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Addressing Cancer Financial Hardship Begins With Comprehensive Assessment of Patient Economic Burden

Year: 2021
Type: editorial
Abstract: The Surveillance, Epidemiology, and End Results (SEER) registry data linked with Medicare enrollment and claims (SEER-Medicare) have created unprecedented opportunities for health services research since their inception (1) and have been the main source to project national costs of cancer care (2-4). As the influx of expensive new treatments threatens the affordability of cancer care—to the extent that “financial toxicity” has become common terminology in oncology—policy makers have been relying on case studies or claims data from commercial insurance to glean information on the economic burden of cancer to patients. The use of SEER-Medicare to understand the full scope of costs to cancer patients and their families has been hindered by the quality of out-of-pocket (OOP) payment information, which remains labeled as one of the “measures that are problematic” on the SEER-Medicare website (5). However, in this issue of the Journal, through clever data analytic strategy that capitalizes on the strengths of SEER-Medicare and the Medical Expenditure Panel Survey (MEPS), Yabroff and colleagues (6) overcome inherent data limitations in SEER-Medicare to produce the most comprehensive national estimate yet of the economic burden of cancer on patients, projected at $21.1 billion for 2019 and including OOP and time costs. Following well-established methods in NCI’s cost reporting (2-4), the Yabroff et al. (6) study applied the phase-of-care approach to analyze the costs borne by cancer patients and by matched controls to arrive at the “net cost” of cancer—overall and for the 15 most prevalent cancers (7). The reporting of net cost is consistent with the concept of “marginal” or “incremental” cost in economics; such estimates can inform policy makers about the additional economic burden imposed by cancer. In this regard, 2 related points merit discussion, especially when interpreting OOP costs in the context of net cost. First, patient economic burden reported as net cost reflects the OOP and time costs borne by patients expressly as a result of their cancer diagnosis and treatment after removing (netting out) the costs incurred due to noncancer-related care. This is accomplished by identifying the total costs incurred by cancer patients and then subtracting the costs incurred by statistically similar individuals without cancer. Arguably, cancer patients themselves, and their families, would likely be focused on the total (cancer plus noncancer) costs they bear. From their perspective, it is the totality of these health-care–related cost burdens that reflects the overall financial toxicity they must cope with following a cancer diagnosis. The cost components for such a summary analysis are clearly available here [see Tables 2, 3, 5, and 6 in Yabroff et al. (6)], potentially setting the stage for a complementary version of Table 7 in Yabroff et al. (6) for the projected total cost borne by cancer patients, overall, and by cancer. Second, although the more aggressive cancer treatment patterns seen among younger patients likely lead to higher overall costs than the costs for older patients, this need not translate into higher total OOP costs for younger patients. Total OOP costs depend, in part, on insurance benefit design, and an important difference between Medicare and private insurance, which covered approximately 65% of individuals younger than 65 years in 2019 (7), is the OOP maximum provision in many private plans. By 2016 nearly 98% of American workers were covered in a plan with an OOP maximum (8). This provision, however, does not apply to Medicare fee-for-service plans, which may be especially salient in relation to the total cost faced by cancer patients. As evident from Table 5 in Yabroff et al. (6), estimated total annual OOP costs from MEPS for “cancer survivors” are lower for those aged 18-64 years compared with those aged 65 years and older for both medical services ($743 vs $1041.8, a ratio of 0.71) and prescription medications ($280.8 vs $574.5, a ratio of 0.49). Thus, if one were to use MEPS data to adjust SEER-Medicare estimates of total OOP to corresponding estimates applicable to survivors aged 18-64 years, the ratios of 0.71 and 0.49 would presumably apply, implying lower projected annual total OOP for younger, non-Medicare cancer patients. By contrast, when the focus is on net cost, the ratios comparing OOP cost for patients aged 18-64 years with 65 years and older are quite different, as the authors correctly calculated: $232.7/$97.7 = 2.38 for medical services; $87.4/$67.0 = 1.30 for prescription medications. Again, the net cost approach and a focus on the absolute economic burden for patients and their families represent important, complementary perspectives. Based on the data presented, the higher absolute burden faced by the aged 65 years and older group should inform policy discussions about possible reforms in Medicare benefit plan design. The authors are applauded for a very well-conducted study that fully capitalizes on the cost-related information in SEER-Medicare and MEPS. They should be equally applauded for a frank, careful assessment of data limitations. These limitations include the absence of information on family or caregiver economic burden, especially time costs, which can be considerable. Relying on MEPS to project costs for the under-65 population precluded direct assessment of phase-of-care costs, by cancer type, for younger patients. Although MEPS can provide nationally representative estimates of health-care use and expenditures, it lacks the granularity ideal for assessing the economic burden for any given disease—including cancer. SEER-Medicare has much of that granularity but, as the authors note, currently does not include those in Medicare Advantage (representing approximately 30% of Medicare enrollees). What would enhance net cost analyses and cancer care costing methods in general is the availability of population-based cancer registry data linked to a broad array of claims databases—not only Medicare but also Medicaid and commercial insurers. Among the many payoffs from such efforts would be the ability to derive OOP cost estimates for all age groups with sufficient level of detail and specificity. The development of policies and interventions to mitigate the financial hardship experienced by cancer patients and their families can benefit greatly from a clear understanding, grounded in accurate projections, of the magnitude of the associated economic burdens. The study by Yabroff et al. (6) contributes immensely through a comprehensive national-level appraisal of the economic impact of cancer on those diagnosed with the disease. The study lays groundwork for additional, novel strategies to improve our understanding of the economic burden of cancer at the individual level by synthesizing information across complementary data sources. Dr Shih acknowledges funding from the National Cancer Institute (R01CA207216, R01CA225646). Role of the funder: The funder had no role in the writing of this editorial or the decision to submit it for publication. Disclosures: Y-CTS received consulting fees, travel, and accommodations for serving on a grants review panel for Pfizer Inc and an advisory board for AstraZeneca in 2019. JL has no disclosures. Author contributions: Writing- original draft: Y-CTS, JL. Writing- reviewing and editing: Y-CTS, JL. Not applicable.
DOI: 10.1093/jnci/djab193
Language: English
Open Access status: green
OpenAlex ID: W3208257844
Cites: 6
Cited by: 1
Related to: 10