Medical Financial Hardship Research Articles

The association of disability and medical financial hardship among cancer survivors in the US.

136 Background: Medical financial hardship (MFH) in cancer survivors is well-documented. Little is known about how disability impacts healthcare needs and costs in cancer survivorship. We examined associations of disability and MFH among survivors in the US. Methods: We identified cancer survivors ≥18 years with (n=2,795) and without (n=12,263) a disability from the National Health Interview Survey 2019 to 2022. The Washington Group Short Set, a validated six-item measure intended to describe the functional status of adults (e.g. disability in seeing, hearing, or walking) was used to identify those with disabilities. MFH was categorized into three domains: 1) material (e.g. problems paying medical bills), 2) psychological (e.g. worrying about medical bills), and 3) behavioral (e.g. delaying/forgoing care due to cost). Adjusted logistic regressions were used to examine associations of disability and MFH among cancer survivors. Results: Cancer survivors with a disability were more likely to experience any MFH (57.2% vs. 47.0%, p<0.05) or any individual domain (Material: 26.4% vs. 13.3%, p<0.05; Psychological: 50.5% vs. 43.0%, p<0.05; Behavioral: 23.2% vs. 12.9%, p<0.05) compared with those without a disability. In addition, survivors with a disability were more likely to report experiencing multiple domains of MFH (29.1% vs. 15.9%; p<0.05). Conclusions: Cancer survivors with a disability face higher risks of MFH. Our findings can inform interventions alleviating MFH in this especially vulnerable population. Association of disability with medical financial hardship among cancer survivors, National Health Interview Survey 2019-2022. Cancer Survivors with a Disabilityn = 2,795 Cancer Survivors without a Disabilityn = 12,263 AME(95% CI) AME(95% CI) Any material financial hardship 26.4(24.7, 28.0) 13.3(12.5, 14.2) Any psychological financial hardship 50.5(49.1, 52.0) 43.0(42.0, 44.0) Any behavioral financial hardship 23.2(21.7, 24.7) 12.9(12.0, 13.7) Any MFH 57.2(55.8, 58.6) 47.0(46.0, 48.0) 1 domain of MFH 57.2(55.8, 58.6) 47.0(46.0, 48.0) 2+ domains of MFH 29.1(27.5, 30.6) 15.0(14.1, 15.8) Note: In adjusted analyses, covariates included age, sex, race/ethnicity, marital status, education, family income as % of Federal Poverty Level, insurance, year, and survey design; AME=Average Marginal Effect; CI = Confidence Interval.

Medical financial hardship in the Southern United States: the struggle continues across generations pre- and post- the Affordable Care Act

IntroductionMedical financial hardship in the United States is a growing public health concern. This study aims to assess the south vs. non-south disparities in medical financial hardship among US adults of different generations – Boomers (born between 1946 and 1964), Generation X (born between 1965 and 1980), and the Millennials (born between 1981 and 1996) across periods pre- and post- Affordable Care Act (ACA).MethodsThis observational study utilizes data from multiple waves of the National Health Interview Survey (NHIS) split into three periods: pre–ACA (2011–2013), ii) post ACA (2015–2018), and iii) COVID-19 pandemic (2021–2022). Multivariable logistic regressions were fitted, separately for each generation in each period, to compare the extent of medical financial hardship among those from South to rest of the US, and Karlson-Holm-Breen (KHB) decomposition was applied to analyze whether there was a mediating impact of health insurance coverage.ResultsAdults living in the South were more likely to experience medical financial hardship in all three periods. Residing in the South was associated with 1.7 to 2.6% points (pp) higher probability of medical financial hardship among boomers, 1.8 to 4.0 pp among generation Xers, and 1.7 to 2.8 pp among millennials. The relationship was robust after accounting for chronic comorbidities, sociodemographic and socioeconomic attributes and was partially mediated through differences in health insurance coverage.ConclusionsThe problem of medical financial hardship has been deeply rooted in the South across generations, which was partly attributable to the regional differences in health insurance coverage.

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.

Financial distress and medical financial hardship among young adult survivors of blood cancer.

