Prevalence and Correlates of Medical Financial Hardship in the USA

Financial Hardship: A Qualitative Study Exploring Perspectives of Seriously Ill Patients and Their Family

CONTEXT

Seriously ill patients, such as those who experience critical illness, and their families experience a variety of poor outcomes, including financial hardship. However, little is known about the ways in which these seriously ill patients and their families experience financial hardship.

OBJECTIVE

To examine seriously ill patients' and families' experiences of financial hardship and perspectives on addressing these concerns during and after critical illness.

METHODS

We conducted a thematic analysis of semi-structured interviews with seriously ill patients who recently experienced a critical care hospitalization (n=15) and family caregivers of these patients (n=18).

RESULTS

Our analysis revealed three themes: 1) Prioritizing Survival and Recovery; 2) Living with Uncertainty-including experiences of prolonged uncertainty, navigating bureaucratic barriers, and long-term worries; and 3) Preferences for Financial Guidance. Our results suggest patients and families prioritize survival over financial hardship initially, and feelings of uncertainty about finances persist. However, patients and family caregivers are reluctant to have their physicians address financial hardship.

CONCLUSIONS

Our findings suggest that the acute and time sensitive nature of treatment decisions in critical care settings provides a unique context for experiences of financial hardship. Additional research is needed to better understand these experiences and design context-sensitive interventions to mitigate financial hardship and associated poor patient- and family-centered outcomes.

Addressing financial hardship in malignant hematology and hematopoietic cell transplant: a team approach

ABSTRACT

Financial hardship is a common experience for patients and their families after the diagnosis of a hematologic malignancy and is associated with worse outcomes. Health care costs, increased costs of living, income poverty, and inadequate wealth contribute to financial hardship after the diagnosis and treatment of a hematologic malignancy and/or hematopoietic cell transplant. Given the multidimensional nature of financial hardship, a multidisciplinary team-based approach is needed to address this public health hazard. Hematologists and oncologists may mitigate the impact of financial hardship by matching treatment options with patient goals of care and reducing symptom burden disruptive to employment. Social workers and financial navigators can assist with screening and resource deployment. Policymakers and researchers can identify structural and policy changes to prevent financial hardship. By alleviating this major health care burden from patients, care teams may improve survival and quality of life for patients with hematologic malignancies.

Medical Debt and the Mental Health Treatment Gap Among US Adults

Importance

Medical debt is common in the US and may hinder timely access to care for mental disorders.

Objective

To estimate the prevalence of medical debt among US adults with depression and anxiety and its association with delayed and forgone mental health care.

Design, Setting, and Participants

Cross-sectional, nationally representative survey study of US adult participants in the 2022 National Health Interview Survey who had current or lifetime diagnoses of depression or anxiety.

Exposures

Self-reported lifetime clinical diagnoses of depression and anxiety; moderate to severe symptoms of current depression (Patient Health Questionnaire-8 score ≥10) and anxiety (Generalized Anxiety Disorder-7 score ≥10) irrespective of lifetime diagnoses; and past-year medical debt.

Main Outcomes and Measures

Self-reported delaying and forgoing mental health care because of cost in the past year.

Results

Among 27 651 adults (15 050 [54.4%] female; mean [SD] age, 52.9 [18.4] years), 5186 (18.2%) reported lifetime depression, 1948 (7.3%) reported current depression, 4834 (17.7%) reported lifetime anxiety, and 1689 (6.6%) reported current anxiety. Medical debt was more common among adults with lifetime depression (19.9% vs 8.6%; adjusted prevalence ratio [aPR], 1.97; 95% CI, 1.96-1.98), lifetime anxiety (19.4% vs 8.8%; aPR, 1.91; 95% CI, 1.91-1.92), current depression (27.3% vs 9.4%; aPR, 2.34; 95% CI, 2.34-2.36), and current anxiety (26.2% vs 9.6%; aPR, 2.24; 95% CI, 2.24-2.26) compared with adults without the respective mental disorders. Medical debt was associated with delayed health care among adults with lifetime depression (29.0% vs 11.6%; aPR, 2.68; 95% CI, 2.62-2.74), lifetime anxiety (28.0% vs 11.5%; aPR, 2.45; 95% CI, 2.40-2.50), current depression (36.9% vs 17.4%; aPR, 2.25; 95% CI, 2.13-2.38), and current anxiety (38.4% vs 16.9%; aPR, 2.48; 95% CI, 2.35-2.66) compared with those without these diagnoses. Medical debt was associated with forgone health care among adults with lifetime depression (29.4% vs 10.6%; aPR, 2.66; 95% CI, 2.61-2.71), lifetime anxiety (28.2% vs 10.7%; aPR, 2.63; 95% CI, 2.57-2.68), current depression (38.0% vs 17.2%; aPR, 2.35; 95% CI, 2.23-2.48), and current anxiety (40.8% vs 17.1%; aPR, 2.57; 95% CI, 2.43-2.75) compared with those without the diagnoses.

Conclusions and Relevance

Medical debt is prevalent among adults with depression and anxiety and may contribute to the mental health treatment gap. In the absence of structural reform, new policies are warranted to protect against this financial barrier to mental health care.

A Systematic Review of Interventions Targeting Cancer-Related Financial Hardship: Current Evidence and Implications

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.

Self-Reported Financial Difficulties Among Patients with Multiple Myeloma and Chronic Lymphocytic Leukemia Treated at U.S. Community Oncology Clinics (Alliance A231602CD)

Objectives

To estimate the proportion and correlates of self-reported financial difficulty among patients with multiple myeloma (MM) or chronic lymphocytic leukemia (CLL).

Setting

23 U.S. community and minority oncology practice sites affiliated with the National Cancer Institute Community Oncology Research Program (NCORP).

Participants

521 patients (≥18 years) with MM or CLL were consented and 416 responded to a survey (completion rate=79.8%). Respondents had a MM diagnosis (74.0%), an associate degree or higher (53.4%), were White (89.2%), insured (100%) and treated with clinician-administered drugs (68.0%).

Interventions

Observational, prospective, protocol-based survey administered in 2019-2020.

Primary and secondary outcome measures

Financial difficulty was assessed using a single-item standard measure, the EORTC QLQC30: "Has your physical condition or medical treatment caused you financial difficulties in the past year?" and using an 'any-or-none' composite measure of 22 items assessing financial difficulty, worries and the use of cost-coping strategies. Multivariable logistic regression models assessed the association between financial difficulty, diagnosis, and socioeconomic and treatment characteristics.

Results

16.8% reported experiencing financial difficulty using the single-item measure and 60.3% using the composite measure. Most frequently endorsed items in the composite measure were financial worry about having to pay large medical bills related to cancer and difficulty paying medical bills. Financial difficulty using the single-item measure was associated with having MM versus CLL (adjusted odds ratio [aOR], 0.34; 95% CI, 0.13-0.84; P=.02), having insurance other than Medicare (aOR, 2.53; 95% CI, 1.37-4.66; P=.003), being non-White (aOR, 2.21; 95% CI, 1.04-4.72; P=.04), and having a high school education or below (aOR, 0.36; 95% CI, 0.21-0.64; P=.001). Financial difficulty using the composite measure was associated with having a high school education or below (aOR, 0.62; 95% CI, 0.41-0.94; P=.03).

Conclusions

U.S. patients with blood cancer report financial difficulty, especially those with low socio-economic status. Evidence-based and targeted interventions are needed.

Predictors of ICU Surrogates' States of Concurrent Prolonged Grief, Post-Traumatic Stress, and Depression Symptoms

OBJECTIVES

Scarce research explores factors of concurrent psychologic distress (prolonged grief disorder [PGD], post-traumatic stress disorder [PTSD], and depression). This study models surrogates' longitudinal, heterogenous grief-related reactions and multidimensional risk factors drawing from the integrative framework of predictors for bereavement outcomes (intrapersonal, interpersonal, bereavement-related, and death-circumstance factors), emphasizing clinical modifiability.

DESIGN

Prospective cohort study.

SETTING

Medical ICUs of two Taiwanese medical centers.

SUBJECTS

Two hundred eighty-eight family surrogates.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Factors associated with four previously identified PGD-PTSD-depressive-symptom states (resilient, subthreshold depression-dominant, PGD-dominant, and PGD-PTSD-depression concurrent) were examined by multinomial logistic regression modeling (resilient state as reference). Intrapersonal: Prior use of mood medications correlated with the subthreshold depression-dominant state. Financial hardship and emergency department visits correlated with the PGD-PTSD-depression concurrent state. Higher anxiety symptoms correlated with the three more profound psychologic-distress states (adjusted odds ratio [95% CI] = 1.781 [1.562-2.031] to 2.768 [2.288-3.347]). Interpersonal: Better perceived social support was associated with the subthreshold depression-dominant state. Bereavement-related: Spousal loss correlated with the PGD-dominant state. Death circumstances: Provision of palliative care (8.750 [1.603-47.768]) was associated with the PGD-PTSD-depression concurrent state. Surrogate-perceived quality of patient dying and death as poor-to-uncertain (4.063 [1.531-10.784]) correlated with the subthreshold depression-dominant state, poor-to-uncertain (12.833 [1.231-133.775]), and worst (12.820 [1.806-91.013]) correlated with the PGD-PTSD-depression concurrent state. Modifiable social-worker involvement (0.004 [0.001-0.097]) and a do-not-resuscitate order issued before death (0.177 [0.032-0.978]) were negatively associated with the PGD-PTSD-depression concurrent and the subthreshold depression-dominant state, respectively. Apparent unmodifiable buffering factors included surrogates' higher educational attainment, married status, and longer time since loss.

