Medical Debt Research Articles

Association Between Medical Debt and Vaccine Uptake in the USA, 2021-2022.

Many individuals do not receive recommended vaccines, increasing infectious disease morbidity and mortality. It is unknown whether the financial practices of US healthcare institutions contribute to vaccine hesitancy. To determine whether medical debt is associated with low vaccine uptake. Cross-sectional analysis of the association between medical debt and vaccine receipt. 56,373 adult participants in the 2021-2022 National Health Interview Survey. Presence of medical debt at the time of survey administration. We used logistic regression models to assess whether medical debt was associated with recent vaccine receipt, adjusting for sociodemographic, health, and access-to-care variables. We performed a sensitivity analysis restricted to individuals with health insurance and conducted a falsification test of the hypothesis that current medical debt would not be associated with remote prior vaccination (i.e., > 1year prior, likely before debt acquisition). Individuals with medical debt were less likely than those without such debt to receive any recent vaccine (adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.76-0.91), including influenza vaccination (aOR 0.83, 95% CI 0.75-0.91) or COVID-19 vaccination (aOR 0.79, 95% CI 0.69-0.91). Analyses limited to insured individuals had similar findings (aOR for any recent vaccination 0.79, 95% CI 0.72-0.88). In the falsification test, current medical debt was not associated with remote prior vaccination (aOR 1.04, 95% CI 0.93-1.16). Current medical debt is associated with lower likelihood of recent vaccine receipt in both insured and uninsured individuals. Policies that minimize medical debt may improve vaccine coverage.

Financial Health Among Louisiana Medicaid Enrollees

This cross-sectional study compares average credit scores and unpaid medical and nonmedical debts in collections among Black, Hispanic, and White adults with Medicaid coverage.

Association of county-level medical debt and survival among individuals newly diagnosed with cancer in the United States.

156 Background: Individuals diagnosed with cancer often bear significant health care costs and productivity loss, with over half incurring cancer-related medical debt. Medical debt is increasingly recognized as a social determinant of health care and health outcomes. Using newly available nationwide county-level medical debt information from 2011 to 2019 linked with national cancer registry data, we examined the association of county-level medical debt with survival among individuals newly diagnosed with cancer in the US. Methods: Individuals aged ≥18 years with newly diagnosed first primary cancer in 2011-2019 were identified from the National Cancer Database, which was linked with credit bureau data on county-level percentage of adults with medical debt in collections based on patients’ year of diagnosis. Patients were followed from diagnosis through December 31, 2019. Hazard Ratios (HR) and were derived from Cox proportional hazard models to estimate the associations of county-level medical debt quartiles with overall survival, adjusting for year of diagnosis, age, sex, race and ethnicity, insurance status, comorbidity score, metropolitan status, county-level social deprivation index and medically underserved area designation, and state of residency. Stratified analyses were conducted by cancer type and sociodemographic and clinical factors. Results: A total of 7,558,658 individuals newly diagnosed with cancer were identified, with a median county-level medical debt of 18%, ranging from 0% to 56%. County-level medical debt decreased since 2015. The highest percentage of county-level medical debts was found among patients racialized as non-Hispanic Black, uninsured, and living in medically underserved areas. In adjusted analyses, patients living in counties with the highest quartile of medical debt had 17% increased risks of death compared with those living in counties with the lowest quartile of medical debt (HR=1.17, 95%CI=1.16-1.18), with a statistically significant dose-response relationship for the higher quartiles (P-trend<.0001). The pattern was consistently seen across cancer types as well as socioeconomic and clinical groups. Conclusions: County-level medical debt was strongly associated with worse survival among individuals newly diagnosed with cancer, consistent across socioeconomics and clinical subgroups. Policies preventing and relieving medical debt maybe effective ways to improve cancer outcomes at population level. Hazard ratios for risk of death associated with county-level medical debt by cancer site and stage at diagnosis. County-Level Share of Population with Medical Debt Q1 Q2 Q3 Q4 All cancers 1 1.08 1.13 1.17 Female breast 1 1.10 1.13 1.16 Prostate 1 1.06 1.11 1.13 Lung 1 1.06 1.10 1.12 Colon and rectum 1 1.07 1.11 1.14 Stage I-III 1 1.09 1.14 1.19 Stage IV 1 1.07 1.11 1.13 All P for trend <.0001.

Income, wealth, and debt among families with a history of cancer.

