financial fears-and the systems sustaining them-may pose a threat to RCT completion and to equitable access to legal MC. Such findings support calls for embedding qualitative substudies and community partnerships within RCTs, while also suggesting the importance of subsidisation to overcoming injustices. PATIENT OR PUBLIC CONTRIBUTION A patient advisory committee informed RCT design. This qualitative substudy foregrounds patients' decision-making, perceptions and experiences.
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Affiliation(s)
- Rebecca E. Olson
- School of Social ScienceUniversity of QueenslandSt LuciaQueenslandAustralia
| | - Alexandra Smith
- School of Social ScienceUniversity of QueenslandSt LuciaQueenslandAustralia
| | - Phillip Good
- Mater Health Services, Mater Research InstituteUniversity of QueenslandBrisbaneQueenslandAustralia
- Palliative CareSt Vincent's Private Hospital BrisbaneBrisbaneQueenslandAustralia
| | - Morgan Dudley
- School of Social ScienceUniversity of QueenslandSt LuciaQueenslandAustralia
| | - Taylan Gurgenci
- Mater Health Services, Mater Research InstituteUniversity of QueenslandBrisbaneQueenslandAustralia
- School of MedicineUniversity of QueenslandHerstonQueenslandAustralia
| | - Janet Hardy
- Mater Health Services, Mater Research InstituteUniversity of QueenslandBrisbaneQueenslandAustralia
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Wu J, Moss H. Financial Toxicity in the Post-Health Reform Era. J Am Coll Radiol 2023; 20:10-17. [PMID: 36509218 DOI: 10.1016/j.jacr.2022.09.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/21/2022] [Accepted: 09/27/2022] [Indexed: 12/13/2022]
Abstract
The Patient Protection and Affordable Care Act (ACA), enacted in March 2010, was comprehensive health care reform legislation aimed to improve health care access and quality of care and curb health care-related costs. This review focuses on key provisions of the ACA and their impact on financial toxicity. We will focus our review on cancer care, because this is the most commonly studied disease process in respect to financial toxicity. Patients with cancer face rising expenditures and financial burden, which in turn impact quality of life, compliance to treatment, and survival outcomes. Health insurance expansion include dependent-coverage expansion, Medicaid expansion, and establishment of the Marketplace. Coverage reform focused on reducing financial barriers by limiting cost sharing. Payment reforms included new innovative payment and delivery systems to focus on improving outcomes and reducing costs. Challenges remain as efforts to reduce costs have led to the expansion of insurance plans, such as high-deductible health plans, that may ultimately worsen financial toxicity in cancer and high out-of-pocket costs for further diagnostic testing and procedures. Further research is necessary to evaluate the long-term impacts of the ACA provisions-and threats to the ACA-on outcomes and the costs accrued by patients.
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Affiliation(s)
- Jenny Wu
- Resident, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina.
| | - Haley Moss
- Assistant Professor, Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
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Su CT, Shankaran V. Defining the Role of the Modern Oncology Provider in Mitigating Financial Toxicity. J Am Coll Radiol 2023; 20:51-56. [PMID: 36513257 PMCID: PMC9898149 DOI: 10.1016/j.jacr.2022.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/19/2022] [Accepted: 10/20/2022] [Indexed: 12/14/2022]
Abstract
Financial toxicity, the cumulative financial hardships resulting from cancer diagnosis and treatment, is a growing problem in the United States. With the proliferation of costly novel therapeutics and improved cancer survival, financial toxicity will remain a major issue in cancer care delivery. Frontline oncology providers serve as gatekeepers in the medical system and, as such, could play essential roles in recognizing and addressing financial toxicity. Providers and health systems could help mitigate financial toxicity through routine financial toxicity screening, financial navigation, and advocacy. Specific strategies include developing and implementing financial screening instruments that can be integrated in electronic medical records and establishing team-based financial navigation programs to help patients with out-of-pocket medical costs, nonmedical spending, and insurance optimization. Finally, providers should continue to advocate for policies and legislation that decrease cost and promote value-based care. In this review, we examine opportunities for provider engagement in these areas and highlight gaps for future research.
