Financial Distress Common Among Cancer Patients, Especially Underinsured Interview with:

Dr. Fumiko Chino, MD Duke Radiation Oncology Duke School of Medicine

Dr. Chino

Dr. Fumiko Chino, MD
Duke Radiation Oncology
Duke School of Medicine What is the background for this study? What are the main findings?

Response: The financial burden of cancer treatment is a growing concern. Out-of-pocket expenses are higher for patients with cancer than for those who have other chronic illnesses. Fifty percent of elderly cancer patients spend at least 10% of their income on treatment-related out-of-pocket expenses. Additionally, high financial burden is associated with both increased risk of poor psychological well-being and worse health-related quality of life. A cancer diagnosis has been shown to be an independent risk factor for declaring personal bankruptcy, and cancer patients who declare personal bankruptcy are at greater risk for mortality. These potentially harmful outcomes resulting from financial burden have been recognized as the financial toxicity of cancer therapy, analogous to the more commonly considered physical toxicity.

We conducted an IRB approved study of financial distress and cost expectations among patients with cancer presenting for anti-cancer therapy. In this cross-sectional, survey based study of 300 patients, over one third of patients reported higher than expected financial burden. Cancer patients with highest financial distress are underinsured, paying nearly 1/3 of income in cancer-related costs. In adjusted analysis, experiencing higher than expected financial burden was associated with high/overwhelming financial distress (OR 4.78; 95% CI 2.02-11.32; p<0.01) and with decreased willingness to pay for cancer care (OR 0.48, 95% CI 0.25-0.95, p=0.03).

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Changes in Hospital Inpatient Stays Over Ten Years: Less Cardiac Care, More Mental Health and Sepsis Admissions Interview with:
Ruirui Sun, Service Fellow, Economist
Center for Delivery, Organization and Markets
Agency for Healthcare Research and Quality What is the background for this study?

Response: Hospital inpatient care has experienced changes due to factors such as population growth, rising of prevalence of chronic disease and efforts to reduce unnecessary hospitalizations. We generated information from the National Hospital Utilization and Costs path on Fast Stats ( ), to present the trends on national hospitalization and costs from 2005 to 2014, as well as the most common diagnoses among inpatient stays over the 10-year period. What are the main findings?

  • Between 2005 and 2014, the inflation-adjusted mean cost per inpatient stay increased by 12.7 percent, from $9,500 to $10,900.
  • Inflation-adjusted cost per stay for patients covered by private insurance or Medicaid increased 16-18 percent. Cost per stay for Medicare-covered patients and the uninsured changed minimally.
  • The rate of inpatient stays decreased the most among patients in the highest income quartiles (15-20 percent decrease).
  • The proportion of Medicaid-covered inpatient stays increased by 15.7 percent, whereas the proportion paid by private insurance and that were uninsured decreased by 12.5 and 13.0 percent, respectively.
  • Mental health/substance use accounted for nearly 6 percent of all inpatient stays in 2014, up 20.1 percent from 2005.
  • Between 2005 and 2014, septicemia and osteoarthritis became two of the five most common reasons for inpatient stays. Septicemia hospital stays almost tripled.
  • Nonspecific chest pain and coronary atherosclerosis decreased by more than 60 percent from 2005 to 2014, falling off the list of top 10 reasons for hospitalization. 

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Moral Hazard Encourages Consumers To Choose More Expensive Treatment Options Interview with:

Nitin Mehta PhD Associate Professor in Marketing Rotman School

Dr. Mehta

Nitin Mehta PhD
Associate Professor in Marketing
Rotman School What is the background for this study?

Response: The focus of this paper is an investigation of the increase in health care costs associated with chronic disease in the context of consumers enrolled in employer sponsored insurance plans. Chronic illnesses – including conditions such as heart disease, cancer, hypertension, rheumatoid arthritis, respiratory diseases, diabetes, and kidney disease – account for nearly 75 percent of health care expenditures in the U.S. Treatments vary widely in terms of cost and impact: expensive “frontier” treatments provide the best outcome for only the seriously ill, while cheaper, established treatments prove effective for most other patients. As an example, the annual cost to an insurer for “biologics” – novel genetically modified protein drugs – is upwards of $20,000, while the more established drug – methotrexate – costs only $1,000 a year.

We investigate whether a part of the increase in healthcare costs stems from consumers opting for the more expensive treatments even when the lesser expensive treatments may have worked well. To do so, we examined data from a health insurer in the United States on the insurance plan and treatment options for 3,000 chronically ill patients over a three year period.