350 Background: Cancer survivors and their families often experience financial hardship due to high out-of-pocket medical costs and lost income from time away from work during treatment for patients and informal family caregivers. Little is known about detailed income, wealth, and debt among families with a history of cancer. Methods: The 2021 Panel Study of Income Dynamics was used to identify families with a cancer history. Family characteristics included survey response person’s age, sex, marital status, and race and ethnicity, number of dependent children living in the family, and time since cancer diagnosis. For families with multiple cancer diagnoses, time since cancer diagnosis was calculated according to the most recent cancer diagnosis. Family income was assessed by total income in tax year 2020, which consisted of combined taxable and transfer income of the response person, spouse/partner, and other family members. Wealth with and without equity (i.e., value of home minus mortgage) were assessed by sum of values of different types of assets (e.g. savings, checking, bonds, retirement accounts) net of debts (e.g., credit card debt, student loans, and medical bills). Results: A total of 701 families were identified with a cancer history. Within families, half of cancer survivors were 18-64 years and the other half were >65 years at the survey. About two thirds were married or living with partners, three fourths of response persons were male, one fifth had dependent children living in the same family, two thirds were non-Hispanic white, and two thirds of cancer survivors were diagnosed > 6 years prior to the survey. The median family income was $67,498 (inter-quartile range: $33,480 to $121,200), and the median wealth with and without equity were $188,000 and $5,5000, respectively. Moreover, 29.9% of families had credit debt (median: $4,500; inter-quartile range [IQR]: $1800-$14,000); 11.3% of families carried student loans (median: $4,500; IQR: $15,000-$60,000); and 10.7% of families had outstanding medical bills (median: $4,000; IQR: $2,000-$9,000). Conclusions: Families with a history of cancer have multiple types of debts, including medical debt, even years after diagnosis. Efforts to identify changes in wealth and income before and after cancer diagnosis are warranted. Income, wealth, and debt among families with a history of cancer. Family income Wealth without equity Wealth with equity Mean (Std) Median (IQR) Mean (Std) Median (IQR) Mean (Std) Median (IQR) $94,776(123,870) $67,498(33,480, 121,200) $459,956(1,142,647) $5,5000(4,000, 391,364) $649,912(1,307,959) $188,000(30,400, 645,000) Credit card debt (n=693) Student loans (n=698) Medical bills (n=627) n (%) Mean (Std) Median (IQR) n (%) Mean (Std) Median (IQR) n (%) Mean (Std) Median (IQR) 207(29.9%) $8,832 (10,300) $4,500(1800, 14,000) 79(11.3%) $55,948(75,256) $35,000(15,000, 60,000) 67(10.7%) $13,309(32,525) $4000(2,000, 9,000)

Access to patient assistance programs for rural cancer patients in an NCI designated comprehensive cancer center: A retrospective cohort study.

94 Background: 35% of Oregon’s and 14% of Washington’s populations live in rural/frontier communities. These populations often experience a higher incidence of cancer disparities across the care continuum and a disproportionate burden of the high costs associated with cancer care compared to urban populations. Methods: The Oregon Health & Science University (OHSU) Knight Cancer Institute (KCI) operates a multidisciplinary cancer program catering to Oregon and Southwest Washington from its Portland-based campuses. OHSU launched an enterprise Patient Assistance (PA) program partnership with Atlas Health which included an Artificial Intelligence (AI)-powered platform integrated with the electronic health record and 4 Patient Advocates who enrolled patients into matched PA programs. Rural patients receiving intravenous (IV) infusion therapy who benefited from PA programs were compared to the overall treated population at OHSU infusion centers to determine if rural patients who are at high risk for financial toxicity were identified and provided an effective intervention. Patient zip codes were used to designate residence in urban or rural/frontier counties. Results: A retrospective analysis reviewed unique patients treated in the OHSU KCI infusion centers, PA Enrolled, and PA Awarded patient cohorts. Conclusions: The Enterprise PA program partnership notably and proportionately benefited rural communities who are at high risk for financial toxicity and experience significant cost barriers to care. OHSU collected over 599,000 which reduced the risk of bad debt for the institution and cancer related medical debt for patients. Average PA award of 1,426 was significant due to 40% of Americans cannot afford a 1,000 emergency or unexpected medical bill. This underscores that an enterprise PA program may be considered a care delivery intervention to decrease health disparities. Further study is needed to determine if increasing rural cancer patients’ access to PA programs helps improve clinical access and treatment outcomes across the spectrum of cancer care services. Patient cohort comparison 12/15/2023-3/31/2024. Patient Cohort OHSU Infusion Center Cohort Patient Assistance Enrolled Cohort Patient Assistance Awarded Cohort Total Number of Patients 9,197 554 420 Total Number of Patients Residing in Oregon and Washington 9,064 552 418 Total Number of Patients Residing in Oregon and Washington Rural Counties 1,668 117 122 Percentage Rural Patients 18% 21% 29% Drug Manufacturer Co-Pay Programs - $ 590,785.70 $ 459,095.08 Charitable Co-Pay Assistance Programs - $ 96,024.70 $ 139,981.33 Total - $ 686,810.40 $ 599,076.41 Average Expected/Received Award Per Patient - $ 1,239.73 $ 1,426.37

