Medical Financial Hardship Screening, Referral, and Payment Practices

Background: Financial toxicity (FT), or medical-related economic hardship, is an increasingly common side effect of cancer, owing, in part, to the high costs of treatment and shifts in cost sharing between payer and patient. FT is associated with delayed/skipped care, reduced quality of life, and worse morbidity and mortality, and it drives inequities in healthcare access and disparities in both health and financial outcomes. While FT is now well-described in the literature, its association with financial behaviors related to medical bill payment remains unexplored. This secondary analysis examines self-reported borrowing practices, credit card debt accrual, and use of savings to pay medical bills during cancer treatment.

Methods: As part of a quality improvement project, a FT screening for patients receiving treatment for breast, gynecologic, gastrointestinal, or thoracic cancer was implemented at a comprehensive cancer center from 09/2022-08/2023. Screening included the 11-item Comprehensive Score for Financial Toxicity (COST) tool (scored 0-44, lower scores = worse FT), and patients were screened at project baseline and four months later. Consistent with prior literature, a COST score ≤20 was considered a positive screen, and financial/assistance counseling referral was offered. Patients also self-reported borrowing practices (including bank loans, borrowing from friends/family, other “personal loans”), incurring credit card debt, and using savings (if the patient reported having savings) to pay medical bills associated with cancer treatment. Multivariable analyses that considered demographic and clinical characteristics determined associations of FT with use of loans, credit cards, and savings to pay for medical bills at baseline and follow-up.

Results: 8,167 patients completed the COST screening at both timepoints: median COST at the baseline was 23.0 (IQR: 16-31), median COST at 4-month follow-up was 28.1 (IQR: 21-36). At baseline, 39% had financial toxicity; 13% reported borrowing money, 5% incurred credit card debt, and 20% use savings to pay for treatment. At follow-up, 23% had financial toxicity; 17% borrowed money, 7% incurred credit card debt, and 21% used savings for treatment-related medical bills.

In multivariable models, FT was associated with borrowing money for treatment (OR: 11.2, 95% CI: 9.1, 13.7), incurring treatment-related credit card debt (OR: 14.4, 95% CI: 10.1, 20.6), and using savings to pay for treatment (OR: 6.1, 95% CI: 5.2, 7.1) at baseline. Baseline FT was also predictive of borrowing money (OR: 6.7, 95% CI: 5.8, 7.8), credit card debt (OR: 11.0, 95% CI: 8.4, 14.4), and using savings (OR: 5.1, 95% CI: 4.4, 5.9) at 4-month follow-up. However, for a subset of patients who screened positive and were contacted by financial counselors (n=568), the impact of FT is attenuated when receipt of financial counseling is considered.

Conclusions: Among patients with cancer, FT can impact financial behaviors, including paying medical bills through loans, credit cards, and savings. Prevention and mitigation efforts are needed to lessen the negative consequences of FT on material and psychosocial well-being. At the patient-level, social work plays an important role in FT screening, insurance/financial navigation, and facilitating referrals for direct financial support and co-payment assistance, although systemic interventions are needed as well.