CONCLUSIONS

Surrogates' concurrent bereavement distress was positively associated with clinically modifiable factors: poor quality dying and death, higher surrogate anxiety, and palliative care-commonly provided late in the terminal-illness trajectory worldwide. Social-worker involvement and a do-not-resuscitate order appeared to mitigate risk.

Contemporary Patterns of Financial Toxicity Among Patients With Rheumatologic Disease in the United States

BACKGROUND/OBJECTIVE

Rheumatologic diseases encompass a group of disabling conditions that often require expensive clinical treatments and limit an individual's ability to work and maintain a steady income. The purpose of this study was to evaluate contemporary patterns of financial toxicity among patients with rheumatologic disease and assess for any associated demographic factors.

METHODS

The cross-sectional National Health Interview Survey was queried from 2013 to 2018 for patients with rheumatologic disease. Patient demographics and self-reported financial metrics were collected or calculated including financial hardship from medical bills, financial distress, food insecurity, and cost-related medication (CRM) nonadherence. Multivariable logistic regressions were used to assess for factors associated with increased financial hardship.

RESULTS

During the study period, 20.2% of 41,502 patients with rheumatologic disease faced some degree of financial hardship due to medical bills, 55.0% of whom could not pay those bills. Rheumatologic disease was associated with higher odds of financial hardship from medical bills (adjusted odds ratio, 1.29; 95% confidence interval, 1.22-1.36; p < 0.001) with similar trends for patients suffering from financial distress, food insecurity, and CRM nonadherence (p < 0.001 for all). Financial hardship among patients with rheumatologic disease was associated with being younger, male, Black, and uninsured ( p < 0.001 for all).

CONCLUSION

In this nationally representative study, we found that a substantial proportion of adults with rheumatologic disease in the United States struggled with paying their medical bills and suffered from food insecurity and CRM nonadherence. National health care efforts and guided public policy should be pursued to help ease the burden of financial hardship for these patients.

Hysterectomy and medical financial hardship among U.S. women

OBJECTIVE

Hysterectomy is one of the common surgical procedures for women in the United States. Studies show that hysterectomy is associated with elevated risk of developing chronic conditions, whichmay cause financial toxicity in patients. This study aimed to assess whether women who underwent hysterectomy had a higher risk of experiencing medical financial hardship compared to women who didn't.

METHODS

Using data on 32,823 adult women from the 2019 and 2021 waves of the National Health Interview Survey, we estimated binomial and multinomial logistic regressions to assess the relationship between hysterectomy and financial hardship, defined as problems paying or unable to pay any medical bills. Further, we performed a Karlson-Holm-Breen (KHB) decomposition to examine whether the association could be explained by chronic comorbidity.

RESULTS

While the prevalence of financial hardship was 13.6 % among all women, it was 16.2 % among women who underwent a hysterectomy. The adjusted odds of experiencing medical financial hardship among women with a hysterectomy were 1.36 (95 % CI: 1.22-1.52) times that of their counterparts who did not have a hysterectomy. The KHB decomposition suggested that 34.5 % of the size of the effect was attributable to chronic conditions. Women who had a hysterectomy were also 1.45 (95 % CI: 1.26-1.67) times more likely to have unpaid medical debts.

CONCLUSIONS

Our results suggested that women, who underwent a hysterectomy in the US, were vulnerable to medical financial hardship. Policy makers and health professionals should be made aware of this issue to help women coping against this adversity.

Financial hardship after COVID-19 infection among US Veterans: a national prospective cohort study

BACKGROUND

Research suggests an association between COVID-19 infection and certain financial hardships in the shorter term and among single-state and privately insured samples. Whether COVID-19 is associated with financial hardship in the longer-term or among socially vulnerable populations is unknown. Therefore, we examined whether COVID-19 was associated with a range of financial hardships 18 months after initial infection among a national cohort of Veterans enrolled in the Veterans Health Administration (VHA)-the largest national integrated health system in the US. We additionally explored the association between Veteran characteristics and financial hardship during the pandemic, irrespective of COVID-19.

METHODS

We conducted a prospective, telephone-based survey. Out of 600 Veterans with COVID-19 from October 2020 through April 2021 who were invited to participate, 194 Veterans with COVID-19 and 194 matched comparators without a history of infection participated. Financial hardship outcomes included overall health-related financial strain, two behavioral financial hardships (e.g., taking less medication than prescribed due to cost), and seven material financial hardships (e.g., using up most or all savings). Weighted generalized estimating equations were used to estimate risk ratios (RR) and 95% confidence intervals (CI) of financial hardship by COVID-19 status, and to assess the relationship between infection and Veteran age, VHA copay status, and comorbidity score, irrespective of COVID-19 status.

RESULTS

Among 388 respondents, 67% reported at least one type of financial hardship since March 2020, with 21% reporting behavioral hardships and 64% material hardships; 8% reported severe-to-extreme health-related financial strain. Compared with uninfected matched comparators, Veterans with a history of COVID-19 had greater risks of severe-to-extreme health-related financial strain (RR: 4.0, CI: 1.4-11.2), taking less medication due to cost (RR: 2.9, 95% CI: 1.0-8.6), and having a loved one take time off work to care for them (RR: 1.9, CI: 1.1-3.6). Irrespective of COVID-19 status, Veterans aged < 65 years had a greater risk of most financial hardships compared with Veterans aged ≥ 65 years.

CONCLUSIONS

Health-related financial hardships such as taking less medication due to cost and severe-to-extreme health-related financial strain were more common among Veterans with a history of COVID-19 than among matched comparators. Strategies are needed to address health-related financial hardship after COVID-19.

TRIAL REGISTRATION

NCT05394025, registered 05-27-2022.

Cost transparency in otolaryngology: Outpatient procedures cost information at New England hospitals

PURPOSE

Healthcare costs have dramatically increased, resulting in barriers to care for many Americans. To address this, the Centers for Medicare & Medicaid Services implemented a price transparency mandate, requiring hospitals to provide cost-estimate tools. This study evaluates the accessibility and usability of these tools for common otolaryngology outpatient procedures.

MATERIALS AND METHODS

Cost transparency was investigated using cost-estimate tools from websites of the seven New England hospitals ranked on the US News top 50 list. Ten common current procedural terminology codes were used to collect data on availability of cost information, cost comparison, and ease-of-use by six investigators acting as "patients" for each hospital and procedure.

RESULTS

All investigated hospitals had cost-estimate tools, with a 35.7 % mean success rate of generating an estimate. The mean times to cost-estimate tools and generated estimates were 35.69 and 34.15 s, respectively. Pre-insurance costs varied by hospital and procedure; creation of eardrum had the largest range. Seven out of ten procedures resulted in lower post-insurance costs. The mean ease-of-use rating was 5.76 out of ten.

CONCLUSION

All hospitals complied with the Centers for Medicare & Medicaid Services price transparency policy. The information available is sparse, difficult to access, and frequently lacks specific estimates for common otolaryngology procedures. Although hospitals are following new Centers for Medicare & Medicaid Services mandates, the estimators currently in existence are ineffective tools for financial decision-making.

Association between financial hardship and psychological burden and the role of social and mental health support: An observational study

We aimed to assess the association between medical financial hardship and psychological burden and the moderating role of social and mental health support. 2021 United States National Health Interview Survey was used. Financial hardship was defined as having financial worry, material hardship, or cost-related care nonadherence. Psychological burden was measured using perceived general health status, satisfaction with life, and serious psychological distress (SPD). Of 29,370 included adults, 49% experienced financial hardship in the last 12 months. Financial hardship was associated with a higher psychological burden (odds ratio [OR], 3.58; 95% confidence interval [CI], 2.43-5.47 for SPD). Eleven percent received counseling/therapy from mental health professionals, and 90% had experienced frequent social support. Frequent social support was associated with lower financial hardship (OR, 0.71; 95% CI, 0.63-0.80) and psychological burden (OR, 0.28; 95% CI, 0.19-0.42 for SPD). Previous mental health support was associated with higher financial hardship (OR,1.40; 95% CI, 1.28-1.54) and psychological burden (OR, 9.75; 95% CI, 6.97-13.94 for SPD). Those experiencing financial hardship had lower odds of SPD if they received mental health support in the last 12 months (OR, 0.57; 95% CI, 0.39-0.85). Future interventions should also focus on improving social support and mental health for patients as a way of mitigating medical financial hardship.

Precision emergency medicine

BACKGROUND

Precision health is a burgeoning scientific discipline that aims to incorporate individual variability in biological, behavioral, and social factors to develop personalized health solutions. To date, emergency medicine has not deeply engaged in the precision health movement. However, rapid advances in health technology, data science, and medical informatics offer new opportunities for emergency medicine to realize the promises of precision health.

METHODS

In this article, we conceptualize precision emergency medicine as an emerging paradigm and identify key drivers of its implementation into current and future clinical practice. We acknowledge important obstacles to the specialty-wide adoption of precision emergency medicine and offer solutions that conceive a successful path forward.

RESULTS

Precision emergency medicine is defined as the use of information and technology to deliver acute care effectively, efficiently, and authentically to individual patients and their communities. Key drivers and opportunities include leveraging human data, capitalizing on technology and digital tools, providing deliberate access to care, advancing population health, and reimagining provider education and roles. Overcoming challenges in equity, privacy, and cost is essential for success. We close with a call to action to proactively incorporate precision health into the clinical practice of emergency medicine, the training of future emergency physicians, and the research agenda of the specialty.

