Out-of-Pocket Expenses and Cancer Care

Chicago—According to survey-based research presented at the ASCO meeting, patients who have health insurance but must pay a portion of their cancer care through out-of-pocket expenses are burdened by a decrease in their standard of living, quality of care, and satisfaction with care. Yousuf Zafar, MD, the study’s lead author, who spoke about the trial during an oral abstract session, said, “It was really an eye-opening experience.” Dr. Zafar mentioned a 2008 study that set 3 criteria for defining the underinsured: out-of-pocket expenses ≥10% of their annual income; out-of-pocket expenses ≥5% of their annual income for low-income families; or deductibles ≥5% of their annual income. According to a 2008 Health Affairs article cited by Dr. Zafar, 12% of adults in the United States were underinsured in 2003 compared with 20% in 2007. “We can only wonder what those numbers are today,” Dr. Zafar said. “We have to assume the number of underinsured is higher as cost-sharing has increased. But what is the day-to-day impact on patients who are receiving cancer care? We know the treatments we give patients can result in a physical toxicity, but do they also result in a financial toxicity?,” he added. To answer those questions, Dr. Zafar and his colleagues enrolled patients from Duke University’s Cancer Institute and the Healthwell Foundation, a nonprofit organization that helps patients with copays, coinsurance, and premium payments. Study participants had to have received chemotherapy or hormonal therapy for solid tumor malignancy for ≥1 month before enrollment. At baseline, patients completed a 3-part survey on the Internet or on paper (depending on their preference) that assessed demographics, the strategies used to cope with out-of-pocket expenses, and their perception on the quality of their healthcare. After finishing the survey, patients completed cost diaries once per month for 4 months. Of the 908 patients contacted, 602 agreed to participate and 216 completed the baseline survey. The mean age of the patients was 64 years, 88% of the patients were female, 80% were Caucasian, 76% had breast cancer, and 32% had metastatic disease. In addition, 66% of patients had an annual household income <$40,000. According to Dr. Zafar, the median annual household income in the United States was $49,000 in 2009. Furthermore, 83% of patients had prescription drug coverage and 99% were insured, with 66% receiving their coverage through Medicare. The patients had mean out-of-pocket direct and indirect expenses of $712 per month, of which 26% went to insurance premiums, 19% went to prescription medications, and 16% went to lost wages. Of the survey respondents, 39% said they experienced a “moderate” financial burden, 30% experienced a “significant” financial burden, and 11% experienced a “catastrophic” financial burden. The survey asked patients how they coped with expenses related to medications. Of the group, 26% said they did not fill the prescriptions, 22% filled part of the prescriptions, and 20% took less than the prescribed amount. In addition, 60% said they obtained free samples from their doctors, 51% shopped for the lowest price, and 49% asked their doctors for less expensive medications, according to the survey results. To cope with the high costs of cancer care, 70% of respondents reduced their spending on leisure activities, 48% allocated all or a portion of their savings for cancer care, 47% reduced their spending on basics such as food or clothing, and 18% sold possessions or property. Dr. Zafar said there was a significant positive correlation between the use of coping strategies and financial burden (P<.001) as well as a significant positive correlation between the use of coping strategies and talking with doctors about the cost burden (P<.001). There was a significant negative correlation between the use of coping strategies and satisfaction with care (P<.001). Dr. Zafar said the study may have been limited because of a small sample size and also because most patients were women with breast cancer. In addition, the response rate was 23%, and the researchers did not assess disease-related outcomes.