The long-term financial impact of cancer care has not been adequately addressed in young adults. As part of a remote intervention study, we describe medical financial distress and hardship among young adult survivors of blood cancer at study entry. Young adults were recruited from 6 US hospitals. Using a Research Electronic Data Capture link, young adults confirmed their eligibility-namely, currently 18 to 39 years of age, blood cancer diagnosis 3 or more years ago, off active treatment, and not on parent's insurance. Following consent, the baseline assessment was sent. The primary outcome measure, the Personal Financial Wellness Scale, measured financial distress (scored as severe, 1-2; high, 3-4; average, 5-6; and low to no, 7-10). Medical financial hardship encompassed material hardship, psychological impact, and coping behaviors. Descriptive summary statistics and linear regression were used. Among the 126 participants, 54.5% came from minority racial or ethnic groups. Median time since diagnosis was 10 years (interquartile range = 6-16 years), with 56% having received a diagnosis when they were between 18 and 39 years of age. The overall mean (standard deviation) Personal Financial Wellness Scale score was 5.1 (2.4), but 49% reported severe or high distress. In multivariable analysis, female sex, Hispanic ethnicity, and lower income were strongly associated with worse Personal Financial Wellness Scale scores. Among participants with severe financial distress (n = 26), 72% reported 2 or more household material hardships, had worse scores across all psychological domains, and altered survivorship care because of cost (68%). Nearly half of long-term young adult cancer survivors reported severe or high levels of financial distress. Individuals with severe or high distress also reported more medical financial hardship than other participants. This finding highlights the need for ongoing financial intervention in this vulnerable population. NCT05620979.

Financial Distress in Genitourinary Cancer: Insights From CDC National Health Interview Survey.

This study leverages CDC National Health Interview Survey data to examine Financial Distress (FD) among genitourinary (GU) cancer survivors, specifically prostate cancer (PC), kidney cancer (KC), and bladder cancer (BC). It investigates the economic impacts faced by these patients, especially in relation to disparities in insurance coverage and its effects on material, psychological, and behavioral aspects of FD. We retrospectively analyzed responses from GU cancer survivors, stratifying by cancer status and age (18-64 years, ≥65 years). Medical financial hardship was divided into three domains: material, psychological, and behavioral. Associations between cancer history, hardship, and clinical factors were assessed using generalized ordinal logistic regressions. Significant health care access disparities were found, particularly for mental health services, with 25% of younger BC survivors and 4.7% of younger KC survivors reporting affordability issues, in contrast to 2.7% of noncancer individuals. Dental care was also problematic, with higher avoidance rates among younger BC (27%) and KC (15%) survivors compared with the general population. Surprisingly, noncancer individuals reported more difficulty in affording prescriptions than BC survivors across both age groups. PC survivors, however, showed lower FD across all domains versus noncancer controls, indicating fewer concerns about medical bills and a lesser tendency to forgo care. The study underscores significant gaps in the financial support system for GU cancer survivors, with urgent needs in mental and dental health care access. Policy interventions, including comprehensive insurance reforms, are imperative to alleviate the financial burdens on these individuals.

Association between financial hardship and psychological burden and the role of social and mental health support: An observational study.

We aimed to assess the association between medical financial hardship and psychological burden and the moderating role of social and mental health support. 2021 United States National Health Interview Survey was used. Financial hardship was defined as having financial worry, material hardship, or cost-related care nonadherence. Psychological burden was measured using perceived general health status, satisfaction with life, and serious psychological distress (SPD). Of 29,370 included adults, 49% experienced financial hardship in the last 12 months. Financial hardship was associated with a higher psychological burden (odds ratio [OR], 3.58; 95% confidence interval [CI], 2.43-5.47 for SPD). Eleven percent received counseling/therapy from mental health professionals, and 90% had experienced frequent social support. Frequent social support was associated with lower financial hardship (OR, 0.71; 95% CI, 0.63-0.80) and psychological burden (OR, 0.28; 95% CI, 0.19-0.42 for SPD). Previous mental health support was associated with higher financial hardship (OR,1.40; 95% CI, 1.28-1.54) and psychological burden (OR, 9.75; 95% CI, 6.97-13.94 for SPD). Those experiencing financial hardship had lower odds of SPD if they received mental health support in the last 12 months (OR, 0.57; 95% CI, 0.39-0.85). Future interventions should also focus on improving social support and mental health for patients as a way of mitigating medical financial hardship.

