Financial Strain and Cancer Outcomes
Financial status in at least two cancer has an impact on care and more so quality of life. This is a bit long but the message is gold regarding another article connecting impaired outcomes in those with limited resources
- Robert M. Kaplan⇑
- Agency for Healthcare Research and Quality, Rockville, MD
- Corresponding author: Robert M. Kaplan, PhD, University of California Los Angeles Department of Health Services, CHS Third Floor, Los Angeles, CA 90025; e-mail: firstname.lastname@example.org.
- Arnold Milstein
+ Author Affiliations
- Stanford University, Stanford, CA
In the article accompanying this editorial, Lathan et al1 use the nationally representative Cancer Care Outcomes Research and Surveillance Consortium study to suggest that limited financial reserves are associated with greater symptom burden and reduced quality of life among patients with comparable clinical stages of lung or colorectal cancer. Using multivariable analysis, the authors attempted to rule out alternative explanations, including age, race/ethnicity, sex, income, health insurance status, cancer stage, and the presence of other chronic illnesses. The results complement a growing literature that documents strong associations between socioeconomic status and longevity.2
Financial strain was assessed using a single question asking respondents how long they could maintain their current residence and standard of living if they lost their primary source of income. The concept of financial strain is related to net worth of a household, which is defined as the sum of the market value of all assets owned by the all members of the household minus the liabilities of the household members.3 Although it is difficult to say that financial strain independently caused poorer cancer outcomes, the stress associated with limited financial reserves is a plausible hypothesis. For someone with few financial assets in reserve, a cancer diagnosis can be devastating. A person might have a reasonable income that allows her to own a home and drive a nice car, and yet a diagnosis of breast cancer and subsequent treatment is likely to start a cascade of absence from work and inability to make mortgage and loan payments. Within a short time, these problems might hasten the need to file bankruptcy. Without financial reserves, people can move rapidly from comfort to crisis.
A substantial number of people are victims of this sort of financial chaos. One recent analysis suggested that one in four black families has less than $5 in cash or liquid assets set aside in case of an emergency. White families in the lowest income category have, on average, 75 times this amount of cash reserve.4 Excluding equity in a home, 2011 US Census data suggest that the median net worth of black Americans is $2,124, in comparison with $33,408 for white non-Hispanic Americans. Black families report having much greater difficulty getting back on their feet after a financial meltdown, in comparison with white families. Even among black families with incomes between $50,000 and $85,000 per year, approximately 30% have had trouble meeting all of their financial obligations. Among white families, the threshold of 30% having difficulty paying bills is not reached until family incomes dip to $25,000 per year4
Confronted with a cancer diagnosis, the average black American is likely to exhaust his or her household reserves within 1 month. When people run out of financial reserves, unfortunate things happen. Unable to pay utility bills, a person can lose basic services such as lighting and heat. If a person is unable to pay minor fines for traffic tickets, they can have wages garnished, which, in turn, accelerates the downward spiral. In summary, the Lathan et al1 analysis offers an important message for the cancer care community. Financial status adds significantly to the complexity of cancer care and cancer outcomes.
Despite the many strengths of the article by Lathan et al1, there are also some concerns. For example, financial strain and net worth are part of a larger cluster of socioeconomic factors known to be associated with poor health outcomes. As a result of the collinearity between these factors, teasing out the individual influences can be difficult. Many of the variables are measured with error and, as a result, multivariable analysis results in only partial adjustment. Two variables, education and ethnicity, are of particular importance. Both of these are systematically related to financial strain. Substantial evidence suggests that educational attainment is perhaps the strongest correlate of longevity and other health outcomes, even among those with adequate financial resources.5,6 In addition, the strong relationship between education and net worth is hard to remove completely using multivariable analysis. The most recent census data (2011) show that the median net worth of those with less than a high school education is $2,285, in contrast to $116,493 for people with a graduate degree.
Clearly, Lathan et al1 have identified an important and troubling problem, but what can we do about it? They suggest at least two actions. First, document the problem by administering a one-item financial strain questionnaire. Second, use social workers to help identify community services for people facing serious financial strain. Let’s look at each of these suggestions. Although it seems admirable to document known risk factors, we may need to be cautious about prioritizing financial asset information in the health record. Do we really want those selling expensive services to know what’s in our wallets? Those with a high net worth might be targets for expensive and unnecessary services, whereas those with low financial reserves could be victims of discrimination.
However, documenting the social determinants of health is important for both delivering health care and for conducting health outcomes research. Currently, social and behavioral factors known to be important determinants of health are difficult to find in the electronic health record. The Institute of Medicine recently released an excellent report titled “Capturing Social and Behavioral Domains and Measures in Electronic Health Records.”7 The report systematically reviews the information that should be captured from patients. It is on the basis of thorough reviews of the epidemiology and it offers specific measures that should be included in the health record. We must do a better job of recording a variety of factors known to be associated with poor health outcomes. There is a blueprint and it should be followed.
Although the article by Lathan et al1 takes an important step toward identifying a troubling problem, fixing that problem will be challenging. The paper focuses on reasonable steps that can be taken within the clinical health care system. The suggestion that social workers be engaged to identify community resources is a good one. They can also help patients navigate the administrative shoals en route to the limited price relief offered to the poor by drug manufacturers. Furthermore, the elimination of lifetime medical care expenditure caps and improvements in insurance coverage as a result of the Affordable Care Act may help ease the burden. However, the problem extends beyond the scope of the clinical care system. In addition to better coordination between the health care system and social services, the problem begs for more actively cushioning of the financial strains caused by major illness and for steps to reduce poverty. Increasing average educational attainment, for example, may contribute to the long-term goal of improving outcomes for patients with cancer. These are big challenges that will require advances in social policy and better coordination among the diverse sectors that shape health and dividends for the most gravely ill.