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Out-of-pocket healthcare expenditures for cancer patients in the United States: Findings from the Medical Expenditure Panel Survey Lisa M. Lines, MPH1,2 2 Boston Health Economics, Inc., Waltham, MA USA University of Massachusetts Amherst, Amherst, MA USA Presented at the 9th Annual Health Services and Outcomes Research Conference, Houston, TX, December 3, 2008 1

Background and Objectives  From 1996 to 2002, OOP medical spending increased by 35%—faster than overall medical spending; meanwhile, incomes rose by only about 20% over the same period1  Cancer patients are disproportionately affected by high OOP burdens

 A total of 10,048 individuals with a cancer event were included (mean age=54.7; 88% white; 23% low income) (Table 1)  Approximately 48% were privately insured, 25% had both Medicare and private insurance, 14% had Medicare only, 5% had Medicaid and/or another form of public insurance, and 8% were uninsured (Table 1)

Figure 2: Percent with high OOP burden by income and age group Low income

 The percent with high burden was highest among those with both Medicare and private insurance or Medicare only (Figure 1)

 Previous studies on OOP spending by cancer patients have presented the results of analyses limited to specific populations (elderly vs. nonelderly) or years2-5

 In unadjusted analyses, older and low-income individuals were most likely to have a high burden (Figure 2)  Persons with cancer were nearly twice as likely as those without cancer to have a high burden (Figure 3)

 The purpose of this study was to describe the OOPEs of cancer patients in the US using a population-based approach

Percent with high burden

 Having a high OOP burden may put patients at risk of nonadherence to prescribed treatment, of opting out of receiving treatment perceived as too expensive, or of not being offered the treatment

 This study included all respondents with known ages, incomes, and insurance status in MEPS between 1996 and 2005 who had a cancer diagnosis (ICD-9-CM codes 140-239) recorded for at least 1 pharmacy, inpatient, outpatient, office, home health, or ER event during a 12-month time period  Data from all 10 years were pooled and weighted (using the year-specific MEPS person-weight variables) to create nationally representative, “average annual” estimates  Descriptive analyses of demographics, socioeconomics, and insurance status were performed – Individuals were categorized as uninsured if they were not covered by Medicare, Medicaid, other public programs, private insurance, or TRICARE during 1 or more months during the year

 Total annual family income and person-level total and OOP expenditures (in 2007 US$) were calculated – Family incomes were calculated by summing the incomes of all persons in a household who were identified as being in the same family (using the CPSFAMID variable) and categorized by poverty category as follows: low income: <200% of the Federal poverty level (FPL); middle income: 200-399% of FPL; high income: >400% of FPL

 Patient-level OOP expenditures were calculated, including copayment or coinsurance expenditures, deductibles, payments for noncovered expenses, and monthly insurance premiums – Part B premiums were added to OOP expenditures for Medicare enrollees using published year-specific data; premiums for dual eligibles were assumed to be covered by Medicaid 6

– OOP expenditures for privately insured individuals included actual monthly premiums paid for respondents in the years 2001-2005 and averages from those years applied to respondents in 1996-2000 (premium data were not collected in 1997-99)

 As in previous studies, individuals were defined as having a high OOP burden if their OOP expenditures exceeded 10% of family income (or 5% if low income), including monthly insurance premiums1,7

Measure Unweighted N Age Mean <45 years 45 to 54 years 55 to 64 years 65 to 74 years 75+ years


67% 62%




50% 42% 40%

35% 29%


24% 17%

51% 50%

31% 30%


0% 75+

13% 4%




88.1% 5.7% 4.0% 1.6% 0.6%

Education Less than 12 years 12 years or GED More than 12 years Unknown

17.8% 30.3% 50.5% 1.5%

Income Low income Middle income High income

23.2% 29.6% 47.2% 48.1% 13.8% 24.9% 5.4% 7.8%





Low income

Middle income

High income

Demographic Group


54.5 27.8% 16.1% 17.6% 20.5% 18.0%



0% 65-74




55 - 64





45 - 54







Race/ethnicity White, non-Hispanic African American, non-Hispanic Hispanic, any race Asian or Pacific Islander Multiple races/other

Payor Private only Medicare only Medicare + private Medicaid/dual/other public Uninsured Source: MEPS 1996-2005


Percent with high burden






Figure 1: Percent with high OOP burden, by payor




Table 1: Demographics of individuals receiving care for cancer




 The bulk of OOP expenditures were for monthly insurance premiums (75%); about 11% of expenditures went toward prescription drugs (Table 2)

Cancer population



 Mean family income was $73,204, and annual OOP expenditures totaled $5,775, or 8% of family income (Table 2)

– Improvements in treatment and survival have led to more patients living with cancer as a chronic condition

General population

High income


 Overall, approximately 41% of individuals had a high OOP burden (Figure 1)

– Today, most cancer care is performed in the outpatient oncology setting, which may expose patients to a greater share of total costs than in the past

Middle income

Figure 3: Comparison of percent with high burden, general population and cancer population

Percent with high burden

 There is an increasing focus on the impact of out-of-pocket (OOP) medical expenditures on individuals in the US healthcare system




60% 49%

50% 41% 40%

 Among individuals with cancer, the average OOP expenditure, including monthly insurance premiums, was $5,775, and over 40% of individuals had a high OOP burden





 The proportion of individuals with a high OOP burden was highest among low-income and older individuals and those with Medicare plus private insurance

20% 10%

 Because cancer patients with high OOP burdens may have difficulty receiving optimal treatment, it is important to explore ways to reduce OOP expenditures for these individuals

0% All







Table 2: Annual income, OOP expenditures, and share of family income, overall and by payor All Private only Medicare only Medicare + private Medicaid/dual/other public Uninsured

Mean Annual Family Income $73,204 $95,697 $44,293 $58,114 $34,870 $60,268

OOPEs for Prescription Drugs $616 $397 $1,147 $825 $471 $466

Total Annual Total OOP Share OOPEs of Family Income (incl. premiums) (incl. premiums) $5,775 8% $7,121 7% $3,221 7% $6,635 11% $946 3% $2,581 4%

References 

Merlis M, Gould D, Mahato B. Rising out-of-pocket spending for medical care: a growing strain on family budgets. 2006. Accessed November 18, 2008.

Banthin JS, Bernard DM. Changes in financial burdens for health care: national estimates for the population younger than 65 years, 1996 to 2003. JAMA. 2006;296:2712-2719.

Bernard DM, Banthin JS, Encinosa WE. Health care expenditure burdens among adults with diabetes in 2001. Med Care. 2006;44:210-215.

Howard DH, Molinari N, Thorpe KE. National estimates of medical costs incurred by nonelderly cancer patients. Cancer. 2004;100:891.

Langa KM, Fendrick AM, Chernew ME, et al. Out-of-pocket health-care expenditures among older Americans with cancer. Value Health. 2004;7:186-194.

US Census Bureau. Poverty thresholds for 2007 by size of family and number of related children under 18 years. 2008. Accessed August 4, 2008.

Centers for Medicare and Medicaid Services (CMS). Annual report of the Boards of Trustees. 2007., Table V.C2. Accessed November 18, 2008.

Schoen C, Collins SR, Kriss JL, Doty MM. How many are underinsured? Trends among U.S. adults, 2003 and 2007. Health Aff (Millwood). 2008 Jul-Aug;27(4):w298-309.

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