Hysterectomy and medical financial hardship among U.S. women

ObjectiveHysterectomy is one of the common surgical procedures for women in the United States. Studies show that hysterectomy is associated with elevated risk of developing chronic conditions, whichmay cause financial toxicity in patients. This study aimed to assess whether women who underwent hysterectomy had a higher risk of experiencing medical financial hardship compared to women who didn’t. MethodsUsing data on 32,823 adult women from the 2019 and 2021 waves of the National Health Interview Survey, we estimated binomial and multinomial logistic regressions to assess the relationship between hysterectomy and financial hardship, defined as problems paying or unable to pay any medical bills. Further, we performed a Karlson-Holm-Breen (KHB) decomposition to examine whether the association could be explained by chronic comorbidity. ResultsWhile the prevalence of financial hardship was 13.6 % among all women, it was 16.2 % among women who underwent a hysterectomy. The adjusted odds of experiencing medical financial hardship among women with a hysterectomy were 1.36 (95 % CI: 1.22–1.52) times that of their counterparts who did not have a hysterectomy. The KHB decomposition suggested that 34.5 % of the size of the effect was attributable to chronic conditions. Women who had a hysterectomy were also 1.45 (95 % CI: 1.26–1.67) times more likely to have unpaid medical debts. ConclusionsOur results suggested that women, who underwent a hysterectomy in the US, were vulnerable to medical financial hardship. Policy makers and health professionals should be made aware of this issue to help women coping against this adversity.

Disparate Patient Advocacy When Facing Unaffordable and Problematic Medical Bills

People in the US face high out-of-pocket medical expenses, yielding financial strain and debt. To understand how households respond to medical bills they disagree with or cannot afford. A retrospective cohort study was carried out using a survey fielded between August 14 and October 14, 2023. The study included a random sample of adult (aged ≥18 years) survey respondents from the Understanding America Study (UAS). Participant responses were weighted to be nationally representative. The analysis took place from November 3, 2023, through January 8, 2024. Respondents reported if their household received a medical bill that they could not afford or did not agree with in the prior 12 months, and if anyone contacted the billing office regarding their concerns. Those who did reach out were asked about their experience and those who did not were asked why. The survey was sent to 1233 UAS panelists, of which 1135 completed the survey, a 92.1% cooperation rate. Overall, 1 in 5 of the 1135 respondents received a medical bill that they disagreed with or could not afford. Leading bill sources were physician offices (66 [34.6%]), emergency room or urgent care (22 [19.9%]), and hospitals (31 [15.3%]), and 136 respondents (61.5%) contacted the billing office to address their concern. A more extroverted and less agreeable personality increased likelihood of reaching out. Respondents without a college degree, lower financial literacy, and the uninsured were less likely to contact a billing office. Among those who did not reach out, 55 (86.1%) reported that they did not think it would make a difference. Of those who reached out, 37 (25.7%) achieved bill corrections, better understanding (16 [18.2%]), payment plans (18 [15.5%]), price drop (17 [15.2%]), financial assistance (10 [8.1%]), and/or bill cancellation (6 [7.3%]), while 32 (21.8%) said that the issue was unresolved and 23.8% reported no change. These outcomes aligned well with respondents' billing concerns with financial relief for 75.8% of respondents reaching out about an unaffordable bill, bill corrections for 73.7% of those who thought there was mistake, and a price drop for 61.8% of those who negotiated. This cross-sectional survey of a representative sample of patients in the US found that most respondents who self-advocated achieved bill corrections and payment relief. Differences in self-advocacy may be exacerbating socioeconomic inequalities in medical debt burden, as those with less education, lower financial literacy, and the uninsured were less likely to self-advocate. Policies that streamline the administrative burden or shift it from patients to the billing clinician may counter these disparities.

