Higher Annual Out-of-Pocket Expenses More Common in Cancer Survivors


Out-of-pocket costs can lead to the reduced use of preventive services and increased use of preventive medications.

A recent study found that a high annual out-of-pocket (OOP) burden is more common among non-elderly cancer survivors than those without a cancer history.

High OOP costs potentially have a negative effect on patients and can lead to decreases in access to care, influences clinical practice, and affects treatment choices. Additionally, these expenses can lead to the reduced use of preventive services and uptake of preventive medications.

For the study, published in the American Journal of Preventive Medicine, researchers used a sample from the 2008-2012 Medical Expenditure Panel Survey (MEPS) of 4271 cancer survivors between the ages of 18 to 64 years. These individuals were identified by their affirmative answers to a question on whether their doctor or health provider told them they have a malignancy of any kind.

The comparison group had 96,780 adults within the same age range who did not report a history of cancer. Those who had non-melanoma skin cancer were not classified as cancer survivors in this survey.

The sociodemographic characteristics of the survey’s cancer survivors included: time since diagnosis, age, sex, race/ethnicity, education level, marital status, number of comorbid conditions, health status, health insurance status, employment status, and family income as a percentage of the federal poverty level (FPL).

Individuals categorized as being poor had a family income of <100% FPL, nearly poor and low-income individuals had an income of 100%—200% FPL, and middle and high income individuals were categorized as having incomes ≥200% of FPL.

The annual OOP burden — which includes OOP expenditures towards health services like copayments, coinsurance, and deductibles – was measured as the percentage of OOP costs relative to family income.

The expenditures included cancer screenings, treatments, surveillance, and medical care for other conditions.

High OOP burden was defined as having an annual OOP spending >20% of annual income. For 1.8% of cancer survivors in the sample who reported low or negative incomes, a $100 floor for family income was imposed.

To perform the analysis, statistics were calculated for both groups and compared using chi-square statistics. Multivariable logistic regression models were used to assess the correlation between high OOP burden and access to care and preventative services for cancer survivors.

After adjusting for covariates, the results of the study showed that cancer survivors were more likely to have a high annual OOP burden (4.3%) compared with individuals without a history of cancer (3.4%).

The results of the study found that 36.7% of survivors were diagnosed with cancer within the past 4 years, while 39.1% were diagnosed a minimum of 10 years prior to the survey. Compared with individuals without a cancer history, cancer survivors were found to be mostly older, female, white non-Hispanic, married, insured, in fair or poor health, have more comorbid conditions, and unemployed.

Cancer survivors between 50 to 64-years-old were more likely to have a high total OOP burden than those without cancer (p=0.02). Individuals between the ages of 18 and 49-years-old had similar rates of high OOP burden regardless of their cancer history.

Cancer survivors in the near poor and low income group, and those in the middle and high income group, were more likely to have a high annual OOP burden compared with people without a cancer history and in the same poverty level categories (p=0.02 and p=0.003, respectively).

Privately insured cancer survivors were more likely to have high OOP burden than individuals without a history of cancer (p<0.001). Furthermore, high OOP burden was more common among cancer survivors working full-time than individuals working full-time without a history of cancer (p=0.02).

High OOP burden was most prevalent among cancer survivors who were poor, unemployed, and uninsured or with public insurance. High OOP burden is also associated with being unable to receive needed medical care or a delay of medical care. Furthermore, it is associated with lower breast cancer screenings for female cancer survivors of the appropriate age.

The MEPS data source is one of the most detailed and nationally representative sources available for estimating OOP burden at this time. However, there were still several limitations within the study including: the reliance on household-reported data, which introduces potential reporting biases; the use of family pre-tax income as opposed to post-tax income to compute the OOP burden; and the results of only applying to the non-institutionalized civilian adult population.

“High annual OOP burden is more common among cancer survivors than individuals without a cancer history,” the researchers concluded. “High OOP burden has the potential to reduce access to care and the utilization of preventive services. With the continuing increase in the number of cancer survivors and rising healthcare costs, trends in OOP burden among cancer survivors and efforts to improve communication between patients and providers about cost will be important to monitor and follow.”

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