CONCLUSIONS

Precision emergency medicine leverages new technology and data-driven artificial intelligence to advance diagnostic testing, individualize patient care plans and therapeutics, and strategically refine the convergence of the health system and the community.

Financial hardship after cancer: revision of a conceptual model and development of patient-reported outcome measures

Aim: This qualitative study refined a conceptual model of financial hardship and developed measures corresponding to model constructs. Methods: Eighteen women with breast cancer recruited through a comprehensive cancer center completed interviews. A qualitative framework analysis was conducted of the interviews. Results: Participants experienced varying levels of financial hardship. Protective factors included good health insurance, work accommodations and social support. Participants worried about cancer care costs and employment. Programs for alleviating financial hardship had high administrative burdens. Four preliminary financial hardship measures were developed: coping, impacts, depression and worry. Conclusion: Reducing administrative barriers to benefits could reduce financial hardship after cancer. More research is needed on the effects of out-of-network/formulary care and denials of coverage and to validate the measures.

Financial Toxicity in Renal Patients (FINTORE) Study: A Cross-Sectional Italian Study on Financial Burden in Kidney Disease-A Project Protocol

Financial toxicity (FT) refers to the negative impact of health-care costs on clinical conditions. In general, social determinants of health, especially poverty, socioenvironmental stressors, and psychological factors, are increasingly recognized as important determinants of non-communicable diseases, such as chronic kidney disease (CKD), and their consequences. We aim to investigate the prevalence of FT in patients at different stages of CKD treated in our universal health-care system and from pediatric nephrology, hemodialysis, peritoneal dialysis and renal transplantation clinics. FT will be assessed with the Patient-Reported Outcome for Fighting Financial Toxicity (PROFFIT) score, which was first developed by Italian oncologists. Our local ethics committee has approved the study. Our population sample will answer the sixteen questions of the PROFFIT questionnaire, seven of which are related to the outcome and nine the determinants of FT. Data will be analyzed in the pediatric and adult populations and by group stratification. We are confident that this study will raise awareness among health-care professionals of the high risk of adverse health outcomes in patients who have both kidney disease and high levels of FT. Strategies to reduce FT should be implemented to improve the standard of care for people with kidney disease and lead to truly patient-centered care.

Healthcare Cost Burden and Self-Reported Frequency of Depressive/Anxious Feelings in Older Adults

Using the 2018-2021 National Health Interview Survey data, we examined the associations between healthcare cost burden and depressive/anxious feelings in older adults. Nearly12% reported healthcare cost burden and 18% daily/weekly depressive/anxious feelings. Healthcare cost burden was higher among women, racial/ethnic minorities, those with chronic illnesses, mobility impairment, and those with Medicare Part D, but lower among individuals with Medicare-Medicaid dual eligibility, Medicare Advantage, VA/military insurance, and private insurance. Daily/weekly depressive/anxious feelings was higher among healthcare cost burden reporters. The COVID-19 pandemic-related medical care access problems were also associated with a higher risk of reporting healthcare cost burden and depression/anxiety.

Injuries Among Hispanic/Latinx Agricultural Workers Seen in Illinois Hospitals

OBJECTIVE

Agriculture is a dangerous industry, with evidence indicating a disproportionate burden among Hispanic/Latinx workers. There is a need to expand the utilization of different data systems to improve the surveillance of precarious workers within agriculture. This analysis describes inclusion criteria to identify farm-related injuries and illnesses in hospital data utilizing ICD-10 codes to better assess health equity issues involving Hispanic/Latinx workers and their associated costs.

METHODS

Discharge data of agriculture-related injuries and illnesses treated in Illinois hospitals and emergency departments from 2018 to 2021 were extracted using ICD-10 diagnosis and location of injury codes. Injury cause, nature, severity, and course of clinical care are stratified by ethnicity. Multivariable models were developed to assess differences in injury severity, level of care required, and cost of care.

RESULTS

We identified 3,745 farm-related injuries and illnesses treated in Illinois hospitals between 2018 and 2021, of which 196 involved Hispanic/Latinx individuals. Hispanic/Latinx patients were substantially younger and disproportionately covered by workers' compensation insurance or uninsured. Compared to non-Hispanic/Latinx individuals, Hispanic/Latinx patients suffered injuries from different mechanisms, particularly involving animals and cutting/piercing instruments. While non-Hispanic/Latinx individuals demonstrated more severe injuries based on the descriptive statistics, after controlling for confounding (particularly age), we did not observe ethnic disparities in injury severity or level of care required. However, the cost of care was equivalent to or higher among Hispanic/Latinx persons.

CONCLUSION

The case definition used for this analysis identified agriculture-related cases and provided insights on the course of clinical care by ethnicity. This strategy would likely yield valuable information in states with larger and more diverse agricultural workforces. More targeted research to appropriately scope the issue and inform interventions is needed to understand differential exposure and reduce agricultural workplace hazards and address the financial burden resulting from farm-related injuries.

Association of Medicare eligibility with access to and affordability of care among older cancer survivors

PURPOSE

Older cancer survivors have substantial needs for ongoing care, but they may encounter difficulties accessing care due to cost concerns. We examined whether near-universal insurance coverage through Medicare-a key source of health insurance coverage in this population-is associated with improvements in care access and affordability among older cancer survivors around age 65.

METHODS

In a nationally representative sample of cancer survivors (aged 50-80) from 2006-2018 National Health Interview Survey, we employed a quasi-experimental, regression discontinuity design to estimate changes in insurance coverage, delayed/skipped care due to cost, and worries about or problems paying medical bills at age 65.

RESULTS

Medicare coverage sharply increased from 8.3% at age 64 to 98.2% at age 65, ensuring near-universal insurance coverage (99.5%). Medicare eligibility at age 65 was associated with reductions in delayed/skipped care due to cost (discontinuity, - 5.7 percentage points or pp; 95% CI, - 8.1, - 3.3; P < .001), worries about paying for medical bills (- 7.7 pp; 95% CI, - 12.0, - 3.2; P = .001), and problems paying medical bills (- 3.2 pp; 95% CI, - 6.1, - 0.2; P = .036). However, a sizable proportion reported any access or affordability problems (29.7%) between ages 66 and 80.

CONCLUSIONS

Near-universal Medicare coverage at age 65 was associated with a reduction-but not elimination-of access and affordability problems among cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

These findings reaffirm the role of Medicare in improving access and affordability for older cancer survivor and highlight opportunities for reforms to further alleviate financial burden of care in this population.

Associations of Medical Debt With Health Status, Premature Death, and Mortality in the US

Importance

Medical debt is increasingly common in the US. Little is known regarding its association with population health.

Objective

To examine the associations of medical debt with health status, premature death, and mortality at the county level in the US.

Design, Setting, and Participants

This cross-sectional study was conducted at the US county level using 2018 medical debt data from the Urban Institute Debt in America project linked with 2018 data on self-reported health status and premature death from the County Health Rankings & Roadmaps and with 2015 to 2019 mortality data from the National Center for Health Statistics. Data analysis was performed from August 2022 to May 2023.

Exposure

Share of population with any medical debt in collections and median amount of medical debt.

Main Outcomes and Measures

Health status was measured as (1) the mean number of physically and mentally unhealthy days in the past 30 days per 1000 people, (2) the mean number of premature deaths measured as years of life lost before age 75 years per 1000 people, and (3) age-adjusted all-cause and 18 cause-specific mortality rates (eg, malignant cancers, heart disease, and suicide) per 100 000 person-years. Multivariable linear models were fitted to estimate the associations between medical debt and health outcomes.

Results

A total of 2943 counties were included in this analysis. The median percentage of the county population aged 65 years or older was 18.3% (IQR, 15.8%-20.9%). Across counties, a median 3.0% (IQR, 1.2%-11.9%) of the population were Black residents, 4.3% (IQR, 2.3%-9.7%) were Hispanic residents, and 84.5% (IQR, 65.7%-93.3%) were White residents. On average, 19.8% (range, 0%-53.6%) of the population had medical debt. After adjusting for county-level sociodemographic characteristics, a 1-percentage point increase in the population with medical debt was associated with 18.3 (95% CI, 16.3-20.2) more physically unhealthy days and 17.9 (95% CI, 16.1-19.8) more mentally unhealthy days per 1000 people during the past month, 1.12 (95% CI, 1.03-1.21) years of life lost per 1000 people, and an increase of 7.51 (95% CI, 6.99-8.04) per 100 000 person-years in age-adjusted all-cause mortality rate. Associations of medical debt and elevated mortality rates were consistent for all leading causes of death, including cancer (1.12 [95% CI, 1.02-1.22]), heart disease (1.39 [95% CI, 1.21-1.57]), and suicide (0.09 [95% CI, 0.06-0.11]) per 100 000 person-years. Similar patterns were observed for associations between the median amount of medical debt and the aforementioned health outcomes.

Conclusions and Relevance

These findings suggest that medical debt is associated with worse health status, more premature deaths, and higher mortality rates at the county level in the US. Therefore, policies increasing access to affordable health care, such as expanding health insurance coverage, may improve population health.

Lives Saved Through Increasing Adherence to Follow-Up After Abnormal Cervical Cancer Screening Results

OBJECTIVE

To model the potential number of cancers prevented and life-years saved over a range of adherence rates to cervical cancer screening, surveillance follow-up, and follow-up colposcopy that may result from removing financial barriers to these essential clinical services.

METHODS

A previously validated decision-analytic Markov microsimulation model was used to evaluate the increase in adherence to screening, surveillance, and colposcopy after an abnormal cervical cancer screening result. For each incremental increase in adherence, we modeled the number of cervical cancer cases avoided, the stages at which the cancers were detected, the number of cervical cancer deaths avoided, and the number of life-years gained.