Medical Debt and the Mental Health Treatment Gap Among US Adults

Medical debt is common in the US and may hinder timely access to care for mental disorders. To estimate the prevalence of medical debt among US adults with depression and anxiety and its association with delayed and forgone mental health care. Cross-sectional, nationally representative survey study of US adult participants in the 2022 National Health Interview Survey who had current or lifetime diagnoses of depression or anxiety. Self-reported lifetime clinical diagnoses of depression and anxiety; moderate to severe symptoms of current depression (Patient Health Questionnaire-8 score ≥10) and anxiety (Generalized Anxiety Disorder-7 score ≥10) irrespective of lifetime diagnoses; and past-year medical debt. Self-reported delaying and forgoing mental health care because of cost in the past year. Among 27 651 adults (15 050 [54.4%] female; mean [SD] age, 52.9 [18.4] years), 5186 (18.2%) reported lifetime depression, 1948 (7.3%) reported current depression, 4834 (17.7%) reported lifetime anxiety, and 1689 (6.6%) reported current anxiety. Medical debt was more common among adults with lifetime depression (19.9% vs 8.6%; adjusted prevalence ratio [aPR], 1.97; 95% CI, 1.96-1.98), lifetime anxiety (19.4% vs 8.8%; aPR, 1.91; 95% CI, 1.91-1.92), current depression (27.3% vs 9.4%; aPR, 2.34; 95% CI, 2.34-2.36), and current anxiety (26.2% vs 9.6%; aPR, 2.24; 95% CI, 2.24-2.26) compared with adults without the respective mental disorders. Medical debt was associated with delayed health care among adults with lifetime depression (29.0% vs 11.6%; aPR, 2.68; 95% CI, 2.62-2.74), lifetime anxiety (28.0% vs 11.5%; aPR, 2.45; 95% CI, 2.40-2.50), current depression (36.9% vs 17.4%; aPR, 2.25; 95% CI, 2.13-2.38), and current anxiety (38.4% vs 16.9%; aPR, 2.48; 95% CI, 2.35-2.66) compared with those without these diagnoses. Medical debt was associated with forgone health care among adults with lifetime depression (29.4% vs 10.6%; aPR, 2.66; 95% CI, 2.61-2.71), lifetime anxiety (28.2% vs 10.7%; aPR, 2.63; 95% CI, 2.57-2.68), current depression (38.0% vs 17.2%; aPR, 2.35; 95% CI, 2.23-2.48), and current anxiety (40.8% vs 17.1%; aPR, 2.57; 95% CI, 2.43-2.75) compared with those without the diagnoses. Medical debt is prevalent among adults with depression and anxiety and may contribute to the mental health treatment gap. In the absence of structural reform, new policies are warranted to protect against this financial barrier to mental health care.

Medical Students' Views of the Future in a Rapidly Changing World.

Physicians have long been considered valued members of a solid US health care system. Significant changes in medical education, health care, and society at-large suggest that current medical students may face a different future. To help guide educators and policy makers, we set out to understand medical students' perceptions of the future of health care and their place in it. In year one of a longitudinal study, we conducted in-depth interviews of Case Western Reserve University medical students. A multidisciplinary team performed iterative thematic analyses and sampling until reaching saturation on major themes. Eleven medical student participants described social and health care issues as major influences on their professional futures. Concerns included health care system failings, unsustainable costs, climate change, demographic shifts, disinformation, and public distrust in health care. Students looked forward to team practice and using technology, data, and artificial intelligence in care delivery. They hoped for greater access and equity in health care, with a focus on prevention and social, behavioral, and environmental drivers of health. Most students expected to be employed rather than in private practice and sought time/flexibility for professional and personal interests. Paying off medical school debt and advocating for patients and change were priorities. Many saw primary care as important, but fewer envisioned it as their career path of choice. Medical students envision a future shaped by health care systems and social issues. These findings can inform those helping students prepare for uncertainty and rapid change in their careers, their lives, and the lives of their patients.

Prevalence of financial hardship and health-related social needs among patients with missed radiology appointments