Interventions to mitigate cancer-related medical financial hardship: A systematic review and meta-analysis.

This study systematically reviewed interventions mitigating financial hardship in patients with cancer and assessed effectiveness using a meta-analytic method. PubMed, Cochrane, Scopus, CINAHL, and Web of Science were searched for articles published in English during January 2000-April 2023. Two independent reviewers selected prospective clinical trials with an intervention targeting and an outcome measuring financial hardship. Quality appraisal and data extraction were performed independently by two reviewers using a quality assessment tool. A random-effects model meta-analysis was performed. Reporting followed the preferred reporting items for systematic review and meta-analyses guidelines. Eleven studies (2211 participants; 55% male; mean age, 59.29 years) testing interventions including financial navigation, financial education, and cost discussion were included. Financial worry improved in only 27.3% of 11 studies. Material hardship and cost-related care nonadherence remained unchanged in the two studies measuring these outcomes. Four studies (373 participants; 37% male, mean age, 55.88 years) assessed the impact of financial navigation on financial worry using the comprehensive score of financial toxicity (COST) measure (score range, 0-44; higher score=lower financial worry) and were used for meta-analysis. There was no significant change in the mean of pooled COST score between post- and pre-intervention (1.21; 95% confidence interval, -6.54 to 8.96; p=.65). Adjusting for pre-intervention COST, mean change of COST significantly decreased by 0.88 with every 1-unit increase in pre-intervention COST (p=.02). The intervention significantly changed COST score when pre-intervention COST was ≤14.5. A variety of interventions have been tested to mitigate financial hardship. Financial navigation can mitigate financial worry among high-risk patients.

Health-related social needs, medical financial hardship, and mortality risk among cancer survivors.

Cancer survivors may face challenges affording food, housing, and other living necessities, which are known as health-related social needs (HRSNs). However, little is known about the associations of HRSNs and mortality risk among adult cancer survivors. Adult cancer survivors were identified from the 2013-2018 National Health Interview Survey (NHIS) and linked with the NHIS Mortality File with vital status through December 31, 2019. HRSNs, measured by food insecurity, and nonmedical financial worries (e.g., housing costs), was categorized as severe, moderate, and minor/none. Medical financial hardship, including material, psychological, and behavioral domains, was categorized as 2-3, 1, or 0 domains. Using age as the time scale, the associations of HRSNs and medical financial hardship and mortality risk were assessed with weighted adjusted Cox proportional hazards models. Among cancer survivors 18-64 years old (n=5855), 25.5% and 18.3% reported moderate and severe levels of HRSNs, respectively; among survivors 65-79 years old (n=5918), 15.6% and 6.6% reported moderate and severe levels of HRSNs, respectively. Among cancer survivors 18-64 years old, severe HRSNs was associated with increased mortality risk(hazards ratio [HR], 2.00; 95% confidence interval [CI], 1.36-2.93, p < .001; reference = minor/none) in adjusted analyses. Among cancer survivors 65-79 years old, 2-3 domains of medical financial hardship was associated with increased mortality risk (HR, 1.58; 95% CI, 1.13-2.20, p = .007; reference = 0 domain). HSRNs and financial hardship are associated with increased mortality risk among cancer survivors; comprehensive assessment of HRSN and financial hardship connecting patients with relevant services can inform efforts to mitigate adverse consequences of cancer.

Cancer diagnosis and treatment in working-age adults: Implications for employment, health insurance coverage, andfinancial hardship in the United States.