RESULTS

Compared with current adherence rates, the model estimated that an optimized scenario of perfect screening, surveillance, and colposcopy adherence per 100,000 women currently eligible for screening in the United States was 128 (95% CI, 66-199) fewer cervical cancers detected (23%), 62 (95% CI, 7-120) fewer cervical cancer deaths (20%), and 2,135 (95% CI, 1,363-3,057) more life-years saved. Sensitivity analysis revealed that any increase in adherence led to clinically meaningful health benefits.

CONCLUSION

The consequences of not attending routine screening or follow-up after an abnormal cervical cancer screening result are associated with preventable cervical cancer morbidity and premature mortality. Given the potential for the removal of consumer cost sharing to increase the use of necessary follow-up after abnormal screening results and to ultimately reduce cervical cancer morbidity and mortality, public and private payers should remove cost barriers to these essential services.

Medical financial hardship between young adult cancer survivors and matched individuals without cancer in the United States

BACKGROUND

Young adult cancer survivors face medical financial hardships that may lead to delaying or forgoing medical care. This study describes the medical financial difficulties young adult cancer survivors in the United States experience in the post-Patient Protection and Affordable Care Act period.

METHOD

We identified 1009 cancer survivors aged 18 to 39 years from the National Health Interview Survey (2015-2022) and matched 963 (95%) cancer survivors to 2733 control individuals using nearest-neighbor matching. We used conditional logistic regression to examine the association between cancer history and medical financial hardship and to assess whether this association varied by age, sex, race and ethnicity, and region of residence.

RESULTS

Compared with those who did not have a history of cancer, young adult cancer survivors were more likely to report material financial hardship (22.8% vs 15.2%; odds ratio = 1.65, 95% confidence interval = 1.50 to 1.81) and behavior-related financial hardship (34.3% vs 24.4%; odds ratio = 1.62, 95% confidence interval = 1.49 to 1.76) but not psychological financial hardship (52.6% vs 50.9%; odds ratio = 1.07, 95% confidence interval = 0.99 to 1.16). Young adult cancer survivors who were Hispanic or lived in the Midwest and South were more likely to report psychological financial hardship than their counterparts.

CONCLUSIONS

We found that young adult cancer survivors were more likely to experience material and behavior-related financial hardship than young adults without a history of cancer. We also identified specific subgroups of young adult cancer survivors that may benefit from targeted policies and interventions to alleviate medical financial hardship.

Caring for Children in Relation to Financial Hardship, Advance Care Planning, and Genetic Testing Among Adolescent and Young Adults with Cancer

Purpose: When a cancer diagnosis coincides with caring for children, it may influence the financial impacts of cancer and decisions to pursue advance care planning (ACP) or genetic testing. We examined associations between caring for children and financial hardship, ACP, and genetic testing among female adolescent and young adult (AYA) cancer survivors in North Carolina and California. Methods: Participants were diagnosed at ages 15-39 years with breast, melanoma, gynecologic, lymphoma, or thyroid cancer during 2004-2016. We estimated adjusted prevalence differences (aPDs) and ratios (aPRs) for each outcome by child caring status using marginal structural binomial regression models. Results: Among 1595 women ages 19-54 years at survey (median = 7 years since diagnosis), 819 (51.3%) reported that they were caring for children at diagnosis. Women caring for children had a higher prevalence of material financial hardship (e.g., medical debt; 30% vs. 21.9%; aPD = 9%, 95% confidence interval [CI]: 3 to 14; aPR = 1.39, 95% CI: 1.12 to 1.72) but similar levels of psychological financial hardship compared to noncaregivers. Women caring for children were more likely to complete ACPs (42.2% vs. 30.7%; aPD = 9%, 95% CI: 3 to 16; aPR = 1.30, 95% CI: 1.08 to 1.57). Among the 723 survivors of breast, endometrial, and ovarian cancer, the prevalence of genetic testing was higher among women caring for children (89%) than noncaregivers (81%); this difference was not statistically significant. Conclusion: Women caring for children at diagnosis may be at elevated risk for adverse financial outcomes and may benefit from additional financial navigation support. Childcare responsibilities may further complicate health decision-making for AYAs diagnosed with cancer.

Expanding the Catalog of Patient and Caregiver Out-of-Pocket Costs: A Systematic Literature Review

Out-of-pocket (OOP) health care expenditures in the United States have increased significantly in the past 5 decades. Most research on OOP costs focuses on expenditures related to insurance and cost-sharing payments or on costs related to specific conditions or settings, and does not capture the full picture of the financial burden on patients and unpaid caregivers. The aim for this systematic literature review was to identify and categorize the multitude of OOP costs to patients and unpaid caregivers, aid in the development of a more comprehensive catalog of OOP costs, and highlight potential gaps in the literature. The authors found that OOP costs are multifarious and underestimated. Across 817 included articles, the authors identified 31 subcategories of OOP costs related to direct medical (eg, insurance premiums), direct nonmedical (eg, transportation), and indirect spending (eg, absenteeism). In addition, 42% of articles studied an expenditure that the authors did not label as "OOP." A holistic and comprehensive catalog of OOP costs can inform future research, interventions, and policies related to financial barriers to health care in the United States to ensure the full range of costs for patients and unpaid caregivers are acknowledged and addressed.

A Financial Toxicity Screening and Care Coordination Quality Improvement Program in a Gynecology Oncology Urban Practice

Background

Educating a multidisciplinary team on financial toxicity (FT) risk, screening, and care coordination is an approach to addressing gaps in care among newly diagnosed patients with stage III or IV cancer.

Objective

The goal of this quality improvement project (QIP) was to supply an education program for the multidisciplinary team providing insights for the following objectives: (1) Increase the rate of FT screening where there was no baseline screening, (2) Increase referrals for resource care coordination among patients experiencing FT, and (3) Evaluate the relationship between FT and selected demographic identifiers during the 8-week project.

Methods

The Plan-Do-Study-Act (PDSA) model was adopted for learning and leading the change during the QIP, focusing on the COmprehensive Score for financial Toxicity (COST) and resource care coordination for newly diagnosed participants with stage III or IV gynecologic cancer.

Results

Of the 42 (80.75%) participants consenting to the QIP, 61.90% had COST scores below 23, with 100% (26) of the participants receiving referrals for resource care coordination. On average, 6.50 patients enter the practice for care, with 50% (3.25) reporting FT. At this rate, 162.50 patients were experiencing FT in a 50-week year and were not receiving resource care coordination. However, because some patients did not consent to the QIP, the average FT (Yes) count could potentially be between 199.50 to 225.00 patients in a 50-week year, leading to a potential 62.50 with FT (or 28% of 225.00) not receiving referrals. Age was the main driver for FT COST Score in this QIP. Many variables were unobserved in this QIP and could impact the FT COST Score. However, separate modeling reveals that age alone explains approximately 15% of FT COST scores' observed changes. Controlling for more variables may refine the model, but it seems unlikely by the data analysis that age would disappear as a driver of change in the FT COST score.

Conclusion

Developing a multidisciplinary education program focusing on a structured QIP-PDSA plan can be an example of standardizing an FT screening and care coordination program. The QIP team successfully incorporated a PDSA model roadmap screening program to identify the participants experiencing FT and promptly referred 100% for resource care coordination.

Factors Associated with Delaying and Forgoing Care Due to Cost among Long-term, Appalachian Cancer Survivors in Rural North Carolina

Background

Little research exists on delayed and forgone health and mental health care due to cost among rural cancer survivors.

Methods

We surveyed survivors in 7 primarily rural, Appalachian counties February to May 2020. Univariable analyses examined the distribution and prevalence of delayed/forgone care due to cost in the past year by independent variables. Chi-square or Fisher's tests examined bivariable differences. Logistic regressions assessed the odds of delayed/forgone care due to cost.

Results

Respondents (n=428), aged 68.6 years on average (SD: 12.0), were 96.3% non-Hispanic white and 49.8% female; 25.0% reported delayed/forgone care due to cost. The response rate was 18.5%. The proportion of delayed/forgone care for those aged 18-64 years was 46.7% and 15.0% for those aged 65+ years (P<0.0001). Females aged 65+ years (OR: 2.00; CI: 1.02-3.93) had double the odds of delayed/forgone care due to cost compared to males aged 65+ years.

Conclusion

About one in four rural cancer survivors reported delayed/forgone care due to cost, with rates approaching 50% in survivors aged <65 years.

Impact

Clinical implications indicate the need to: 1) ask about the impact of care costs, and 2) provide supportive services to mitigate effects of treatment costs, particularly for younger and female survivors.

The personal financial burden associated with idiopathic inflammatory myopathies

The economic burden of idiopathic inflammatory myopathies (IIMs) within the US is underexplored. We hypothesized that IIMs patients experience considerable personal financial burden due to risks of multi-specialist visits, chronic long-term care, costs associated with disability, medical treatment, and overall high spending costs within the US healthcare system. We surveyed members of Myositis Support and Understanding (MSU) (response rate 4.7 %), and of the 470 survey participants that self-reported with diagnoses of IIMs, we assessed financial burden using two validated measures: (1) Financial Worry Score, and (2) Financial Burden Composite Score (FBCS). We determined factors associated with increased FBCS using logistic and Poisson regression respectively. High financial worry was endorsed by 202 participants (43 %) and the average FBCS ± SD was 1.8 ± 1.9. The odds of financial worry among participants with Medicaid is 3.016 times the odds of financial worry among participants without Medicaid (p = 0.011), and the odds of financial worry among participants with private high-deductible insurance is 3.216 times the odds of financial worry among participants who do not have private high-deductible insurance (p =< 0.001). Given the link between personal financial burden and potential effects on patient outcomes, it is essential for physicians to consider patient financial health when determining management or treatment courses. Identifying specific risk factors that can further exacerbate personal financial burden can help physicians identify vulnerable patients to reduce financial hardship.