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Study Finds Disconnect Between Price and Quality in Health Care Interview with:
Eric Roberts, PhD

Post-doctoral fellow
Department of Health Care Policy
Harvard Medical School What is the background for this study? What are the main findings?

Response: Increasing consolidation of health care providers has raised regulatory concerns that less competition will lead to higher health care prices and possibly lower quality care for patients. On the other hand, some industry observers have contended that larger and higher-priced practices are better able invest in systems to support care management, and ultimately, better patient care. In this study, we examined whether larger and higher-priced physician practices provided better and more efficient care to their patients.

Higher-priced physician groups were paid an average of 36% more by commercial insurers, and were substantially larger than lower-priced practices located within the same geographic areas. Despite large differences in practices’ prices and size, we found few differences in their patients’ quality and efficiency of care. For example, when we compared patients who received care in high-priced versus low-priced practices, we found no differences in patients’ overall care ratings, physician ratings, access to care, physician communication, and use of preventive services. We also found no differences in patients’ hospital admissions or total spending, suggesting that higher-priced practices were not managing their patients’ care more efficiently than their lower-priced counterparts.

We did find that patients in higher-priced practices were more likely to receive recommended vaccinations, review of their medications, and results of medical tests, and that they spent less time in the waiting room for a scheduled doctor’s appointment. However, once practice prices exceeded the average for their geographic area, we observed no further gains in quality on most of these measures.

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Economic Evaluation of a Home-Based Age-Related Macular Degeneration Monitoring System Interview with:
John Wittenborn

Senior research scientist
NORC’s Public Health Analytics
University of Chicago What is the background for this study? What are the main findings?

Response:The emergence of anti-VEGF treatment for wet-form AMD (choroidal neovascularization) has had a dramatic impact on preserving vision for many Americans. However, community-based studies show that most patients are not diagnosed with wet-form AMD until they have already lost a significant, and largely unrecoverable amount of their vision.  Early detection of wet-form AMD is key to effective treatment and the preservation of vision. The ForeseeHome telemonitoring technology provides patients with a means to check their own eyes on a daily basis to detect the earliest signs of vision loss from wet-form AMD.

This is a novel technology that has the potential to improve visual health outcomes for AMD patients.  A prior clinical trial (the AREDS-2 HOME study) demonstrated that this technology can detect wet-form AMD earlier, and with less vision loss than standard care alone. However, that is exactly where that study ended as it reported no cost information nor follow-up. Since the end of this study, the device has been cleared by the FDA and approved for reimbursement by Medicare for certain higher risk patients, but no study has yet considered the long-term implications of adoption of this technology.

In our analysis, we use a computer simulation model to essentially estimate what will come next, after patients realize earlier detection of wet-form AMD by utilizing home monitoring. Basically, we follow simulated patients from the time they begin monitoring for the rest of their lives, recording the likely impacts of home monitoring on patients’ long term outcomes including visual status, costs and quality of life.

We find that home telemonitoring among the population indicated for reimbursement by Medicare would cost $35,663 per quality adjusted life year (QALY) gained.  Medicare would expect to incur $1,312 in net budgetary costs over 10 years for each patient who initiates monitoring.  However, Medicare patients may expect to achieve lifetime net savings when accounting for the chance of avoided vision loss and its associated costs later in life.

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Heart Disease Costs Expected To Top $1Trillion Per Year By 2035 Interview with:

Olga Khavjou RTI International

Olga Khavjou

Olga Khavjou
RTI International What is the background for this study? What are the main findings?

Response: Cardiovascular disease (CVD) is the leading cause of death in the United States and is one of the costliest chronic diseases. As the population ages, CVD costs are expected to increase substantially. To improve cardiovascular health and control health care costs, we must understand future prevalence and costs of CVD.

In 2015, 41.5% (more than 100 million people) of the U.S population was estimated to have some form of CVD. By 2035, the number of people with CVD is projected to increase to over 130 million people, representing a 30% increase in the number of people with CVD over the next 20 years. Between 2015 and 2035, real total direct medical costs of CVD are projected to more than double from $318 billion to $749 billion and real indirect costs (due to productivity losses) are projected to increase from $237 billion to $368 billion. Total costs (medical and indirect) are projected to more than double from $555 billion in 2015 to $1.1 trillion in 2035.

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Diabetes Most Expensive Health Care Condition in US Interview with:

Joseph Dieleman, PhD Institute for Health Metrics and Evaluation | University of Washington Seattle, WA 98121

Dr. Joseph Dieleman

Joseph Dieleman, PhD
Institute for Health Metrics and Evaluation
University of Washington
Seattle, WA 98121 What is the background for this study? What are the main findings?

