High Out-of-Pocket Costs Degrade Quality of Cancer Care

Financial toxicity common in oncology
August 2011 Vol 4, No 4, Special Issue - Health Economics

A survey-based study from Duke University and the Dana-Farber Cancer Institute reveals that insured patients with cancer often face high out-of-pocket (OOP) expenses for their very expensive treatments and prescription drugs.

As patients are working less and insurers are shifting more costs to patients, the overall ranks of the underinsured have grown—to 20% in 2007 and likely much more in 2011, said S. Yousuf Zafar, MD, Division of Medical Oncology, Duke University, Durham, NC.

Dr Zafar shared eye-opening survey responses, in which patients with cancer reported not having money for food, or becoming homeless, as a result of paying for their cancer care, which often carries heavy OOP expenses, even for those with medical insurance.

The study was based on 216 survey responses by patients (age, 33-88 years; mean, 64 years) from the HealthWell Foundation, which helps patients with uncovered medical costs, and from the Duke Cancer Institute. Most patients were white (80%) and female (88%). All patients were receiving chemotherapy or hormonal therapy for solid tumors; 76% of them had breast cancer, and of these, 32% were metastatic.

Underinsurance for Patients with Cancer

Patients completed cost diaries for 4 months. Most of them had insurance coverage, “Two thirds of our sample had Medicare…99% were insured, and 83% had prescription drug coverage,” Dr Zafar emphasized, but underinsurance was clearly a problem. “Under - insured” was defined as OOP expenses totaling at least 10% of a family’s income (5% for low-income families), or as deductibles totaling at least 5% of the income.

The mean OOP expenses were $712 per month (median, $459). Funds were used mainly for insurance premiums, medications, and lost wages. Based on their responses, of these patients:

  • 39% had a moderate financial burden
  • 30% had a significant burden
  • 11% had a catastrophic burden. Financial burden triggered 3 types of “financial toxicity”—reduced standard of living; impacts on quality of care as patients skipped appointments, medications, and tests; and reduced satisfaction with care.

Clinical Implications of Financial Toxicity

To cope with drug costs, 26% of patients did not fill prescriptions, and 22% filled them partially. “Keep in mind that 83% of our respondents endorsed having drug coverage,” Dr Zafar said.

Patients also altered the way they obtained medications (eg, requesting samples from their doctor or purchasing them from another country). Lifestyle changes included using an assistance program (64%—mainly HealthWell), reducing spending on basics such as food and clothing (51%), and borrowing money (43%).

Other coping strategies patients used to minimize cost included spreading out or missing chemotherapy or clinic appointments and forgoing recommended tests or procedures. In addition, 48% used a portion or all of their savings, 47% reduced spending on basics, 36% borrowed money, and 18% sold possessions or property. On patients exhausting their savings, Dr Zafar commented, “Keep in mind that the median age of our sample was 65.”

Finally, there was a significant correlation between the use of these coping strategies and a low level of satisfaction with care.

Several relevant questions to consider are, as patients are taking fewer medications, is treatment-related toxicity affected? Is disease-related survival affected by curtailing treatments and tests? Could overall costs actually be higher as a result of incomplete or insufficient care?

The source of the financial toxicity is in large part a health policy that shifts the costs of care to patients, Dr Zafar said. “By understanding that out-ofpocket expenses actually impact health outcomes and patient satisfaction, we can start including that in the discussion and get a better judgment of where that cost-sharing spectrum should fall,” he ended.

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Last modified: September 6, 2011
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