PurposeWe aimed to evaluate the prevalence of financial hardship and Health-Related Social Needs (HRSN) among patients who missed their radiology appointment. MethodsEnglish-speaking adult patients, with a missed outpatient imaging appointment at any of a tertiary care imaging centers between 11/2022 and 05/2023 were eligible. We measured self-reported general financial worry using Comprehensive Score for Financial Toxicity (COST), imaging hardship (worry that the current imaging is a financial hardship to patient and their family), material hardship (e.g., medical debt), cost-related care nonadherence, and HRSNs including housing instability, food insecurity, transportation problems, and utility help needs. Results282 patients were included (mean age 54.7 ± 15.0 years; 70.7 % female). Majority were non-Hispanic White (52.4 %), followed by Asian (23.0 %) and Hispanic (16.0 %) racial/ethnic background. Most missed appointments were patient-initiated (74.8 %); 13.5 % due to cost or insurance coverage and 6.4 % due to transportation and parking. Mean COST score was 26.8 with 44.4 % and 28.8 % reporting their illness and imaging as a source of financial hardship. 18.3 % and 35.2 % endorsed cost-related care nonadherence and material hardship. 32.7 % had at least one HRSNs with food insecurity the most common (25.4 %). Only 12.5 % were previously screened for financial hardship or HRSNs. Having comorbidity and living in more disadvantaged neighborhoods was associated with higher report of financial hardship and HRSNs. ConclusionFinancial hardship and HRSNs are common among those who miss radiology appointments. There needs to be more rigorous screening for financial hardship and HRSNs at every health encounter and interventions should be implemented to address these.

Health care access barriers among metropolitan and nonmetropolitan populations of eight geographically diverse states, 2018.

Nonmetropolitan populations face frequent health care access barriers compared to their metropolitan counterparts, but differences in the number of these barriers across groups are not known. Our objective was to examine the differences in health care access barriers across metropolitan, micropolitan, and noncore populations. We used Behavioral Risk Factor Surveillance System data from the optional "Health Care Access" module to perform a cross-sectional analysis examining access barriers across levels of rurality using bivariate analyses and Poisson models. Access barriers were operationalized as a count ranging from 0 to 5, reflective of the number of financial barriers and nonfinancial barriers. Micropolitan and noncore respondents had lower educational attainment, were older, and were less racially/ethnically diverse than metropolitan respondents. They also reported more barriers, including lacking health insurance, medical debt, and foregoing care or medication due to cost. These barriers were most pronounced in non-Hispanic Black, Hispanic, and American Indian/Alaska Native nonmetropolitan populations, compared to their White counterparts. In adjusted analysis, micropolitan respondents reported more barriers compared to metropolitan (prevalence rate ratio=1.06; 95% confidence interval: 1.02-1.10) as did women, racial/ethnic minority populations, and those with less education. Micropolitan populations experience more barriers to health care, and nonmetropolitan respondents report more cost-related barriers than their metropolitan counterparts, raising concerns on health care disparities and financial burdens for these underserved populations. This underscores the need to mitigate these barriers, particularly among those in micropolitan areas and minorized populations.

Examining the financial landscape of cancer: An analysis of debt and bankruptcy among patients in Massachusetts (2010-2019).

11032 Background: Financial toxicity is commonly reported by patients following a cancer diagnosis. Prior patient surveys indicate that up to one-third of cancer patients incur medical debt, of which 55% carry balances exceeding $10,000. In addition to debt and bankruptcy, credit scores are an important indicator of socioeconomic well-being following cancer diagnosis, because they affect housing stability, transportation access, and may even be predictive of health. Limited studies quantify incurred debt, bankruptcy rates, or credit scores following a cancer diagnosis compared with patients without a cancer diagnosis. Methods: Individuals with a cancer diagnosis in Massachusetts from 2010 to 2019 were identified through the Massachusetts Cancer Registry, and patient-level records on debt, bankruptcy, and other measures of financial well-being were linked using data from a major United States credit bureau. Changes in medical debt, credit score and bankruptcy filings were evaluated over time and compared with a random sampling of individuals residing in Massachusetts over the same time period that did not have a cancer diagnosis and were matched based on demographic factors. Results: 99,175 individuals with cancer and 188,875 individuals without cancer were identified, and average annual total debt balances were $758 and $669, respectively, throughout the study period. The highest total debt balances were observed among individuals with thyroid cancer ($913). Average annual medical collection balances were $45 for individuals without cancer and $52 among those with cancer with the highest balances among those with liver cancer ($66). Across the study period, the average annual bankruptcy incidence rate per 100 persons was 7.15 for those without cancer and 6.22 among those with cancer, with the highest incidence rates among those with thyroid cancer (7.34). Although there was a gradual increase in credit score in the control population, survivors of bladder, liver, ovarian, colorectal and lung cancers experienced a decline in credit scores. Conclusions: High rates of financial toxicity among individuals with cancer suggest that widespread healthcare and consumer finance reforms have not yet fully alleviated medical debt and bankruptcy in Massachusetts. Further research is needed to understand drivers of financial burden over time among those with cancer.

Who Bears the Burden? Understanding the Socioeconomic Patterns of Educational Debt in Orthopaedic Surgery Residency Candidates.

