Understanding Financial Toxicity in Head and Neck Cancer Survivors as a Framework for Shared Decisions and Avoidance of Low-Value Care

Presentation: AHNS-034
Topic: Value / Quality
Type: Oral
Date: Thursday, May 2, 2019
Session: 6:00 AM - 7:00 AM Scientific Session 5 - Value I
Authors: Leila J Mady, MD, PhD, MPH1, Maryanna S Owoc, BS1, Kate Meng Zhao2, Lingyun Lyu, MS3, Michael Corcoran2, Shyamal D Peddada, PhD3, Teresa Hagan Thomas, PhD, RN4, Lindsay M Sabik, PhD5, Marci L Nilsen, PhD, RN, CHPN4, Jonas T Johnson, MD1
Institution(s): 1University of Pittsburgh School of Medicine, 2UPMC Insurance Services Strategic Analysis of Clinical Affairs, 3University of Pittsburgh Graduate School of Public Health, 4University of Pittsburgh School of Nursing, 5University of Pittsburgh Health Policy Institute

Importance: Extreme financial distress has been linked to greater mortality risk in cancer patients. With increasing complexity of cancer care and growing numbers of head and neck cancer (HNC) survivors, evaluating treatment-related financial harm is critical to our understanding of how patients define high-value care.

Objective: To understand survivors’ treatment/post-treatment related financial burden.

Design, Setting, and Participants:  To assess objective out-of-pocket expenses (OOPE), paid claims data were queried for health plan members with HNC-primary diagnosis codes (n=5,156) who received either/or a combination of surgery, chemotherapy or radiation (C/RT) between July 2013–June 2015. OOPE were the dollars associated with copays, coinsurance, and deductibles. To evaluate subjective financial well-being (FWB), patients seen in our HNC survivorship clinic between January–August 2018 were offered a survey of financial toxicity/distress (n=252). Patients with claims and survey data were the target population for this analysis.

Main Outcomes and Measures: Main outcomes were OOPE and FWB. OOPE were obtained through HNC-related medical and pharmacy claims between July 2013–March 2018. FWB was assessed with: 1) the Financial Distress Questionnaire (FDQ) (2-item tool, scored low or high financial distress); 2) the COmprehensive Score for financial Toxicity (COST) (11-item tool, scored 0–44, wherein lower scores equate to worse toxicity).

Results: Of 3,779 health plan members who received HNC treatment-related services (73%) and 244 patients who completed FWB surveys (97%), 71 met inclusion criteria as our target population. Of these 71 patients (mean age, 64±10yr), 48 were male (68%), 65 were white (92%) and they were, on average, 6±6yr since treatment completion. The most common insurance was Medicare (n=27, 38%), followed by Commercial employer-based (n=17, 24%). Most had advanced stage III-IV disease (n=50, 70%) and 14 (20%) had recurrence/metastasis/second primary. Primary disease of the oral cavity (n=16, 23%), oropharynx (n=22, 31%) and larynx (n=17, 24%) comprised the majority of tumors. Multimodality therapy was most common, with 36 (52%) who received surgery + adjuvant treatment and 26 (37%) who received primary C/RT. 4 patients (6%) had immunotherapy. Average per-member OOPE were $3,309, with the highest incurred by Medicare members ($4,264), followed by Commercial members ($3,738), and the lowest incurred by Medicaid members ($384). The continued cost after acute treatment rose over time. When post-treatment length increased from 1 to 3 years, there was an 86% increase in OOPE. When post-treatment length increased from 3 to 5 years, there was a 24% rise in OOPE. 31 (44%) reported high financial distress by FDQ. Mean COST was 25±11 with the worst toxicity in Medicare members (COST=19). In multiple linear regression modeling, lower education level (p=0.020) and being single/divorced/separated/widowed (p=0.037) were significantly associated with worse toxicity (COST) when controlling for treatment modality and OOPE.

Conclusions and Relevance: As payors continue to shift costs to consumers, addressing the financial harms of treatment is a critical component in shared-decision making. OOPE vary widely across insurance plans, with a considerable proportion of survivors reporting high financial distress. To deliver high-value care, we must account for the financial side-effects of available therapies.