Assessing Patient-Reported Financial Hardship in Patients With Cancer in Routine Clinical Care

Association of patient-reported financial barriers with healthcare utilization among Medicare beneficiaries with a history of cancer

PURPOSE

We examined characteristics associated with financial barriers to healthcare and the association of financial barriers with adverse healthcare events among US adult cancer survivors enrolled in Medicare.

METHODS

We used nationally representative Medicare Current Beneficiary Survey data (2011-2013, 2015-2017) to identify adults with a history of non-skin cancer. We defined financial barriers as cost-related trouble accessing and/or delayed care in the prior year. Using propensity-weighted multivariable logistic regression, we examined associations between financial barriers and adverse healthcare events (any ED visits, any inpatient hospitalizations).

RESULTS

Overall, 11.0% of adult Medicare beneficiaries with a history of cancer reported financial barriers in the prior year, with higher burden among beneficiaries < 65 years of age vs. ≥ 65 (32.5% vs. 8.2%, p < 0.0001) and with annual income < $25,000 vs. ≥ $25,000 (18.1% vs. 6.9%, p < 0.0001). In bivariate models, financial barriers were associated with a 7.8 percentage point (95% CI: 1.5-14.0) increase in the probability of ED visits. In propensity-weighted models, this association was not statistically significant. The association between financial barriers and hospitalizations was not significant in the overall population; however, financial barriers were associated with a decreased probability of hospitalization among Black/African American beneficiaries.

CONCLUSIONS

Despite Medicare coverage, beneficiaries with a history of cancer are at risk for experiencing financial barriers to healthcare. In the overall population, financial barriers were not associated with ED visits or hospitalizations.

IMPLICATIONS FOR CANCER SURVIVORS

Policies limiting Medicare patient out-of-pocket spending and care models addressing health-related social needs are needed to reduce financial barriers experienced.

Cost-of-care discussions for individuals with advanced non-small cell lung cancer and melanoma: Findings from a large, population-based pilot study

BACKGROUND

Costs of cancer care can result in patient financial hardship; many professional organizations recommend provider discussions about treatment costs as part of high-quality care. In this pilot study, the authors examined patient-provider cost discussions documented in the medical records of individuals who were diagnosed with advanced non-small cell lung cancer (NSCLC) and melanoma-cancers with recently approved, high-cost treatment options.

METHODS

Individuals who were newly diagnosed in 2017-2018 with stage III/IV NSCLC (n = 1767) and in 2018 with stage III/IV melanoma (n = 689) from 12 Surveillance, Epidemiology, and End Results regions were randomly selected for the National Cancer Institute Patterns of Care Study. Documentation of cost discussions was abstracted from the medical record. The authors examined patient, treatment, and hospital factors associated with cost discussions in multivariable logistic regression analyses.

RESULTS

Cost discussions were documented in the medical records of 20.3% of patients with NSCLC and in 24.0% of those with melanoma. In adjusted analyses, privately insured (vs. publicly insured) patients were less likely to have documented cost discussions (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.37-0.80). Patients who did not receive systemic therapy or did not receive any cancer-directed treatment were less likely to have documented cost discussions than those who did receive systemic therapy (OR, 0.39 [95% CI, 0.19-0.81] and 0.46 [95% CI, 0.30-0.70], respectively), as were patients who were treated at hospitals without residency programs (OR, 0.64; 95% CI, 0.42-0.98).

CONCLUSIONS

Cost discussions were infrequently documented in the medical records of patients who were diagnosed with advanced NSCLC and melanoma, which may hinder identifying patient needs and tracking outcomes of associated referrals. Efforts to increase cost-of-care discussions and relevant referrals, as well as their documentation, are warranted.

Health-related social needs, medical financial hardship, and mortality risk among cancer survivors

BACKGROUND

Cancer survivors may face challenges affording food, housing, and other living necessities, which are known as health-related social needs (HRSNs). However, little is known about the associations of HRSNs and mortality risk among adult cancer survivors.

METHODS

Adult cancer survivors were identified from the 2013-2018 National Health Interview Survey (NHIS) and linked with the NHIS Mortality File with vital status through December 31, 2019. HRSNs, measured by food insecurity, and nonmedical financial worries (e.g., housing costs), was categorized as severe, moderate, and minor/none. Medical financial hardship, including material, psychological, and behavioral domains, was categorized as 2-3, 1, or 0 domains. Using age as the time scale, the associations of HRSNs and medical financial hardship and mortality risk were assessed with weighted adjusted Cox proportional hazards models.

RESULTS

Among cancer survivors 18-64 years old (n = 5855), 25.5% and 18.3% reported moderate and severe levels of HRSNs, respectively; among survivors 65-79 years old (n = 5918), 15.6% and 6.6% reported moderate and severe levels of HRSNs, respectively. Among cancer survivors 18-64 years old, severe HRSNs was associated with increased mortality risk (hazards ratio [HR], 2.00; 95% confidence interval [CI], 1.36-2.93, p < .001; reference = minor/none) in adjusted analyses. Among cancer survivors 65-79 years old, 2-3 domains of medical financial hardship was associated with increased mortality risk (HR, 1.58; 95% CI, 1.13-2.20, p = .007; reference = 0 domain).

CONCLUSIONS

HSRNs and financial hardship are associated with increased mortality risk among cancer survivors; comprehensive assessment of HRSN and financial hardship connecting patients with relevant services can inform efforts to mitigate adverse consequences of cancer.