Response: The objective of this study was to provide a estimate of total health care spending in the United States for an exhaustive list of health conditions, over an extended period of time – from 1996 to 2013. The study primarily focuses on personal health spending, which includes both individual out-of-pocket costs as well as spending by private and government insurance programs on care provided in inpatient and outpatient facilities, emergency departments, nursing care facilities, dentist offices, and also on pharmaceuticals. There were 155 conditions included in the analysis, and spending was also disaggregated by type of care, and age and sex of the patient.

In 2013, we accounted for $2.1 trillion in personal health spending in the U.S. It was discovered that just 20 health conditions made up more than half of all dollars spent on health care in the U.S. in 2013, and spending for each condition varied by age, sex and type of care. Diabetes was the most expensive condition, totaling $101 billion in diagnoses and treatments, growing at an alarmingly rate – a 6.5% increase per year on average.

Ischemic heart disease, the number one killer in the U.S., ranked the second most expensive at $88.1 billion, followed by low back and neck pain at $87.6, treatment of hypertension at $83.9 billion, and injury from falls at $76.3.

Women aged 85 and older spent the most per person in 2013, at more than $31,000 per person. More than half of this spending (58%) occurred in nursing facilities, while 20% was expended on cardiovascular diseases, 10% on Alzheimer’s disease, and 7% on falls. Men ages 85 and older spent $24,000 per person in 2013, with only 37% on nursing facilities, largely because women live longer and men more often have a partner at home to provide care.

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Cancer Can Mean High Out-of-Pocket Expenses For Seniors With Only Medicare Interview with:

Dr. Amol K. Narang, MD Instructor of Radiation Oncology and Molecular Radiation Sciences Johns Hopkins Sidney Kimmel Comprehensive Cancer Center

Dr. Amol  Narang

Dr. Amol K. Narang, MD
Instructor of Radiation Oncology and Molecular Radiation Sciences
Johns Hopkins Sidney Kimmel Comprehensive Cancer Center What is the background for this study?

Response: We know that cancer care is becoming increasingly expensive in the U.S., but the financial impact on patients in the form of out-of-pocket expenses is not well understood, in part because of the lack of data sources that track this information. As such, we used the Health and Retirement study, a national panel study that closely tracks the out-of-pocket medical expenditures of older Americans, to understand the level of financial strain that Medicare patients experience after a new diagnosis of cancer. We further investigated what factors were associated with high financial strain and what type of health services were driving high costs in this population.

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Autoimmune Specialty Drug Spending Doubles, Accounting for 10 Percent of Drug Expenses Interview with:

Kevin Bowen MD MBA Senior Health Outcomes Researcher Prime Therapeutics LLC 1305 Corporate Center Drive Eagan, MN 55121

Dr. Kevin Bowen

Kevin Bowen MD MBA
Senior Health Outcomes Researcher
Prime Therapeutics LLC
1305 Corporate Center Drive
Eagan, MN 55121 What is the background for this study? What are the main findings?

• Autoimmune specialty drugs now account for about one of every 10 dollars of combined drug expense through the medical and pharmacy benefits in a commercially insured population.
• The autoimmune drug class is one of the fastest growing, with this study finding a doubling in autoimmune drug expenditures and a 38 percent increase in utilization, in the most recent four years.
• Integrated analysis of medical and pharmacy claims is essential for this category of drugs because more than 25 percent of autoimmune specialty drug use is paid through the medical benefit and medical claims diagnosis coding provides a means of determining what conditions were treated with drugs covered by pharmacy claims.
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Advantaged Patients Receive More Low-Value Medical Services Interview with:
Dr. Rachel O. Reid MD MS
Associate Physician Policy Researcher
RAND Corporation What is the background for this study? What are the main findings?

Response:  Waste in the US health care system is both common and expensive, estimated to be in the range of $750 billion annually. Contributing to this waste is over-treatment and use of low value services that offer little or no clinical benefit to patients.

We studied 1.46 million adults from across the US with commercial insurance and found that spending on 28 low value services totaled $32.8 million in 2013, accounting for 0.5% of their medical spending or $22 per person annually.

The most commonly received low-value services included hormone tests for thyroid problems, imaging for low-back pain and imaging for uncomplicated headache. The greatest proportion of spending was for spinal injection for lower-back pain at $12.1 million, imaging for uncomplicated headache at $3.6 million and imaging for nonspecific low-back pain at $3.1 million.

Low-value spending was lower among patients who were older, male, black or Asian, lower-income or enrolled on consumer-directed health plans, which have high member cost-sharing.

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