The rising costs of cancer care and subsequent medical financial hardship for cancer survivors and families are well documented in the United States. Less attention has been paid to employment disruptions and loss of household income after a cancer diagnosis and during treatment, potentiallyresulting in lasting financial hardship, particularly for working-age adults not yet age-eligible for Medicare coverage and their families. In this article, the authors use a composite patient case to illustrate the adverse consequences of cancer diagnosis and treatment for employment, health insurance coverage, household income, and other aspects of financial hardship. They summarize existing research and provide nationally representative estimates of multiple aspects of financial hardship and health insurance coverage, benefit design, and employee benefits, such as paid sick leave, among working-age adults with a history of cancer and compare them with estimates among working-age adults without a history of cancer from the most recently available years of the National Health Interview Survey (2019-2021). Then, the authors identify opportunities for addressing employment and health insurance coverage challenges at multiple levels, including federal, state, and local policies; employers; cancer care delivery organizations; and nonprofit organizations. These efforts, when informed by research to identify best practices, can potentially help mitigate the financial hardship associated with cancer.

Expert consensus on quality control indicators for integrative medicine in rheumatoid arthritis (2023 version)

AbstractThe rising costs of cancer care and subsequent medical financial hardship for cancer survivors and families are well documented in the United States. Less attention has been paid to employment disruptions and loss of household income after a cancer diagnosis and during treatment, potentially resulting in lasting financial hardship, particularly for working‐age adults not yet age‐eligible for Medicare coverage and their families. In this article, the authors use a composite patient case to illustrate the adverse consequences of cancer diagnosis and treatment for employment, health insurance coverage, household income, and other aspects of financial hardship. They summarize existing research and provide nationally representative estimates of multiple aspects of financial hardship and health insurance coverage, benefit design, and employee benefits, such as paid sick leave, among working‐age adults with a history of cancer and compare them with estimates among working‐age adults without a history of cancer from the most recently available years of the National Health Interview Survey (2019–2021). Then, the authors identify opportunities for addressing employment and health insurance coverage challenges at multiple levels, including federal, state, and local policies; employers; cancer care delivery organizations; and nonprofit organizations. These efforts, when informed by research to identify best practices, can potentially help mitigate the financial hardship associated with cancer.

Medical financial hardship between young adult cancer survivors and matched individuals without cancer in the United States.

Young adult cancer survivors face medical financial hardships that may lead to delaying or forgoing medical care. This study describes the medical financial difficulties young adult cancer survivors in the United States experience in the post-Patient Protection and Affordable Care Act period. We identified 1009 cancer survivors aged 18 to 39 years from the National Health Interview Survey (2015-2022) and matched 963 (95%) cancer survivors to 2733 control individuals using nearest-neighbor matching. We used conditional logistic regression to examine the association between cancer history and medical financial hardship and to assess whether this association varied by age, sex, race and ethnicity, and region of residence. Compared with those who did not have a history of cancer, young adult cancer survivors were more likely to report material financial hardship (22.8% vs 15.2%; odds ratio = 1.65, 95% confidence interval = 1.50 to 1.81) and behavior-related financial hardship (34.3% vs 24.4%; odds ratio = 1.62, 95% confidence interval = 1.49 to 1.76) but not psychological financial hardship (52.6% vs 50.9%; odds ratio = 1.07, 95% confidence interval = 0.99 to 1.16). Young adult cancer survivors who were Hispanic or lived in the Midwest and South were more likely to report psychological financial hardship than their counterparts. We found that young adult cancer survivors were more likely to experience material and behavior-related financial hardship than young adults without a history of cancer. We also identified specific subgroups of young adult cancer survivors that may benefit from targeted policies and interventions to alleviate medical financial hardship.

Cancer survivors’ use of crowdfunding campaigns: AI-generated patterns of reported medical financial hardship and unmet social needs.