Inpatient prevalence and factors associated with Merkel Cell Carcinoma inpatient hospitalization in the United States

Merkel Cell Carcinoma is a rare and aggressive cutaneous carcinoma with a propensity for metastasis and death. Our study describes the prevalence, sociodemographics and inpatient mortality of Merkel Cell Carcinoma related hospitalizations in the United States from 2011 to 2020. We conducted an observational study using the Nationwide Inpatient Sample database, which captures a 20% sample of all hospitalizations in the United States. We utilized the International Classification of Disease Clinical Modification codes from the ninth and tenth revision to identify Merkel Cell Carcinoma and demographic factors. There was a total of 28,809 cases of Merkel Cell Carcinoma in the United States from 2011 to 2020. Merkel Cell Carcinoma was associated with white race (11.4 per 100,000) and disposition of death (26.8 per 100,000). It was most prevalent in the highest quartile income (12.5 per 100,000) and Medicare as primary payer (13.0 per 100,000). Hospitalization was lowest in nonwhite races, particularly NH-Blacks and NH-Others. Inpatient mortality was significantly associated with NH-Others (odds ratio 2.18, 95% confidence interval = 1.38-3.45) and self-pay patients (odds ratio = 2.93, 95% confidence interval 1.84-4.67).This study contributes to reported socio-demographic factors related to Merkel Cell Carcinomas and brings awareness to factors associated with increased hospitalization and inpatient mortality.

Cancer diagnosis and treatment in working-age adults: Implications for employment, health insurance coverage, and financial hardship in the United States

The rising costs of cancer care and subsequent medical financial hardship for cancer survivors and families are well documented in the United States. Less attention has been paid to employment disruptions and loss of household income after a cancer diagnosis and during treatment, potentially resulting in lasting financial hardship, particularly for working-age adults not yet age-eligible for Medicare coverage and their families. In this article, the authors use a composite patient case to illustrate the adverse consequences of cancer diagnosis and treatment for employment, health insurance coverage, household income, and other aspects of financial hardship. They summarize existing research and provide nationally representative estimates of multiple aspects of financial hardship and health insurance coverage, benefit design, and employee benefits, such as paid sick leave, among working-age adults with a history of cancer and compare them with estimates among working-age adults without a history of cancer from the most recently available years of the National Health Interview Survey (2019-2021). Then, the authors identify opportunities for addressing employment and health insurance coverage challenges at multiple levels, including federal, state, and local policies; employers; cancer care delivery organizations; and nonprofit organizations. These efforts, when informed by research to identify best practices, can potentially help mitigate the financial hardship associated with cancer.

Association of Major Adverse Financial Events and Later-Stage Cancer Diagnosis in the United States

PURPOSE

This study assessed the prevalence of specific major adverse financial events (AFEs)-bankruptcies, liens, and evictions-before a cancer diagnosis and their association with later-stage cancer at diagnosis.

METHODS

Patients age 20-69 years diagnosed with cancer during 2014-2015 were identified from the Seattle, Louisiana, and Georgia SEER population-based cancer registries. Registry data were linked with LexisNexis consumer data to identify patients with a history of court-documented AFEs before cancer diagnosis. The association of AFEs and later-stage cancer diagnoses (stages III/IV) was assessed using separate sex-specific multivariable logistic regression.

RESULTS

Among 101,649 patients with cancer linked to LexisNexis data, 36,791 (36.2%) had a major AFE reported before diagnosis. The mean and median timing of the AFE closest to diagnosis were 93 and 77 months, respectively. AFEs were most common among non-Hispanic Black, unmarried, and low-income patients. Individuals with previous AFEs were more likely to be diagnosed with later-stage cancer than individuals with no AFE (males-odds ratio [OR], 1.09 [95% CI, 1.03 to 1.14]; P < .001; females-OR, 1.18 [95% CI, 1.13 to 1.24]; P < .0001) after adjusting for age, race, marital status, income, registry, and cancer type. Associations between AFEs prediagnosis and later-stage disease did not vary by AFE timing.

CONCLUSION

One third of newly diagnosed patients with cancer had a major AFE before their diagnosis. Patients with AFEs were more likely to have later-stage diagnosis, even accounting for traditional measures of socioeconomic status that influence the stage at diagnosis. The prevalence of prediagnosis AFEs underscores financial vulnerability of patients with cancer before their diagnosis, before any subsequent financial burden associated with cancer treatment.

Financial Toxicity in Patients with Hematologic Malignancies: a Review and Need for Interventions

INTRODUCTION

Financial toxicity is a developing research area to quantify the financial stress experienced by patients and caregivers, as well as the mechanisms by which they manage the costs associated with treatment and the very real harms that this stress can inflict upon cancer care. Patients with blood malignancies experience increased costs associated with their diagnosis due to possible inpatient admissions for treatment, frequent office visits, and even more frequent lab evaluations and testing.

PURPOSE OF REVIEW

Multiple studies have examined the causes and effects of financial toxicity on patient care and outcomes, and there have been several validated tools developed to identify patients experiencing or at risk for financial harm.

DISCUSSION

However, few studies to date have focused on implementing successful interventions to assist in mitigating financial difficulties for patients diagnosed with hematologic malignancies and their families. In this review, we examine the current literature with an emphasis on levels of care, including providers, systems, and policies. Specifically, we discuss published interventions including physician education about treatment costs, financial navigation in cancer centers, and novel institutional multidisciplinary review of patients' financial concerns. We also discuss the urgent need for societal and governmental interventions to lessen financial distress experienced by these highly vulnerable blood cancer patients.