Educational debt is commonly observed among applicants to orthopaedic surgery residency programs; however, an understanding of the debt burden among minority and nonminority applicants is not well established. Thus, this study aimed to fill these knowledge gaps by examining the extent of and factors shaping educational debt among orthopaedic surgery applicants. (1) What is the educational debt burden among orthopaedic surgery residency applicants? (2) After controlling for relevant confounding variables, what factors are independently associated with increasing levels of educational debt? (3) After controlling for relevant confounding variables, are individuals classified as an underrepresented minority or those with educational debt and socioeconomic disadvantage less likely to match in orthopaedic surgery? A retrospective evaluation of orthopaedic surgery residency application data from the American Association of Medical Colleges was analyzed from 2011 to 2021. The American Association of Medical Colleges database was selected because every residency applicant must register and apply through the American Association of Medical Colleges. Therefore, these data exist for every residency applicant, and the sample was comprehensive. Self-reported data including premedical, medical, and total educational debt burden as well as classification as socioeconomically disadvantaged and application fee waiver use were collected. Applicants were dichotomously categorized as an underrepresented minority or a not underrepresented minority based upon self-identified race and ethnicity. Monetary values were reported in USD and inflation-adjusted to 2021 using the Consumer Price Index. We performed t-tests and chi-square tests for continuous and categorical variables, respectively. Significance was considered at p < 0.05. In all, 12,112 applicants were available in the initial cohort, and 67% (8170 of 12,112) of applicants with complete data were included from 2011 to 2021 in the final study cohort. Of these, 18% (1510 of 8170) were women, 14% (1114 of 8170) were classified as underrepresented minorities, and 8% (643 of 8170) were classified as socioeconomically disadvantaged. Sixty-one percent (4969 of 8170) of applicants reported receiving at least one scholarship, 34% (2746 of 8170) had premedical school debt, and 72% (5909 of 8170) had any educational debt including medical school. Among all applicants, the median (IQR) educational debt was USD 197,000 (25,000 to 288,000). Among those with scholarships, the median amount was USD 25,000 (9000 to 86,000). After controlling for the potentially confounding variables of gender and socioeconomic disadvantage, classification as an underrepresented minority applicant was independently associated with higher scholarship amounts than applicants characterized as not underrepresented minorities (β = USD 20,908 [95% confidence interval (CI) 15,395 to 26,422]; p < 0.001), whereas underrepresented minority classification was not independently associated with a difference in total educational debt (β = USD 3719 [95% CI -6458 to 13,895]; p = 0.47). After controlling for the potentially confounding variables of gender and classification as an underrepresented minority, socioeconomic disadvantage was independently associated with higher scholarship amounts (β = USD 20,341 [95% CI 13,300 to 27,382]; p < 0.001) and higher total educational debt (β = USD 66,162 [95% CI 53,318 to 79,006]; p < 0.001) than applicants not classified as socioeconomically disadvantaged. After controlling for the potentially confounding variables of gender and classification as an underrepresented minority, socioeconomic disadvantage was independently associated with decreased match rates (OR 0.62 [95% CI 0.52 to 0.74]; p < 0.001). These findings underscore the need for comprehensive scholarship initiatives to ensure equitable financial accessibility for applicants from all backgrounds. In the future, orthopaedic surgery may benefit from research comparing the effectiveness of various initiatives aiming to improve fairness in the burden of debt among applicants to orthopaedic surgery residency programs.

103 Parental Occupation and Orthopaedic Surgery Residency Applicants: Implications on Educational Debt, Scholarships, Medical School Ranking, and Resulting Match Rates

OBJECTIVES/GOALS: Parental SES may influence the trajectory of students applying to orthopaedic surgery residency, perpetuating opportunistic disparities. Thus, we sought to examine the relationship between parental occupation/education and applicant match rate, education financing, and medical school background. METHODS/STUDY POPULATION: Data from the Association of American Medical Colleges (AAMC) documented parental occupation and education levels of 10,697 orthopedics applicants from 2011 to 2021. Parental occupations were categorized into physician vs non-physician, healthcare vs non-healthcare, working class vs non-working class, and STEMM (Science, Technology, Engineering, Mathematics, Medicine) vs non-STEMM. Parental education levels spanned from no college degree to doctorate degrees and were used as a proxy for SES. Outcomes analyzed included match success, premedical and medical school debt, total educational debt, scholarships, and representation from top 40 research medical schools as determined by NIH funding. RESULTS/ANTICIPATED RESULTS: Physician parent applicants (20.1%) had better match rates (75.5% vs. 73.5%), lower debts, lesser scholarships, and higher top 40 school representation. Healthcare parent applicants (37.0%) had similar match rates, less debt and scholarships. Working class parent applicants (6.0%) had more debt and scholarships. STEMM parent applicants (48.6%) had higher match rates, lesser debts and scholarships, and higher top 40 representation. Applicants with parents without college degrees had lower match rates (68.6% vs 74.5%), more debt and scholarships. Doctorate parent applicants had better match success (75.9% vs 72.9%), lesser debts, and higher top 40 school representation (34.9% vs 29.6%). DISCUSSION/SIGNIFICANCE: Parental SES was associated with substantial variation in applicant financial burden and educational pedigree. Notably, applicants with parents lacking degrees had lower match rates, underscoring the need for supportive strategies to ensure equitable opportunities for aspiring orthopaedic surgeons.