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Affiliation(s)
- Christopher T Su
- Division of Hematology, University of Washington School of Medicine, Seattle, Washington; and Hutchinson Institute for Cancer Outcome Research, Fred Hutchinson Cancer Center, Seattle, Washington.
| | - Veena Shankaran
- Division of Medical Oncology, University of Washington School of Medicine, Seattle, Washington; and Codirector, Hutchinson Institute for Cancer Outcome Research, Fred Hutchinson Cancer Center, Seattle, Washington
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Barnes JM, Johnson KJ, Adjei Boakye E, Schapira L, Akinyemiju T, Park EM, Graboyes EM, Osazuwa-Peters N. Early Medicaid Expansion and Cancer Mortality. J Natl Cancer Inst 2021; 113:1714-1722. [PMID: 34259321 PMCID: PMC8634305 DOI: 10.1093/jnci/djab135] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/05/2021] [Accepted: 06/30/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Although Medicaid expansion is associated with decreased uninsured rates and earlier cancer diagnoses, no study has demonstrated an association between Medicaid expansion and cancer mortality. Our primary objective was to quantify the relationship between early Medicaid expansion and changes in cancer mortality rates. METHODS We obtained county-level data from the National Center for Health Statistics for adults aged 20-64 years who died from cancer from 2007 to 2009 (preexpansion) and 2012 to 2016 (postexpansion). We compared changes in cancer mortality rates in early Medicaid expansion states (CA, CT, DC, MN, NJ, and WA) vs nonexpansion states through a difference-in-differences analysis using hierarchical Bayesian regression. An exploratory analysis of cancer mortality changes associated with the larger-scale 2014 Medicaid expansions was also performed. RESULTS In adjusted difference-in-differences analyses, we observed a statistically significant decrease of 3.07 (95% credible interval = 2.19 to 3.95) cancer deaths per 100 000 in early expansion vs nonexpansion states, which translates to an estimated decrease of 5276 cancer deaths in the early expansion states during the study period. Expansion-associated decreases in cancer mortality were observed for pancreatic cancer. Exploratory analyses of the 2014 Medicaid expansions showed a decrease in pancreatic cancer mortality (-0.18 deaths per 100 000, 95% confidence interval = -0.32 to -0.05) in states that expanded Medicaid by 2014 compared with nonexpansion states. CONCLUSIONS Early Medicaid expansion was associated with reduced cancer mortality rates, especially for pancreatic cancer, a cancer with short median survival where changes in prognosis would be most visible with limited follow-up.
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Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Kimberly J Johnson
- Brown School, Washington University in St. Louis, St. Louis, MO, USA,Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
| | - Eric Adjei Boakye
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA,Simmons Cancer Institute, Springfield, IL, USA
| | - Lidia Schapira
- Department of Medicine (Oncology), Stanford University School of Medicine, Stanford, CA, USA,Stanford Cancer Institute, Stanford, CA, USA
| | - Tomi Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA,Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Eliza M Park
- Comprehensive Cancer Support Program, University of North Carolina, Chapel Hill, NC, USA,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Evan M Graboyes
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA,Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, USA
| | - Nosayaba Osazuwa-Peters
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA,Duke Cancer Institute, Duke University, Durham, NC, USA,Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA,Correspondence to: Nosayaba (Nosa) Osazuwa-Peters, BDS, PhD, MPH, CHES, Duke University School of Medicine, Department of Head and Neck Surgery and Communication Sciences, 40 Duke Medicine Cir, Duke South Yellow Zone 4080, DUMC 3805, Durham, NC 27710-4000, USA (e-mail: )
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12