Financial Toxicity Monitoring in a Randomized Controlled Trial of Patient-Reported Outcomes During Cancer Treatment (Alliance AFT-39)

PURPOSE

Financial toxicity (FT) affects 20% of cancer survivors and is associated with poor clinical outcomes. No large-scale programs have been implemented to mitigate FT. We evaluated the effect of monthly FT screening as part of a larger patient-reported outcomes (PROs) digital monitoring intervention.

METHODS

PRO-TECT (AFT-39) is a cluster-randomized trial of patients undergoing systemic therapy for metastatic cancer. Practices were randomly assigned 1:1 to digital symptom monitoring (PRO practices) or usual care (control practices). Digital monitoring consisted of between-visit online or automated telephone patient surveys about symptoms, functioning, and FT (single-item screening question from Functional Assessment of Chronic Illness Therapy-COmprehensive Score for financial Toxicity) for up to 1 year, with automated alerts sent to practice nurses for concerning survey scores. Clinical team actions in response to alerts were not mandated. The primary outcome of this planned secondary analysis was development or worsening of financial difficulties, assessed via the European Organisation for Research and Treatment of Cancer QLQ-C30 financial difficulties measure, at any time compared with baseline. A randomly selected subset of patients and nurses were interviewed about their experiences with the intervention.

RESULTS

One thousand one hundred ninety-one patients were enrolled (593 PRO; 598 control) at 52 US community oncology practices. Overall, 30.2% of patients treated at practices that received the FT screening intervention developed, or experienced worsening of, financial difficulties, compared with 39.0% treated at control practices (P = .004). Patients and nurses interviewed stated that FT screening identified patients for financial counseling who otherwise would be reluctant to seek, or unaware of the availability of, assistance.

CONCLUSION

In this report of a secondary outcome from a randomized clinical trial, FT screening as part of routine digital patient monitoring with PROs reduced the development, or worsening, of financial difficulties among patients undergoing systemic cancer therapy.

Relationships Among Health Insurance Literacy, Financial Toxicity, and Sociodemographic Factors in Patients With Cancer

PURPOSE

The objective of the study was to describe the prevalence of health insurance literacy (HIL) and investigate how patient-reported outcome measures assessing HIL are related to financial toxicity in patients with cancer.

METHODS

We assessed HIL and financial toxicity in 404 patients enrolled between December 2019 and January 2021 at two medical centers in the United States. We conducted exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to explore and test the relationships among the factors and items. We fit structural equation models (SEMs) to find the relationships among the factors and sociodemographic/clinical characteristics.

RESULTS

The EFA revealed items loaded on four factors: knowledge about health insurance, confidence related to HIL (HIL confidence), information-seeking behavior related to health insurance, and financial toxicity. The four-factor CFA model had good fit statistics (comparative fit index, 0.960; Tucker-Lewis index, 0.958; root mean square error of approximation, 0.046; and standardized root mean square residual, 0.086). In SEM, income, education level, and race positively predicted knowledge about health insurance. Knowledge about health insurance and number of total lines of cancer treatment was positively associated with HIL confidence. Higher income, older age, and HIL confidence were associated with less financial toxicity. Higher levels of financial toxicity, HIL confidence, and knowledge were associated with greater information-seeking behavior.

CONCLUSION

Our findings showed how different aspects of HIL are related to financial toxicity even after adjustment for sociodemographic and clinical characteristics. Future studies should investigate the longitudinal relationships among these factors to help develop interventions to mitigate financial toxicity.

The association between material-psychological-behavioral framework of financial hardship and markers of inflammation: a cross-sectional study of the Midlife in the United States (MIDUS) Refresher cohort

BACKGROUND

Measures of financial hardship have been suggested to supplement traditional indicators of socioeconomic status (SES) to elucidate household economic well-being. This study formally tested the construct validity of financial hardship and examined its association with markers of inflammation.

METHODS

This study utilized data from the Midlife Development in the United States Refresher Study (MIDUS-R; Age = 23-76, 53.7% female, 71% white). Participants were divided into exploratory factor analysis (EFA; completed SAQs only; N = 2,243) and confirmatory factor analysis sample (CFA; completed SAQs and biomarker assessment; N = 863). Analysis was divided into three steps. First, exploratory factor analysis (EFA) is used to examine if the three-domain factor (material, psychological, and behavioral) is the best fitting model for financial hardship measures. Second, we conducted CFA to test the hypothesized three-factor measurement model of financial hardship. Third, we tested the association between domains and the general latent factor of financial hardship and inflammation (interleukin 6/IL6, c-reactive protein/CRP, and fibrinogen).

RESULTS

Results from EFA supported the three-domain model of financial hardship. The hypothesized three-domain measurement model fits well in a different sample within MIDUS-R. In the models adjusted for age and sex, higher material hardship was associated with elevated IL6, CRP, and fibrinogen, while higher behavioral hardship was associated with higher CRP. The association between the material domain and IL6 remained significant after adding body mass index, education, and race as additional covariates. The second-order financial hardship measurement model was associated with IL6, CRP, and fibrinogen, adjusted for age, sex, BMI, education, and race.

CONCLUSION

Explicating the socioeconomic environment to include indicators of financial hardship can help researchers better understand the pathway between SES and the inflammation process, which may help elucidate pathways between SES and age-related chronic diseases associated with inflammation.

Veterans Health Administration Healthcare Coverage and Medical Financial Hardship in Low-Income Veterans

INTRODUCTION

The Veterans Health Administration (VA) provides low- to no-cost care to enrolled veterans with low incomes. This study assessed the associations between VA coverage and medical financial hardship among U.S. veterans with low incomes.

METHODS

Using 2015-2018 National Health Interview Survey data, veterans aged ≥18 years with incomes <200% of the Federal Poverty Level were identified (crude n=2,468, weighted n=3,872,252). Four types of medical financial hardship were assessed: objective, and subjective material, psychologic, and behavioral medical financial hardship. Survey-weighted proportions of veterans with medical financial hardship were calculated, and adjusted probabilities of medical financial hardship that accounted for Veteran characteristics, year-fixed effects, and survey sampling design were estimated. Analyses were conducted from August through December 2022.

RESULTS

Overall, 34.5% of veterans with low incomes had VA coverage. Among veterans without VA coverage, 38.7% had Medicare insurance, 18.2% had Medicaid insurance, 16.5% had private insurance, 13.5% had other public insurance, and 13.1% were uninsured. In adjusted analyses, veterans with VA coverage had lower probabilities of objective (-8.13 percentage point, p=0.008), subjective material (-6.55 percentage point, p=0.034), subjective psychologic (-10.33 percentage point, p=0.003), and subjective behavioral (-6.72 percentage point, p=0.031) medical financial hardship than veterans with Medicare and no VA coverage.

CONCLUSIONS

VA coverage was associated with protection against four types of medical financial hardship among veterans with low incomes, yet many are not enrolled. Research is needed to understand reasons these veterans lack VA coverage and to identify strategies to address medical financial hardship.

Financial toxicity and skin cancer care in the US: population-based survey from 2011 to 2018

This cross-sectional study aimed to examine financial toxicity among people with skin cancer using pooled National Health Interview Survey data from adults in 2011-2018. Material, behavioral, and psychological markers of financial toxicity were compared by lifetime skin cancer history (any melanoma, any skin cancer beside melanoma, and no skin cancer) using multivariable logistic regression models. Of 257,652 total participants, 1874 (0.73%) had known melanoma and 7073 (2.75%) had any skin cancer beside melanoma. History of skin cancers was not independently associated with increased markers of financial toxicity after adjustment for sociodemographic and medical co-morbidities.

The Association of Childbirth with Medical Debt in the USA, 2019-2020

BACKGROUND

Medical debt affects one in five adults in the USA and may disproportionately burden postpartum women due to pregnancy-related medical costs.

OBJECTIVE

To evaluate the association between childbirth and medical debt, and the correlates of medical debt among postpartum women, in the USA.

DESIGN

Cross-sectional.

PARTICIPANTS

We analyzed female "sample adults" 18-49 years old in the 2019-2020 National Health Interview Survey, a nationally representative household survey.

MAIN MEASURES

Our primary exposure was whether the subject gave birth in the past year. We had two family-level debt outcomes: problems paying medical bills and inability to pay medical bills. We examined the association between live birth and medical debt outcomes, unadjusted and adjusted for potential confounders in multivariable logistic regressions. Among postpartum women, we also examined the association between medical debt with maternal asthma, hypertension, and gestational diabetes and several sociodemographic factors.

KEY RESULTS

Our sample included n = 12,163 women, n = 645 with a live birth in the past year. Postpartum women were younger, more likely to have Medicaid, and lived in larger families than those not postpartum. 19.8% of postpartum women faced difficulty with medical bills versus 15.1% who were not; in multivariable regression, postpartum women had 48% higher adjusted odds of medical debt problems (95% CI 1.13, 1.92). Results were similar when examining inability to pay medical bills, and similar differences were seen for privately insured women. Among postpartum women, those with lower incomes and with asthma or gestational diabetes, but not hypertension, had significantly higher adjusted odds of medical debt problems.

CONCLUSIONS

Postpartum women experience higher levels of medical debt than other women; poorer women and those with common chronic diseases may have an even higher burden. Policies to expand and improve health coverage for this population are needed to improve maternal health and the welfare of young families.