333 Financial Toxicity in Malignant Brain Tumors

INTRODUCTION: As costs for cancer care continue to rise, ongoing development of novel therapeutics have increased the number of patients living with cancer. Cancer survivors are at increased risk of having high medical debt burdens, bankruptcy, delayed treatments, poor compliance with therapy, and even death as a result of financial toxicity. METHODS: Hospital billing database was queried for patients with ICD code C71 who had a bad debt discharge (unpaid balance) on record from 2020-2022. The corresponding hospital chart was then queried for demographic data, patient factors, and clinical factors. RESULTS: 43 total patients had data available for analysis. The patient diagnoses were GBM (50%), Other (45.2%), followed by metastatic disease (4.7%). White patients had an average bad debt of $2742.10, while Black patients averaged $9851.6 (p = 0.017). 38.5% of White patients had more than $2000 in bad debt, compared to 81.8% of Black patients in that category (p = 0.014). The amount of debt differed significantly between tumor types; with 66.7% of GBM patients having more than $2000 in bad debt (p = 0.052). Difference in debt amount based on pre-operative employment status trended towards significance but fell short (p = 0.08). Most patients were unemployed (58.9%), followed by employed patients (33%), and retired patients (7.6%). 61.5% of employed patients had greater than $2000 in bad debt, compared with 56.5% of unemployed patients. 40% of patients had a pre-operative deficit, and of those patients, 54% had a bad debt amount in excess of $2000. 71% of patients without a pre-operative deficit had more than $2000 in bad debt. CONCLUSIONS: Bad debt is a major contributor to financial toxicity in patients with malignant brain tumors.

Survey of Medical Student Debt Status, Financial Literacy, and Desires for Financial Education

Objectives: The purpose of this study was to assess the financial literacy level of medical&amp;nbsp;students, evaluate their perceptions about the importance of financial literacy, and&amp;nbsp;determine the optimal timing and delivery for financial literacy education. Methods: From April to May 2019, a cross-sectional, anonymous, web-based survey was administered to a convenience sample of first-year (M1) to fourth-year (M4) medical students at the University of Michigan Medical School, with 216 of 680 (32%) students completing the survey. Respondents voluntarily answered 15 multiple choice questions on personal finance and 30 questions on their demographics, current financial situation, and opinions on financial literacy education. Individual financial proficiency was defined as answering 60% of the personal finance questions correctly. Results: Overall, respondents correctly answered 5.64 (38%) of the personal finance questions, with 41 (19%) students achieving financial proficiency. Lower performance on the financial literacy assessment was significantly associated with gender, age, and debt. Overall, 192 (89%) medical students believed that they should receive financial literacy training in medical school. Conclusions: Medical students demonstrate low levels of financial literacy and have a&amp;nbsp;strong desire to improve their financial literacy during their medical education. Medical&amp;nbsp;schools are well positioned to harness this interest for financial literacy education and&amp;nbsp;integrate self-directed learning opportunities.

Associations of Medical Debt With Health Status, Premature Death, and Mortality in the US