542 Background: Cancer survivors and their families frequently experience medical financial hardship and may make trade-offs with other household economic needs to save money. Crowdfunding campaigns have become increasingly common for requesting financial support to cover expenses for medical treatments and daily living necessities. However, little is known about cancer survivors’ use of personal crowdfunding campaigns, including the amounts and types of financial support received. Methods: Ten thousand fundraiser stories related to cancer were randomly selected from 2022 GoFundMe using a distributed web scraper. Additional campaign information from publicly available GoFundMe webpages included organizer’s information, fundraising goal, amount of money raised, and donation records. A brief survey was designed and implemented with OpenAI, which analyzed each fundraiser story to extract cancer survivors’ sociodemographic characteristics, medical financial hardship, and unmet social needs. For each campaign, the fundraiser story and the corresponding survey were sent to GPT-3.5-Turbo model through the OpenAI’s application programming interface. Extracted information included beneficiary’s age, cancer site and stage, time since diagnosis, treatment status, employment status and work disruption due to cancer (ages ≥18 years), school absenteeism and parent’s work disruption (ages &lt;18 years), lack of sick leave, income loss, struggles with expenses for medical treatments, housing, food, transportation, and monthly bills. Results: Among 10,000 cancer-related fundraiser stories, 3,275 specified age of the beneficiary with cancer (774 ages &lt;18 years, 2,531 ages ≥18 years). Moreover, the most common cancer sites were breast (n=583), colon (n=223), and brain (n=169) in ages ≥18 years; leukemia (n= 217), brain (n= 139), and bone (n=52) in ages &lt;18 years. Average amount raised was $10,205 (ages &lt;18 years; median: $4,908, inter quantile range [IQR]: $1,692-$13,252) and $8,515 (ages ≥18 years; median: $3,684, inter quantile range [IQR]: $1,495-$9,258). Only 10.8% reached their fundraising goals. Among cancer survivors aged &lt;18 years, 26.6% experienced school absenteeism and 8.8% described parental work disruptions. Among survivors aged ≥18 years, frequently listed reasons for financial support needs include work disruption (51.4%) and income loss (37.1%), lack of sick leave (33.3%), and struggles with expenses for medical treatments (94.0%) and for housing, food, transportation, and monthly bills (22.6%). Conclusions: Cancer-related crowdfunding campaigns are used to pay for medical and other basic household expenses, underscoring the fragility of safety nets in the US. Examination of fundraising stories can provide important insights to the types of financial hardship experienced by cancer survivors and inform future interventions.

Social determinants of health profiles and survival among US cancer survivors: A cluster analysis.

402 Background: Healthcare payers and clinicians increasingly focus on social determinants of health (SDOH) to reduce disparities in care and improve patient outcomes in US. Prognostic value of single SDOH factors has been described, but not for clusters of multiple SDOHs. We characterize cancer survivors by their SDOH profiles and examine associations with survival. Methods: 11,237 cancer survivors were identified from the 2013-2018 National Health Interview Survey (NHIS) with linkage to NHIS Mortality Files. 9 SDOHs were included in 5 a priori identified domains: 1) healthcare access (medical financial hardship, delayed care due to transportation and/or other barriers); 2) economic instability (unemployment, food insecurity, housing insecurity); 3) social isolation (marital status); 4) education and literacy (&lt; high school education); and 5) neighborhood quality (low neighborhood social cohesion (nSC) based on 4 item scale developed by the Project on Human Development in Chicago Neighborhoods Community Survey). The most significant SDOH in each domain was identified with Cox regressions. We then clustered patients into 5 groups using the inter-person Gower distance of the 5 selected SDOHs and examined survival among each cluster adjusting for age, sex, race, region, and survey era. Results: 5 distinct clusters of cancer survivors were identified with top-ranking SDOHs in each domain: 1) Healthy Hopefuls: young, employed, and married with fewer socio-economic and health burdens; 2) Independent Phoenixes: single, employed rising above adversity, maintaining health and financial wellness; 3) Enduring Companions: older, unemployed, and married navigating health challenges while maintaining financial stability; 4) Solo Warriors: older, single, unemployed with health complications and financial hardships; and 5) Resilient Overcomers: unemployed minorities in low-quality neighborhoods, overcoming the obstacles of higher health and socio-economic challenges. Groups 3, 4, and 5 had worse survival than group 1 in adjusted analyses (Table). Conclusions: SDOH profiles were strongly associated with survival in US cancer survivors. Findings support the need to identify SDOH profiles in efforts to personalize mitigation strategies and enhance long-term wellness.[Table: see text]

Financial hardship and psychosocial well-being and quality of life among prostate cancer survivors in the United States.