Expanding research on the impact of financial hardship on emotional well-being: guidance of diverse stakeholders to the Emotional Well-Being and Economic Burden of Disease (EMOT-ECON) Research Network

The Emotional Well-Being and Economic Burden (EMOT-ECON) Research Network is one of six research networks funded by the National Institutes of Health (NIH) to advance research about emotional well-being (EWB), and the only one that focuses on addressing how economic burden due to disease or illness affects EWB. The network convened researchers, patients, patient advocates, health care providers and other stakeholders from across the US to discuss the significance of addressing the impact of the economic burden of disease on EWB, the complexity of this prevalent problem for patients and families, and the research gaps that still need to be studied to ultimately develop strategies to reduce the impact of economic burden of disease on EWB and health. Participants identified some important future areas of research as those investigating: (i) prevalent and relevant emotions for patients experiencing economic burden of disease and financial hardship, and how their broader outlook on life is impacted; (ii) constructs and contexts that influence whether the economic burden is stressful; (iii) strategies to deal and cope and their positive or negative effects on EWB and health; and (iv) multi-level and multi-stakeholder interventions to address economic factors (e.g., costs, ability to pay), administrative burdens, education and training, and especially patients' emotional as well as financial status.

Financial well-being as a mediator of the relationship between multimorbidity and health-related quality of life in people with cancer

BACKGROUND

It is unknown whether financial well-being mediates the impact of multimorbidity on the health-related quality of life (HRQoL) of cancer patients.

METHODS

Participants were recruited from three outpatient oncology clinics of Hong Kong public hospitals. Multimorbidity was assessed using the Charlson Comorbidity Index. Financial well-being, the mediator of the association between multimorbidity and HRQoL outcomes, was assessed using the Comprehensive Score for Financial Toxicity Functional Assessment of Chronic Illness Therapy. The HRQoL outcomes were assessed using the Functional Assessment of Cancer Therapy - General (FACT-G) and its four sub-dimensions. Mediation analyses were conducted using SPSS PROCESS v4.1.

RESULTS

Six-hundred and forty cancer patients participated in the study. Multimorbidity had a direct effect on FACT-G scores independent of financial well-being (β for path c' = -0.752, p < 0.001). In addition, multimorbidity had an indirect effect on FACT-G scores through its effect on financial well-being (β for path a = -0.517, p < 0.05; β for path b = 0.785, p < 0.001). Even after adjustments were made for the covariates, the indirect effect of multimorbidity on FACT-G via financial well-being remained significant, accounting for 38.0% of the overall effect, indicating partial mediation. Although there were no statistically significant associations between multimorbidity, social well-being, and emotional well-being, the indirect effects of multimorbidity on physical and functional well-being through financial well-being remained significant.

CONCLUSIONS

Poor financial well-being attributable to multimorbidity partially mediates the direct impact of chronic conditions on HRQoL in Chinese cancer patients, particularly their physical and functional well-being.

A nationwide cross-sectional study on the association of patient-level factors with financial anxiety in the context of chronic medical conditions

Patient-level characteristics associated with the prevalence and severity of financial anxiety have yet to be described. We conducted a cross-sectional analysis of survey data assessing financial anxiety in patients with chronic medical conditions in December 2020. 1771 patients (42.6% response rate) participated in the survey. Younger age (19-35 age compared to ≥ 75 age) (β, 5.86; 95% CI 2.10-9.63), male sex (β, - 1.9; 95% CI - 3.1 to - 0.73), Hispanic/Latino race/ethnicity (compared with White patients) (β, 2.55; 95% CI 0.39-4.71), household size ≥ 4 (compare with single household) (β, 4.54; 95% CI 2.44-6.64), household income of ≥ $96,000-$119,999 (compared with ≤ $23,999) (β, - 3.2; 95% CI - 6.3 to 0.04), single marital status (compared with married) (β, 2.18; 95% CI 0.65-3.71), unemployment (β, 2.07; 95% CI 0.39-3.74), high-school education (compared with advanced degrees) (β, 3.10; 95% CI 1.32-4.89), lack of insurance coverage (compared with private insurance) (β, 6.05; 95% CI 2.66-9.45), more comorbidities (≥ 3 comorbidities compared to none) (β, 2.95; 95% CI 1.00-4.90) were all independently associated with financial anxiety. Patients who are young, female, unmarried, and representing vulnerable sub-populations are at elevated risk for financial anxiety.

Financial stress among skin cancer patients: a cross-sectional review of the 2013-2018 National Health Interview Survey

Financial stress among skin cancer patients may limit treatment efficacy by forcing the postponement of care or decreasing adherence to dermatologist recommendations. Limited information is available quantifying the anxiety experienced by skin cancer patients from both healthcare and non-healthcare factors. Therefore, the present study sought to perform a retrospective cross-sectional review of the 2013-2018 cycles of the National Health Interview Survey (NHIS) to determine the prevalence, at-risk groups, and predictive factors of skin cancer patient financial stress. Survey responses estimated that 11.45% (95% Cl 10.02-12.88%) of skin cancer patients experience problems paying medical bills, 20.34% (95% Cl 18.97-21.71%) of patients worry about the medical costs, 13.73% (95% Cl 12.55-14.91%) of patients worry about housing costs, and 37.48% (95% Cl 35.83-39.14%) of patients worry about money for retirement. Focusing on at-risk groups, black patients, uninsured patients, and patients with low incomes (< 200% poverty level) consistently experienced high rates of financial stress for each of the four measures. Multivariable logistic regression revealed low education, lack of insurance, and low income to be predictive of financial stress. These findings suggest that a considerable proportion of skin cancer patients experience financial stress related to both healthcare and non-healthcare factors. Where possible, the additional intricacy of treating patients at risk of high financial stress may be considered to optimize patient experience and outcomes.

Cost burden among the CF population in the United States: A focus on debt, food insecurity, housing and health services

BACKGROUND

Advancements in the cystic fibrosis (CF) field have resulted in longer lifespans for individuals with CF. This has led to more responsibility for complex care regimens, frequent health care, and prescription medication utilization that are costly and may not be fully covered by health insurance. There are outstanding questions about unmet medical needs among the U.S. population with CF and how the financial burden of CF is associated with debt, housing instability, and food insecurity.

METHODS

Researchers developed the CF Health Insurance Survey (CF HIS) to survey a convenience sample of people living with CF in the U.S. The sample was weighted to reflect the parameters of the 2019 Cystic Fibrosis Foundation Patient Registry Annual Data Report, and chi-square tests and multiple logistic regression models were conducted.

RESULTS

A total of 1,856 CF patients in the U.S. were included in the study. Of these, 64% faced a financial burden: 55% of respondents faced debt issues, 26% housing issues, and 33% food insecurity issues. A third reported at least one unmet medical need: 24% faced unmet prescription needs, 12% delayed or shortened a hospitalization, and 10% delayed or skipped a care center visit as a result of the cost of care.

CONCLUSIONS

People with CF in the U.S. experience high financial burden, which is associated with unmet medical needs. Income is the biggest risk factor for financial burden for people with CF, with people dually covered by Medicare and Medicaid particularly at risk.

Financial Toxicity and Its Association With Health-Related Quality of Life Among Partners of Colorectal Cancer Survivors

Importance

Partners of colorectal cancer (CRC) survivors play a critical role in diagnosis, treatment, and survivorship. While financial toxicity (FT) is well documented among patients with CRC, little is known about long-term FT and its association with health-related quality of life (HRQoL) among their partners.

Objective

To understand long-term FT and its association with HRQoL among partners of CRC survivors.

Design, Setting, and Participants

This survey study incorporating a mixed-methods design consisted of a mailed dyadic survey with closed- and open-ended responses. In 2019 and 2020, we surveyed survivors who were 1 to 5 years from a stage III CRC diagnosis and included a separate survey for their partners. Patients were recruited from a rural community oncology practice in Montana, an academic cancer center in Michigan, and the Georgia Cancer Registry. Data analysis was performed from February 2022 to January 2023.

Exposures

Three components of FT, including financial burden, debt, and financial worry.

Main Outcomes and Measures

Financial burden was assessed with the Personal Financial Burden scale, whereas debt and financial worry were each assessed with a single survey item. We measured HRQoL using the PROMIS-29+2 Profile, version 2.1. We used multivariable regression analysis to assess associations of FT with individual domains of HRQoL. We used thematic analysis to explore partner perspectives on FT, and we merged quantitative and qualitative findings to explain the association between FT and HRQoL.

Results

Of the 986 patients eligible for this study, 501 (50.8%) returned surveys. A total of 428 patients (85.4%) reported having a partner, and 311 partners (72.6%) returned surveys. Four partner surveys were returned without a corresponding patient survey, resulting in a total of 307 patient-partner dyads for this analysis. Among the 307 partners, 166 (56.1%) were aged younger than 65 years (mean [SD] age, 63.7 [11.1] years), 189 (62.6%) were women, and 263 (85.7%) were White. Most partners (209 [68.1%]) reported adverse financial outcomes. High financial burden was associated with worse HRQoL in the pain interference domain (mean [SE] score, -0.08 [0.04]; P = .03). Debt was associated with worse HRQoL in the sleep disturbance domain (-0.32 [0.15]; P = .03). High financial worry was associated with worse HRQoL in the social functioning (mean [SE] score, -0.37 [0.13]; P = .005), fatigue (-0.33 [0.15]; P = .03), and pain interference (-0.33 [0.14]; P = .02) domains. Qualitative findings revealed that in addition to systems-level factors, individual-level behavioral factors were associated with partner financial outcomes and HRQoL.