Medical debt is increasingly common in the US. Little is known regarding its association with population health. To examine the associations of medical debt with health status, premature death, and mortality at the county level in the US. This cross-sectional study was conducted at the US county level using 2018 medical debt data from the Urban Institute Debt in America project linked with 2018 data on self-reported health status and premature death from the County Health Rankings & Roadmaps and with 2015 to 2019 mortality data from the National Center for Health Statistics. Data analysis was performed from August 2022 to May 2023. Share of population with any medical debt in collections and median amount of medical debt. Health status was measured as (1) the mean number of physically and mentally unhealthy days in the past 30 days per 1000 people, (2) the mean number of premature deaths measured as years of life lost before age 75 years per 1000 people, and (3) age-adjusted all-cause and 18 cause-specific mortality rates (eg, malignant cancers, heart disease, and suicide) per 100 000 person-years. Multivariable linear models were fitted to estimate the associations between medical debt and health outcomes. A total of 2943 counties were included in this analysis. The median percentage of the county population aged 65 years or older was 18.3% (IQR, 15.8%-20.9%). Across counties, a median 3.0% (IQR, 1.2%-11.9%) of the population were Black residents, 4.3% (IQR, 2.3%-9.7%) were Hispanic residents, and 84.5% (IQR, 65.7%-93.3%) were White residents. On average, 19.8% (range, 0%-53.6%) of the population had medical debt. After adjusting for county-level sociodemographic characteristics, a 1-percentage point increase in the population with medical debt was associated with 18.3 (95% CI, 16.3-20.2) more physically unhealthy days and 17.9 (95% CI, 16.1-19.8) more mentally unhealthy days per 1000 people during the past month, 1.12 (95% CI, 1.03-1.21) years of life lost per 1000 people, and an increase of 7.51 (95% CI, 6.99-8.04) per 100 000 person-years in age-adjusted all-cause mortality rate. Associations of medical debt and elevated mortality rates were consistent for all leading causes of death, including cancer (1.12 [95% CI, 1.02-1.22]), heart disease (1.39 [95% CI, 1.21-1.57]), and suicide (0.09 [95% CI, 0.06-0.11]) per 100 000 person-years. Similar patterns were observed for associations between the median amount of medical debt and the aforementioned health outcomes. These findings suggest that medical debt is associated with worse health status, more premature deaths, and higher mortality rates at the county level in the US. Therefore, policies increasing access to affordable health care, such as expanding health insurance coverage, may improve population health.

Medical Debt—An Iatrogenic Epidemic With Mortal Consequences

Medical Debt—An Iatrogenic Epidemic With Mortal Consequences

The Double-Edged Sword of Third-Party Resources: Examining Use and Financial Burden of Extracurricular Tools in Medical Students

Background Since before the COVID-19 pandemic, use of third-party resources (or educational tools separate from the in-house medical curriculum) has been steadily increasing. The transition to virtual learning in 2020 fostered a greater reliance on these mostly online resources during medical training, yet their contributions have rarely been evaluated. Thus, we aimed to review third-party resources and their implications for medical education, particularly their financial burden on students. Methods We examined 31 peer-reviewed articles that discuss third-party resources for medical students and relevant studies related to their equitable access. Results Studies suggest third-party resources are used in a task-dependent manner with a supplemental role to the in-house lectures during the preclinical phase and a primary role for USMLE preparation during the clinical phase. Medical students ubiquitously access these resources out of a perceived necessity to use them to perform well on board exams, prompted by studies demonstrating their efficacy in increasing USMLE Step 1 scores. Though certain resources have been more frequently cited for improving board performance (e.g.,First Aid and UWorld), students may combine multiple third-party resources to best serve their exam preparation. Findings also show the subscription-pricing model of most third-party resources and 12-month access prices range from $100 to $479, suggesting that third-party resource use contributes to an increase financial strain on students. This, coupled with overwhelming medical student debt, may exacerbate existing socioeconomic disparities in medical education. Conclusion Institutions should evaluate third-party resource use among their medical students and consider provisions to increase access to these co-curricular tools.

Education and Financial Knowledge in Health-Related Financial Decisions.

The high cost of health care in the United States creates complex decisions where suboptimal choices may negatively affect an individual's physical and financial health. The challenge for patients is that the complex nature of health-related financial decisions requires specialized knowledge to avoid these suboptimal choices. While the benefits of improved health literacy are well documented, the connection between health care and household finances may mean that there is a role for education and financial knowledge in improving outcomes. This study uses data from the Financial Industry Regulatory Authority's Financial Capability Survey in a binomial logistic regression to examine the role of education and financial knowledge in health-related financial decisions. The results show that both higher levels of education and financial knowledge are related to a higher likelihood of obtaining health insurance coverage and a lower likelihood of having medical debt and engaging in cost avoidance. Income disparities remain, however, especially for those in the middle-income brackets. These results raise the possibility that increases in general education and financial knowledge may improve health outcomes, but those facing the most complex health care decisions may need more specialized knowledge. This implies that given the connection between health care and personal finances, increasing objective and subjective knowledge may lead to better outcomes for patients' financial and physical health.