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April 22, 2018

Financial Burden an Unintended Outcome of Cancer Care

Surabhi Dangi-Garimella, PhD
K. Robin Yabroff, PhD, strategic director, Surveillance and Health Services Research Program, American Cancer Society, would like to see more longitudinal studies that can develop more informed policies to alleviate patient financial hardship. Yabroff was speaking at the Cost-Sharing Roundtable co-hosted by the Patient Access Network Foundation and The American Journal of Managed Care®
Bringing cancer care back into perspective in her presentation, Yabroff asked, “What’s happening with the monthly price of cancer drugs?” She then shared data from a 2009 paper by Peter Bach, MD, which showed a steady increase in the monthly price of cancer drugs—in the hundreds in the 1960s and 1970s and averaging between $5000 and $10,000 by 2010.3 Taking note of the new modes of immunotherapy treatments, including the chimeric antigen receptor (CAR) T treatments, Yabroff said that the price tag of $450,000 would completely skew these calculations.

And the consequence of the growing cost burdens? Bankruptcy. A research study from the Fred Hutchison Cancer Center at Washington University noted that patients with cancer had a bankruptcy risk 2.65 times higher than that of those without cancer in Washington State.4 Medicare might afford protection to older patients, because younger patients had a 2- to 5-fold higher rate of bankruptcy than those 65 years and older. Furthermore, the group showed that the stress of financial insolvency was a significant risk factor for mortality in this patient population.5  

Using these data as their foundation, Yabroff and her colleagues have developed a financial hardship framework where they created a Venn diagram that intersects material conditions (medical debt, trouble repaying bills, high OOP costs, etc), psychological response (distress and worry), and coping behaviors (delaying or foregoing care due to cost).6 Results from the Medical Expenditure Panel Survey found that younger patients (aged 18-64 years) reported being more susceptible to psychological and material financial hardship (40%) compared with the over-65 population (22%), according to Yabroff. When the authors drilled down further into these data, using the 2012 LIVESTRONG Experiences with Cancer survey,7 they found that 76% of survivors aged 18 to 64 reported material hardship (borrowed money, filed for bankruptcy, etc) and nearly 64% reported psychological hardship.

“Importantly, there is potential for widening disparities in health and health outcomes,” Yabroff said, drawing attention to a study that found the behavioral impact of financial hardships on patients with cancer: a higher rate of delayed prescription filling, less medication intake, or skipping medication doses, compared with patients without a cancer history.

Not surprisingly, race, economic and employment status, and insurance had a significant bearing on the risk of a patient facing financial hardship, Yabroff noted.

So where lies the solution? There is, of course, no single factor that can help resolve the financial stress patients face consequent to treatment—it would require a combined effort from multiple stakeholders beyond the patient and their immediate family and caregivers. Hinting at a need for more research efforts within the organization or practice setting, Yabroff noted that we need policy changes at the state and federal level to help support the needs of these patients, including:
  • Financial navigators for patients and their families to reach out to
  • Open conversations around cost and benefits of treatment with providers and care teams
  • Implementing value-based insurance design to help eliminate low-value care
  • Medicaid expansion, which she said would especially benefit patients on expensive specialty medications who just breeze through the Medicare Part D donut hole.
“There is need for more longitudinal data,” Yabroff said, to better understand the initiation of patient financial hardship and how long patients endure it. It is important, she said, “to develop appropriate measures, collect primary data, and conduct national surveys, so we can develop strategies, inform policy, and improve health outcomes for patients and families.”

  1. Multiple chronic conditions among US adults: a 2012 update. Ward BW, Schiller JS, Goodman RA. Prev Chronic Dis. 2014;11:E62. doi: 10.5888/pcd11.130389.
  2. Martinez ME, Zammitti EP, Cohen RA. Health insurance coverage: early release of estimates from the National Health Interview Survey, January–September 2017. CDC website. Published February 2018. Accessed February 26, 2018.
  3. Bach P. Limits on Medicare’s ability to control rising spending on cancer drugs. N Engl J Med. 2009; 360(6):626-633. doi: 10.1056/NEJMhpr0807774.
  4. Ramsey S, Blough D, Kirchhoff A, et al. Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. Health Aff (Millwood). 2013;32(6):1143-1152. doi: 10.1377/hlthaff.2012.1263.
  5. Ramsey SD, Bansal A, Fedorenko CR, et al. Financial insolvency as a risk factor for early mortality among patients with cancer. J Clin Oncol. 2016;34(9):980-986. doi: 10.1200/JCO.2015.64.6620.
  6. Altice CK, Banegas MP, Tucker-Seeley RD, Yabroff KR. Financial hardships experienced by cancer survivors: a systematic review. J Natl Cancer Inst. 2016;109(2). pii: djw205.
  7. 2012 LIVESTRONG survey: survivors experience with financial concerns. LIVESTRONG website. Published 2012. Accessed February 27, 2018.

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