Conclusions and Relevance

This survey study found that partners of CRC survivors experienced long-term FT that was associated with worse HRQoL. Multilevel interventions for both patients and partners are needed to address factors at individual and systemic levels and incorporate behavioral approaches.

Chronic Illness in Children and Foregone Care Among Household Adults in the United States: A National Study

BACKGROUND

Childhood chronic illness imposes financial burdens that may affect the entire family.

OBJECTIVE

The aim was to assess whether adults living with children with 2 childhood chronic illnesses-asthma and diabetes-are more likely to forego their own medical care, and experience financial strain, relative to those living with children without these illnesses.

RESEARCH DESIGN

2009-2018 National Health Interview Survey.

SUBJECTS

Adult-child dyads, consisting of one randomly sampled child and adult in each family.

MEASURES

The main exposure was a diagnosis of asthma or diabetes in the child. The outcomes were delayed/foregone medical care for the adult as well as family financial strain; the authors evaluated their association with the child's illness using multivariable logistic regressions adjusted for potential confounders.

RESULTS

The authors identified 93,264 adult-child dyads; 8499 included a child with asthma, and 179 a child with diabetes. Families with children with either illness had more medical bill problems, food insecurity, and medical expenses. Adults living with children with each illness reported more health care access problems. For instance, relative to other adults, those living with a child with asthma were more likely to forego/delay care (14.7% vs. 10.2%, adjusted odds ratio: 1.27; 95% CI: 1.16-1.39) and were more likely to forego medications, specialist, mental health, and dental care. Adults living with a child with diabetes were also more likely to forego/delay care (adjusted odds ratio: 1.76; 95% CI: 1.18-2.64).

CONCLUSIONS

Adults living with children with chronic illnesses may sacrifice their own care because of cost concerns. Reducing out-of-pocket health care costs, improving health coverage, and expanding social supports for families with children with chronic conditions might mitigate such impacts.

Cost-Related Access Barriers, Medical Debt, and Dissatisfaction with Care Among Privately Insured Americans

BACKGROUND

Understanding experiences with private important to improving the quality of health care coverage.

OBJECTIVE

To examine the association of health with cost-related access barriers, medical debt, and dissatisfaction with care among privately insured Americans.

DESIGN

We classified Americans with private insurance by self-reported health status into five groups (excellent, very good, good, fair, and poor health). We examined self-reported difficulty seeing a doctor due to costs, not taking medications due to costs, medical debt, and dissatisfaction with care among individuals with differing health status. We used logistic regression to examine the association of health status with individuals' experiences after accounting for baseline characteristics. The analysis was repeated among individuals with different forms of private insurance. Odds ratios were converted to risk ratios to improve ease of interpretation of the results.

SETTING

Behavioral Risk Factor Surveillance System of Americans in 17 states RESULTS: The sample included 82,494 US adults with private insurance. Following adjustment, compared to individuals with excellent health those in very good health, good health, fair health, and poor health reported increasingly higher risks of difficulty seeing a doctor due to costs with risk ratios of 1.02 (95% CI 1.01, 1.03), 1.07 (95% CI 1.06, 1.08), 1.18 (95% CI 1.17, 1.20), and 1.29 (95% CI 1.27, 1.31), respectively. Compared to individuals with excellent health, those in very good health, good health, fair health, and poor health reported increasingly higher risks of not taking medication due to costs, outstanding medical debt, and dissatisfaction with care. Similar relationships were seen across individually purchased and employer-sponsored insurance.

CONCLUSION

Cost-related access barriers, medical debt, and dissatisfaction with care were common among individuals with private insurance and most pronounced among those with fair and poor health who likely need and use their health insurance the most.

Financial Hardship and its Associations with Perceived Sleep Quality in Participants with Type 2 Diabetes and Obstructive Sleep Apnea

OBJECTIVES

The purpose of this study was to explore social determinants of health (SDoH), and disease severity as predictors of sleep quality in persons with both Obstructive Sleep Apnea (OSA) and type 2 diabetes (T2D).

METHODS

Disease severity was measured by Apnea-Hypopnea Index [(AHI) ≥ 5] and HbA1c for glycemic control. SDoH included subjective and objective financial hardship, race, sex, marital status, education, and age. Sleep quality was measured by Pittsburgh Sleep Quality Index (PSQI).

RESULTS

The sample (N = 209) was middle-aged (57.6 ± 10.0); 66% White and 34% African American; and 54% men and 46% women. Participants carried a high burden of disease (mean AHI = 20.7 ± 18.1, mean HbA1c = 7.9% ± 1.7%). Disease severity was not significantly associated with sleep quality (all p >.05). Worse sleep quality was associated with both worse subjective (b = -1.54, p = .015) and objective (b = 2.58, p <.001) financial hardship. Characteristics significantly associated with both subjective and objective financial hardship included being African American, female, ≤ 2 years post high school, and of younger ages (all p < .01).Discussion: Financial hardship is a more important predictor of sleep quality than disease severity, age, sex, race, marital status, and educational attainment, in patients with OSA and T2D.

Cost of Cancer in Adolescents and Young Adults in the United States: Results of the 2021 Report by Deloitte Access Economics, Commissioned by Teen Cancer America

PURPOSE

The purpose of this report, commissioned by Teen Cancer America and performed by Deloitte Access Economics in 2021, was to estimate the total costs incurred by adolescent and young adults (AYAs) after cancer diagnosis in the United States (US) over their life course.

METHODS

The incidence of cancer in 2019 among AYAs age 15-39 years was estimated from the US Cancer Statistics Public Use Database, and relative survival was projected from the Surveillance, Epidemiology, and End Results Program. Cost domains included health system, productivity, and well-being costs. Components were estimated with published literature and pooled data from the Medical Expenditure Panel Survey from 2008 to 2012 and inflated to 2019 dollars.

RESULTS

The economic and human costs of cancer in AYAs are substantial-$23.5 billion overall, corresponding to $259,324 per person over the lifetime. The majority of costs are borne by AYA cancer survivors themselves in the form of lost productivity, loss of well-being, and loss of life.

CONCLUSION

These findings underscore the need to address the burden of cancer in AYAs through targeted programs for AYAs, such as financial navigation and health insurance literacy interventions, as well as local and national policy initiatives to address access to and enhanced coverage for clinical trials participation, fertility services, and survivorship care.

Financial Hardship in Adult Survivors of Childhood Cancer in the Era After Implementation of the Affordable Care Act: A Report From the Childhood Cancer Survivor Study

PURPOSE

To estimate the prevalence of financial hardship among adult survivors of childhood cancer compared with siblings and identify sociodemographic, cancer diagnosis, and treatment correlates of hardship among survivors in the era after implementation of the Affordable Care Act.

METHODS

A total of 3,555 long-term (≥ 5 years) survivors of childhood cancer and 956 siblings who completed a survey administered in 2017-2019 were identified from the Childhood Cancer Survivor Study. Financial hardship was measured by 21 survey items derived from US national surveys that had been previously cognitively tested and fielded. Principal component analysis (PCA) identified domains of hardship. Multiple linear regression examined the association of standardized domain scores (ie, scores divided by standard deviation) with cancer and treatment history and sociodemographic characteristics among survivors.

RESULTS

Survivors were more likely than siblings to report hardship in ≥ 1 item (63.4% v 53.7%, P < .001). They were more likely to report being sent to debt collection (29.9% v 22.3%), problems paying medical bills (20.7% v 12.8%), foregoing needed medical care (14.1% v 7.8%), and worry/stress about paying their rent/mortgage (33.6% v 23.2%) or having enough money to buy nutritious meals (26.8% v 15.5%); all P < .001. Survivors reported greater hardship than siblings in all three domains identified by principal component analysis: behavioral hardship (mean standardized domain score 0.51 v 0.35), material hardship/financial sacrifices (0.64 v 0.46), and psychological hardship (0.69 v 0.44), all P < .001. Sociodemographic (eg,

CONCLUSION

Survivors of childhood cancer were more likely to experience financial hardship than siblings. Correlates of hardship can inform survivorship care guidelines and intervention strategies.

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Key Words Collapse

MESH Headings

• United States
• Adult
• Humans
• Child
• Neoplasms/therapy
• Cancer Survivors
• Patient Protection and Affordable Care Act
• Financial Stress
• Cost of Illness
• Survivors
• Surveys and Questionnaires

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Grants

• U24 CA055727 NCI NIH HHS

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Affiliation(s)

Paul C. Nathan The Hospital for Sick Children, Division of Hematology/Oncology, The University of Toronto, Toronto, Ontario, Canada
I-Chan Huang St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Yan Chen University of Alberta, Edmonton, School of Public Health Alberta, Edmonton, Alberta, Canada
Tara O. Henderson University of Chicago Comer Children's Hospital, Section of Pediatric Hematology, Oncology and Stem Cell Transplantation, Chicago, IL
Elyse R. Park Massachusetts General Hospital Cancer Center, Boston, MA
Anne C. Kirchhoff Huntsman Cancer Institute, Cancer Control and Population Sciences, University of Utah, Salt Lake City, UT
Leslie L. Robison St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Kevin Krull St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Wendy Leisenring Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA
Gregory T. Armstrong St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Rena M. Conti Department of Markets, Public Policy and Law, Questrom School of Business, Boston University, Boston, MA
Yutaka Yasui St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
K. Robin Yabroff Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, GA

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Out-of-Pocket Health Care Spending at Older Ages: Do Caregiving Arrangements Matter?