Prostate cancer is the most common cancer diagnosis among men in the United States and the prevalence of prostate cancer survivors is growing. Cancer treatment and lasting or late effects of disease and treatment can adversely affect financial health, psychosocial well-being, and health-related quality of life for prostate cancer survivors, even many years after cancer diagnosis and treatment. These outcomes are important, especially because most men live for many years following a prostate cancer diagnosis. In this essay, we describe health care spending associated with prostate cancer, including patient out-of-pocket costs, and summarize research examining medical financial hardship and associations of financial hardship and psychosocial well-being and health-related quality of life among cancer survivors. We then discuss implications for health care delivery and opportunities to mitigate financial hardship for patients with prostate cancer and their families.

Frailty and medical financial hardship among older adults with cancer in the United States.

Little is known about the association between frailty level and medical financial hardship among older adults with cancer. This study aims to describe the prevalence of frailty and to identify its association with medical financial hardship among older cancer survivors in the United States. The National Health Interview Survey (NHIS; 2019-2020) was used to identify older cancer survivors (n = 3,919). Both the five-item (Fatigue, Resistance, Ambulation, Illnesses, and Low weight-for-height) FRAIL and the three-domain (Material, Psychological, and Behavioral) medical financial hardship questions were constructed based on the NHIS questionnaire. Multivariable logistic models were used to identify the frailty level associated with financial hardship and its intensity. A total of 1,583 (40.3%) older individuals with cancer were robust, 1,421 (35.9%) were pre-frail, and 915 (23.8%) were frail. Compared with robust cancer survivors in adjusted analyses, frail cancer survivors were more likely to report issues with material domain (odds ratio (OR) = 3.19, 95%CI: 2.16-4.69; p < 0.001), psychological domain (OR = 1.47, 95%CI: 1.15-1.88; p < 0.001), or behavioral domain (ORs ranged from 2.19 to 2.90, all with p < 0.050), and greater intensities of financial hardship. Both pre-frail and frailty statuses are common in the elderly cancer survivor population, and frail cancer survivors are vulnerable to three-domain financial hardships as compared with robust cancer survivors. Ongoing attention to frailty highlights the healthy aging of older survivors, and efforts to targeted interventions should address geriatric vulnerabilities during cancer survivorship.

Associations of cancer history, food insecurity, and nonmedical financial worry and mortality risk in the US.

6537 Background: Cancer survivors often face substantial out-of-pocket medical costs, which can adversely affect their financial well-being. Cutting expenses on food and housing to save money are common coping strategies. However, little is known about the extent to which food insecurities and non-medical financial worries affect mortality risk after consideration of medical financial hardship. Methods: The 2013-2018 National Health Interview Survey (NHIS) and the NHIS linked mortality files with vital status through December 31, 2019 were used to identify cancer survivors (ages 18-64: n=5,110; ages 65-79: n=4,949) and individuals without a cancer history (ages 18-64: n=115,643; ages 65-79: n=24,785). Medical financial hardship included 3 domains: material, psychological, and behavioral. Food insecurity (e.g., worry about food running out) and non-medical financial worries (e.g., paying for monthly bills and housing) were separately summarized and categorized as severe, moderate, and minor/none levels. Using age as the time scale, associations of cancer history, food insecurity and non-medical financial worry and mortality risk were examined with weighted Cox proportional hazards models. Adjusted models included medical financial hardship, sex, educational attainment, marital status, health insurance, comorbid conditions, and survey year. All estimates accounted for complex survey design. Results: In our sample, about 13.8% (ages 18-64) and 7.9% (ages 65-79) reported moderate to severe levels of food insecurity, respectively; 32.1% (ages 18-64) and 19.2% (ages 65-79) reported moderate to severe levels of non-medical financial worries, respectively. In adjusted analyses, cancer survivors had increased mortality risk. After controlling for medical financial hardship, food insecurity was associated with higher mortality risk in both age groups, following a dose-response relationship (Table); Non-medical financial worry was associated with higher mortality risk in the 65-79 age group (Table). Conclusions: Standardized and comprehensive assessment of financial hardship and other social needs, such food insecurity, is essential to identify and mitigate adverse economic impacts of cancer. [Table: see text]

Beyond transportation: Financial hardship, food insecurity, and care access barriers among US cancer survivors with transportation barriers to care.

