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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

Estimate

67% 62%

60%

54%

53%

50% 42% 40%

35% 29%

30%

24% 17%

51% 50%

31% 30%

23%

0% 75+

13% 4%

All

Nonelderly

Age

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%

70%

18%

17%

Elderly

Low income

Middle income

High income

Demographic Group

80%

54.5 27.8% 16.1% 17.6% 20.5% 18.0%

42%

40%

0% 65-74

44%

41%

10%

55 - 64

57%

60%

20%

13%

45 - 54

75%

70%

10%

<45

90%

10,048

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

100%

Percent with high burden

Methods

80%

68%

70%

13%

Figure 1: Percent with high OOP burden, by payor

90%

80%

20%

Table 1: Demographics of individuals receiving care for cancer

89%

85%

80%

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

Cancer population

100%

90%

 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

100%

 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

Results

63%

Conclusions

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

32%

30%

22%

24%

 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

Private

Medicare

Medicare&pvt

Medicaid/public

Uninsured

Payor

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. http://www.commonwealthfund.org/usr_doc/Merlis_risingoopspending_887.pdf. 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. http://www.census.gov/hhes/www/poverty/threshld/thresh07.html. Accessed August 4, 2008.

Centers for Medicare and Medicaid Services (CMS). Annual report of the Boards of Trustees. 2007. http://www.cms.hhs.gov/reportstrustfunds/downloads/tr2007.pdf, 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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