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Su CT, Okullo D, Hingtgen S, Levine DA, Goold SD. Affordable Care Act and Cancer Survivors' Financial Barriers to Care: Analysis of the National Health Interview Survey, 2009-2018. JCO Oncol Pract 2021; 17:e1603-e1613. [PMID: 34255545 DOI: 10.1200/op.21.00095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Since Affordable Care Act (ACA) implementation in 2014, studies have demonstrated gains in insurance coverage for cancer survivors < 65 years. We assessed the impact of ACA implementation on financial barriers to care by stratifying survivors at age 65 years, when individuals typically become Medicare-eligible. METHODS We used data from respondents with cancer in the 2009-2018 National Health Interview Survey. We identified 21,954 respondents representing approximately 7.4 million survivors, who were then age-stratified at age 65 years. Survey responses regarding financial barriers to medical care and medications were analyzed, and age-stratified multivariable logistic regression modeling was performed, which evaluated the impact of ACA implementation on these measures, adjusted for demographic and socioeconomic variables. RESULTS After multivariable logistic regression, ACA implementation was associated with higher adjusted odds of Medicaid insurance (odds ratio [95% CI] 2.02 [1.72 to 2.36]; P < .0001) and lower adjusted odds of no insurance (0.57 [0.48 to 0.68]; P < .0001). Regarding financial barriers, ACA implementation was associated with lower adjusted odds of inability to afford medications (0.68 [0.59 to 0.79]; P < .0001), inability to afford dental care (0.83 [0.73 to 0.94]; P = .004), and delaying care (0.78 [0.69 to 0.89]; P = .002) in the 18-64 years group. Similarly, ACA implementation was associated with lower adjusted odds of secondary outcomes such as delaying refills, skipping doses, and anxiety over medical bills. Similar associations were not seen in the > 65 years group. CONCLUSION Survivor-reported measures of financial barriers in cancer survivors age 18-64 years significantly improved following ACA implementation. Similar changes were not seen in the Medicare-eligible cohort, likely because of high Medicare enrollment and few uninsured.
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Affiliation(s)
- Christopher T Su
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.,Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.,Rogel Cancer Center, Michigan Medicine, Ann Arbor, MI
| | - Dolorence Okullo
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Stephanie Hingtgen
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Deborah A Levine
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.,Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Susan D Goold
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.,Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.,Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI
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Abdel-Rahman O, North S. Patterns of cost-related medication underuse among Canadian adults with cancer: a cross-sectional study using survey data. CMAJ Open 2021; 9:E474-E481. [PMID: 33958383 PMCID: PMC8157980 DOI: 10.9778/cmajo.20200186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Cost-related medication underuse (CRMU) has been reported within the general population in Canada. In this study, we assessed patterns of CRMU among Canadian adults with cancer. METHODS This is a cross-sectional study using survey data. We accessed data sets from the 2015/16 Canadian Community Health Survey (CCHS) and reviewed the records of adults (≥ 18 yr) with a history of cancer who were prescribed medication in the previous 12 months. We collected information about sociodemographic features, health behaviours and CRMU, and conducted a multivariable logistic regression analysis for factors associated with CRMU. RESULTS A total of 8581 participants were eligible for the current study. In the weighted multivariable logistic regression analysis, the following factors were associated with CRMU: younger age (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.79-3.63), female sex (male sex v. female sex OR 0.62, 95% CI 0.44-0.88), Indigenous racial background (Indigenous v. White OR 2.37, 95% CI 1.49- 3.77), unmarried status (OR 1.59, 95% CI 1.09-2.30), poor self-perceived health (excellent v. poor self-perceived health OR 0.36, 95% CI 0.17-0.77), lower annual income (< $20 000 v. income ≥ $80 000 OR 3.08, 95% CI 1.75-5.41) and lack of insurance for prescription medications (OR 2.49, 95% CI 1.77-3.50). INTERPRETATION The toll of CRMU among adults seems to be unequally carried by women, racial minorities, and younger (< 65 yr) and uninsured patients with cancer. Discussion about a national pharmacare program for people without private insurance is needed.
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Affiliation(s)
- Omar Abdel-Rahman
- Department of Oncology, University of Alberta and Cross Cancer Institute, Edmonton, Alta.
| | - Scott North
- Department of Oncology, University of Alberta and Cross Cancer Institute, Edmonton, Alta
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