6534 Background: Health care payers and providers increasingly focus on addressing social determinants of health (SDoH) in order to reduce disparities in care and patient outcomes in the US. Transportation barriers to health care, a key SDoH, are associated with increased emergency department use and mortality risk among cancer survivors. Transportation barriers may also be associated with other potentially addressable aspects of SDoH and access barriers. To inform future interventions, we examined financial hardship and barriers to timely care among cancer survivors with transportation challenges in a nationally representative sample. Methods: We identified 18,140 adults with a history of cancer from the 2011-2018 National Health Interview Survey. Transportation barriers were defined as delay in care due to lack of transportation over the past 12 months. Primary outcomes included 1) medical financial hardship (FH) in any of the three following domains: material (problems paying medical bills), psychological (worrying about medical bills), and behavioral hardship (delaying/forgoing care due to cost); 2) food insecurity (worrying food would run out); and 3) delayed care due to other factors (long wait times, inability to get an appointment quickly). We estimated the proportion of survivors who report any financial hardship, food insecurity, or other factors that lead to care delays and compared the age-sex adjusted prevalence of these barriers among cancer survivors by whether or not they reported transportation barriers using logistics regression. Results: Of the 18,123 cancer survivors, 2.9% reported having transportation barriers to care. Survivors with transportation barriers experienced significantly higher financial hardship, food insecurity, or other factors that lead to care delays than survivors without transportation barriers (86.0% vs 45.3%, p&lt;0.001). Additionally, survivors with transportation barriers were more likely to experience medical financial hardship (73.2% vs 38.3%, p&lt;0.001), including material (50.3% vs 27.1%, p&lt;0.001), behavior (57.5% vs 20.4%, p&lt;0.001), and psychological (33.5% vs 15.4%, p&lt;0.001) hardship than survivors without transportation barriers. Additionally, survivors with transportation barriers were more likely to experience food insecurity (43.9% vs 12.0%, p&lt;0.001) and care delays due to other factors (45.6% vs. 11.6%, p&lt;0.001). Conclusions: Most cancer survivors with transportation barriers to care also report struggling financially and experiencing additional barriers to timely care. Findings highlight the importance of screening and addressing social needs and comprehensive interventions to address barriers to care access in this vulnerable population.

Association of medical debt and cancer mortality in the US.

6505 Background: Medical debt is associated with non-medical and medical financial hardship, such as food and housing insecurity, as well as delaying or forgoing recommended health care. This study examines county level associations between medical debt and cancer mortality in the US. Methods: We conducted a county level ecological study, using 2018 medical debt data from the Urban Institute linked with 2015-2019 mortality data from the National Centers for Health Statistics. All US counties with non-missing information on medical debt and other covariates were included. Primary outcomes were age-adjusted mortality rates per 100,000 person-years for all malignant cancers and by cancer type. Multivariable linear mixed models were used to estimate the association of percent of population with medical debt with cancer mortality, adjusting for county level sociodemographic characteristics. Additional analyses examined the association between median amount of medical debt per person and cancer mortality for the subset of counties with these data. Models were weighted by county level population size, with standard errors clustered at the state level. Results: Among 2,943 counties, an average of 19.8% of the population had medical debt, ranging from 0% to 53.6% across counties. Higher percentages of the population with medical debt were observed in non-metro areas, counties with higher percentages of non-Hispanic Black people, adults without high school education, living below poverty level, uninsured, or unemployed. One percentage point increase in the population with medical debt was associated with a 1.12 (95% CI=1.02-1.22) increase in age-adjusted mortality rate (per 100,000 person-years) for all malignant cancers, a 0.47 (95% CI=0.43-0.52) increase for lung cancer, a 0.09 (95% CI=0.07-0.11) increase for colorectal cancer, and a 0.06 (95% CI=0.04-0.07) increase for female breast cancer. Among 1,949 counties with the amount of medical debt available, each $100 increase in median medical debt was associated with a 0.86 (95% CI=0.52-1.21) increase in age-adjusted mortality rate for all malignant cancers. Associations between increases in median medical debt and increased mortality rates were statistically significant for major cancer types. Conclusions: Medical debt is associated with significantly higher cancer mortality at the county level. Policies increasing access to affordable health care may improve cancer outcomes. [Table: see text]

Maxed out: Reaching the annual maximum out-of-pocket limit among insured patients diagnosed with cancer.