Identifying the correlates of out-of-pocket (OOP) health care spending is an important step for ensuring the financial security of older adults. Whether or not someone has a family member providing assistance is one such factor that could be associated with OOP spending. If family caregivers facilitate better health, health care spending could be reduced. On the other hand, costs would be higher if family members facilitate more (or more costly) care for loved ones. This paper explores the relationship between caregiving arrangements and OOP spending using data from 5045 individuals in the 2000-2016 Health and Retirement Study with Medicare coverage and caregiving needs. We do not find a relationship between family caregiving and OOP health care costs, overall. However, among those with Medicare HMO insurance, having a family caregiver is associated with more spending than having no helper. This is mainly due to differences in spending on prescription medications.

"I wish I knew about these programs before!" A brief report exploring barriers to financial assistance reported by gynecological oncology patients

PURPOSE

Despite widespread reports of cancer-related financial hardship, hospital financial assistance programs are underutilized.

APPROACH

Rapid qualitative research.

SAMPLE

Gynecologic oncology patients with recurrent or metastatic disease, under 65 years old, and Comprehensive Score for Financial Toxicity of 26 or under.

METHODS

Semi-structured interviews to elicit (1) financial assistance awareness/knowledge, (2) barriers to accessing assistance, and (3) suggestions for improving access. We analyzed the transcripts using thematic analysis: open coding, consensus building/codebook, and identification of salient themes.

FINDINGS

We interviewed 25 patients and identified four barriers and three suggestions for improving access. Barriers: lack of awareness, perceptions of ineligibility, fear of negative consequences, and being overwhelmed. Suggestions: simplifying financial processes, providing individualized assistance, and being more proactive by intervening earlier.

CONCLUSION

Increase access by reducing stigma, misconceptions, and more proactively engaging at-risk patients.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

Patients may be too afraid or overwhelmed to ask for help. A more proactive, psychosocial approach is needed.

Financial hardship and mental health among cancer survivors during the COVID-19 pandemic: An analysis of the US COVID-19 Household Impact Survey

Purpose

Our objective was to (1) identify associated characteristics of financial hardship (FH), and (2) evaluate associations of FH with mental health symptoms among cancer survivors during the COVID-19 pandemic.

Methods

Using data from the nationally representative COVID-19 Impact Survey, we defined cancer survivors as those with a self-reported diagnosis of cancer (n = 854,7.6%). We defined FH using the following question: "Based on your current financial situation, how would you pay for an unexpected $400 expense?" Multivariable Poisson regression was used to estimate adjusted prevalence ratios (aPR) with 95% confidence intervals (95%CI) to identify associated characteristics of FH and associations of FH with mental health symptoms among cancer survivors overall and by age (18-59 years/60+ years).

Results

Forty-one percent of cancer survivors reported FH, with 58% in 18-59 and 33% in 60+ year old respondents. Compared to cancer survivors aged 60+ years, those aged 30-44 (aPR:1.74,95% CI:1.35-2.24), and 45-59 years (aPR:1.60,95% CI:1.27-1.99) were more likely to report FH. Compared to non-Hispanic(NH)-White cancer survivors, NH-Black cancer survivors had a 56% higher prevalence of FH (aPR:1.56; 95% CI: 1.23-1.97). Among 60+ years aged cancer survivors, NH-Black (aPR:1.80; 95% CI: 1.32-2.45) and NH-Asian cancer survivors (aPR:10.70,95% CI:5.6-20.7) were more likely to experience FH compared to their NH-White counterparts. FH was associated with feeling anxious (aPR:1.51,95% CI:1.11-2.05), depressed (aPR:1.66,95% CI:1.25-2.22), and hopeless (aPR:1.84,95% CI:1.38-2.44).

Conclusion

Minoritized communities, younger adults, and cancer survivors with low socioeconomic status had a higher burden of FH, which was associated with feelings of anxiety, depression, and hopelessness.

ABLE to support patient financial capacity: A qualitative analysis of cost conversations in clinical encounters

OBJECTIVE

To explore how costs of care are discussed in real clinical encounters and what humanistic elements support them.

METHODS

A qualitative thematic analysis of 41 purposively selected transcripts of video-recorded clinical encounters from trials run between 2007 and 2015. Videos were obtained from a corpus of 220 randomly selected videos from 8 practice-based randomized trials and 1 pre-post prospective study comparing care with and without shared decision making (SDM) tools.

RESULTS

Our qualitative analysis identified two major themes: the first, Space Needed for Cost Conversations, describes patients' needs regarding their financial capacity. The second, Caring Responses, describes humanistic elements that patients and clinicians can bring to clinical encounters to include good quality cost conversations.

CONCLUSION

Our findings suggest that strengthening patient-clinician human connections, focusing on imbalances between patient resources and burdens, and providing space to allow potentially unexpected cost discussions to emerge may best support high quality cost conversations and tailored care plans.

PRACTICE IMPLICATIONS

We recommend clinicians consider 4 aspects of communication, represented by the mnemonic ABLE: Ask questions, Be kind and acknowledge emotions, Listen for indirect signals and (discuss with) Every patient. Future research should evaluate the practicality of these recommendations, along with system-level improvements to support implementation of our recommendations.

Catastrophic household expenditure associated with out-of-pocket payments for dental healthcare in Spain

OBJECTIVE

To estimate the prevalence of catastrophic health expenditure due to dental healthcare (CHED) in Spain, quantify its intensity and examine the related sociodemographic household characteristics.

METHODS

Data from the Spanish Household Budget Survey, which addresses more than 20,000 households each year for the period 2008-2015 were included, and the methodology proposed by Wagstaff and van Doorslaer was followed. The prevalence (number of households that devote more than a certain threshold of their income to such payments) and intensity (amount that exceeds a certain percentage of income) were estimated. Ordered logistic regression models were estimated to analyse the sociodemographic factors associated with the prevalence of catastrophic payments.

RESULTS

The prevalence and intensity remained stable during the period under analysis. In terms of prevalence, a mean proportion of 7.36% of the population dedicated, in terms of intensity, more than 10% of their resources to dental care payments [mean: €292.75 per year (SD €2144.14)] and 2.05% dedicated more than 40% [mean: €143.02 per year (SD €1726.42)]. This represents 36.32% and 51.34% (for the thresholds of 10% and 40%) of the total catastrophic expenditure derived from out-of-pocket payments for dental healthcare in Spain.

CONCLUSION

This study shows that a significant proportion of catastrophic healthcare payments correspond to dental services. Being male, aged over 40 years, unattached (single, separated, divorced or widowed), having a low level of education, a low household income, being unemployed and living in an urban area are all associated with a greater risk of CHED. This finding highlights the need to establish policies aimed at increasing dental care coverage to mitigate related financial burdens on a large part of the Spanish population.

Association of Health Insurance Literacy With Financial Hardship in Patients With Cancer

IMPORTANCE

Patient-reported financial hardship is an increasing challenge in cancer care delivery. Health insurance literacy and its association with financial hardship in patients with cancer, especially after controlling for financial literacy, have not been well examined.

OBJECTIVE

To examine the prevalence of and factors in the association between health insurance literacy and financial literacy as well as the overall and individual domains of financial hardship and their association with health insurance literacy, both independently and when adjusted for financial literacy, in patients with cancer.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study recruited and enrolled patients from 2 separate ambulatory infusion centers at Mayo Clinic Arizona in Phoenix, Arizona, and the University of Mississippi Medical Center in Jackson, Mississippi. Adult patients aged 18 years or older were enrolled from December 2019 to February 2020 and from August to October 2020 at Mayo Clinic Arizona (n = 299) and from September 2020 through January 2021 at the University of Mississippi Medical Center (n = 105). Survey respondents received a $5 gift card.

EXPOSURES

Surveys included questions about sociodemographic characteristics, health insurance literacy and financial literacy, financial knowledge, and financial hardship and its domains (material hardship, psychological hardship, and behavioral hardship).

MAIN OUTCOMES AND MEASURES

Financial hardship was assessed using the COST-FACIT (Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy) measure and National Health Interview Survey questions to capture information about the domains of financial hardship. The Health Insurance Literacy Measure is a validated 21-item measure of a consumer's ability to select and use health insurance. Five questions from the National Financial Capability Study assessed financial literacy.

RESULTS

A total of 404 participants were enrolled in the study. Median (IQR) age of the respondents was 63 (54-71) years, and 219 were women (54%), 307 were non-Hispanic White individuals (76%), 153 (38%) had private insurance, and 289 (72%) had solid tumors. Overall financial hardship (denoted by median COST-FACIT score <27 points) was reported by 49% (95% CI, 44%-53%) of the cohort. Prevalence of financial hardship was higher using the National Health Interview Survey questions, with 68% (95% CI, 63%-72%) of respondents reporting at least 1 hardship domain (n = 276). Sixty-six percent (95% CI, 60%-69%) of respondents (n = 265) had a high level of financial literacy. The mean (SD) Health Insurance Literacy Measure score was 64.9 (13.3) points. In multivariable analyses, each 10-point increase in the Health Insurance Literacy Measure score was associated with lower odds of financial hardship (odds ratio, 0.82; 95% CI, 0.68-0.99; P = .04). However, this association was no longer significant after adjusting for financial literacy.

CONCLUSIONS AND RELEVANCE

Results of this study showed that, despite a high level of health insurance literacy and financial literacy, the prevalence of financial hardship was high. Although there were lower odds of financial hardship with increased health insurance literacy, the association was no longer significant when financial literacy was added to the model, suggesting that a high level of financial literacy may help mitigate the adverse outcome of lower health insurance literacy levels in patients with cancer.