How Does Underinsurance Impact Decision Making in Patients With Cancer?

A study in JAMA Oncology has found that unpreparedness for treatment-related expenses among patients being treated for cancer can bear upon the patient’s future decision-making.

Underinsured patients are a growing population and with coverage policies remaining an unknown, financial stress could negatively impact patient decisions about their treatment. With this in mind, authors at Duke University conducted a survey at their cancer center and at 3 affiliated rural oncology clinics.


The cross-sectional study evaluated financial distress and cost expectations in patients who were receiving anticancer treatment. Patients were compensated $10 for participating on the survey. In addition to patient demographic information, data from their electronic health record was abstracted for cancer diagnosis, stage, and type and duration of treatment. Patients were queried on whether their costs met their expectations and on how much they were willing to pay out-of-pocket (OOP) for their cancer treatment (minus their insurance premium).


Of the 300 eligible patients, a little more than half were men (n = 157) and the mean age of the entire cohort was 59.6 years. A majority were white (n = 226), most held private insurance (n = 168), and a significant number earned less than $60,000 annually. The median monthly OOP cost for the group was $592, and more than half of the participants (n = 162) had advanced stage cancer at enrollment.


The study found that the relative cost of care for patients with high or overwhelming distress was 31%, compared with 10% for those who had no, low, or average financial distress. About 39% of patients (n = 118) endorsed they had a higher than expected financial burden from cancer–a factor that was associated with being young, unmarried, nonwhite, unemployed/not retired, lower household income, higher costs, colorectal/breast cancer diagnosis, lower quality of life, and higher financial distress.


The analysis showed that financial burden was significantly associated with financial distress and a reduced willingness to pay for care. More than a third of insured patients in the group faced OOP costs much greater than what they had anticipated, and the underinsured, who were the most distressed, were paying almost a third of their income in healthcare-related costs.


The authors conclude that unexpected treatment costs were associated with a lower willingness to pay for care; so, unpreparedness for treatment-related expenses can bear upon the patient’s future decision-making. They recommend interventions to improve patient literacy around healthcare costs as a path forward to mitigate costs through shared decision making.


The study has been published in JAMA Oncology.

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