6646 Background: Patients with cancer face potentially high out-of-pocket costs associated with their medical care, which may lead to adverse medical and financial outcomes. Depending on their health insurance plan, patients may have to pay several thousands for medical care costs until they reach the annual maximum out-of-pocket [MOOP] spending limit; after which care costs are covered by insurance. The purpose of this study was to measure the proportion of adult patients who reach their health plan MOOP limit in the year of cancer diagnosis. Methods: Electronic health record data from 13,057 patients aged ≥18 years, diagnosed with cancer between Jan. 1, 2016–March 31, 2021 [index cancer], with ≥12 months of continuous health insurance coverage pre-cancer diagnosis were included. The primary outcome was defined as reaching the MOOP limit in the health plan benefit year of index cancer diagnosis (binary, yes/no). We additionally created a secondary outcome using 3 categories: (i) did not reach MOOP; (ii) reached MOOP prior to cancer diagnosis; (iii) reached MOOP after cancer diagnosis. Descriptive statistics were used to assess the distribution of outcomes across patient characteristics including health insurance type (e.g., commercial), high-deductible health plan (HDHP), cancer type, age at diagnosis, and Census-level household income was included. Multivariable logistic regression estimated the association between patient characteristics and the primary outcome. Complete case analyses were performed using Stata 16.1. Results: Patients’ mean age was 66 years (standard deviation [sd]: 13) and mean Census-level household income was $73,100 (sd: $24,000). Approximately 40% of patients had commercial health insurance and 62% had Medicare; 2% (n=283) had a HDHP. Breast (18%), lung (11%) and prostate (11%) cancers were most common. The mean annual MOOP limit was $3,040 for commercial plans and $2,688 for Medicare plans. Among patients with a commercial plan insurance, 46% reached their MOOP limit including 8% before and 37% after cancer diagnosis. For Medicare patients, 20% reached their MOOP limit, including 3% before and 17% after cancer diagnosis. Patients with a HDHP (adjusted Odds Ratio [aOR]: 2.61, 95% CI: 1.96-3.47), breast cancer (aOR: 2.29, 95% CI: 1.84-2.84), and lung cancer (aOR: 2.71, 95% CI: 2.04-3.61) had significantly greater odds of reaching the MOOP than those with a non-HDHP and other cancers. Household income was also significantly associated (aOR: 0.97, 95% CI:0.95-0.99) with reaching the MOOP. Conclusions: A substantial proportion of patients reach the annual MOOP limit during the year of cancer diagnosis, representing a population at high-risk for medical financial hardship. Future longitudinal studies are needed to assess the trajectory of OOP spending and implications on care utilization and health outcomes.

Medical Financial Hardship and Food Security among Cancer Survivors in the United States.

Some cancer survivors experience medical financial hardship, which may reduce their food security. The purpose of this study was to explore whether medical financial hardship is related to food security among cancer survivors. The study was based on cross-sectional data from the 2020 National Health Interview Survey. We used ordinal logistic regression to examine the relationship between material, psychological, and behavioral medical financial hardships and household food security (i.e., high, marginal, low, or very low) among individuals ages ≥18 years who reported a cancer diagnosis from a health professional (N = 4,130). The majority of the sample reported high household food security (88.5%), with 4.8% reporting marginal, 3.6% reporting low, and 3.1% reporting very low household food security. In the adjusted model, the odds of being in a lower food security category were higher for cancer survivors who had problems paying or were unable to pay their medical bills compared with those who did not [OR, 1.73; 95% confidence interval (CI), 1.06-2.82, P = 0.027], who were very worried about paying their medical bills compared with those who were not at all worried (OR, 2.88; 95% CI, 1.64-5.07; P < 0.001), and who delayed medical care due to cost compared with those who did not (OR, 2.56; 95% CI, 1.29-5.09; P = 0.007). Food insecurity is rare among cancer survivors. However, medical financial hardship is associated with an increased risk of lower household food security among cancer survivors. A minority of cancer survivors experience medical financial hardship and food insecurity; social needs screenings should be conducted.