Research spotlight: The high price of financial toxicity
By Sam Marie Engle
“I can’t afford to be sick.”
Emory Radiology’s Gelareh Sadigh, MD, understands that it’s more than a popular lament during cold and flu season. As a neuroradiologist, she increasingly sees patients with chronic, incurable diseases like multiple sclerosis (MS) or cancer forgoing imaging studies and even medication because they can’t afford it.
It worried her so much, she secured an Association of University Radiologists GE Radiology Research Academic Fellowship (GERRAF) and a Radiological Society of North America (RSNA) award in 2018 to investigate the impact of surprising and rising costs of care on MS patients. Her research team included colleagues from the Department of Radiology and Imaging Sciences and the Department of Neurology in the Emory School of Medicine; the Department of Epidemiology in Emory’s Rollins School of Public Health; the Department of Radiology of University of Michigan; The Harvey L. Neiman Health Policy Institute; and the School of Economics at Georgia Tech. The results, published in the March issue of Multiple Sclerosis (available here) confirmed her fears.
“More than one-third of MS patients in our study were care non-adherent: not taking medications, not getting imaging studies to monitor their disease and they were doing so for financial reasons,” she says. “The problem is that non-adherence leads to worsening of the disease, which leads to emergency treatment and hospitalizations, which not only eats any short-term cost-savings, it worsened the patients’ financial situation.”
The term for such situations is financial toxicity. As Dr. Sadigh explains, “Out-of-pocket expenses related to treatment are akin to physical toxicity in that costs can diminish quality of life.”
Both objective financial burden and subjective financial distress are key components of financial toxicity. Once patients get sick, they often work less. Higher bills with less income to pay them force patients to drain their savings and, for some, declare bankruptcy. Escalating worry and anxiety damage emotional well-being, which in turn negatively affects physical wellness, compounding the deleterious effects of behavior intended to alleviate the financial pain: i.e., rationing medications, skipping imaging studies, etc.
Dr. Sadigh’s study of breast cancer patients, published in April in Cancer (available here), similarly correlated financial toxicity with early discontinuation of life-saving/-prolonging endocrine therapies. In this study patients without insurance or covered only by Medicaid and those living in zip codes with high neighborhood deprivation index scores were much more likely to discontinue endocrine therapies than patients living in higher wealth areas and with private insurance.
“This is what we mean by social determinants of health. These external forces are determining who can afford care and for how long.”
Dr. Sadigh now is studying potential interventions, especially those involving radiology. A major source of financial concern and confusion is billing for medical imaging. As Dr. Sadigh notes, the people patients most frequently ask about imaging costs—ordering physicians and radiology schedulers—are ill-equipped to provide such information. That leaves patients confused and frustrated.
The Centers for Medicare and Medicaid Services (CMS) is hoping to help. As of January 2021, CMS says providers must post negotiated rates for all medical services, including imaging studies, online so patients can avoid “sticker shock” or “surprise billing”. Hospitals are further encouraged to provide consumer-friendly price transparency tools that estimate personalized out-of-pocket costs. These tools, however, do not include quality metrics so patients don’t have a way to determine if they’re getting a good deal. Further, the accuracy of their estimates compared to patients’ bills is not clear. Finally, it is not clear whether communication of a high imaging out-of-pocket cost can improve patients' financial ability to cope with the cost or increases rate of cancelling or rescheduling the imaging appointments.
To assess the latter, Dr. Sadigh and Emory Radiology’s health economist Dr. Michal Horný recently received an Emory University Department of Radiology seed grant to evaluate patients’ awareness of price transparency initiatives and the psychosocial and behavioral impacts of such initiatives.
To highlight the significance of quality data for informed patient decision-making, Dr. Sadigh is currently leading a study in which patients were given different combinations of imaging out-of-pocket costs and quality metrics to determine how patients value cost vs. quality when choosing an imaging center. When given only price information, patients tended to choose the less-expensive provider. When given both pieces of information, patients were willing to pay more for providers with higher quality metrics.
Dr. Sadigh and other radiologists are working on standardized quality metrics that can be combined with user-friendly price transparency tools to make it easier for patients to make informed decisions about imaging services.
While such information is important, Dr. Sadigh says it’s not enough. “We also need to help patients with navigating the complexities of costs and payments and then we need to connect them with sources of financial assistance. Radiology is not a luxury. It’s essential to diagnosing, monitoring, and treating disease. We have to make it more affordable.”
Here, too, Dr. Sadigh sees an important role for radiology and imaging sciences professional associations, as she and her research partner Dr. Ruth Carlos of the University of Michigan Department of Radiology explain in a just-published piece in the American Journal of Radiology (available here). As part of a multidisciplinary approach to care, radiology encounters can be used to screen patients for financial fragility and refer those at risk for assistance with financial navigation. The professional associations can provide models and guidance to help radiology practices build financial navigation into their price transparency initiatives so patients can get the financial support for the care they need.
“I can’t afford to be sick.”
Emory Radiology’s Gelareh Sadigh, MD, understands that it’s more than a popular lament during cold and flu season. As a neuroradiologist, she increasingly sees patients with chronic, incurable diseases like multiple sclerosis (MS) or cancer forgoing imaging studies and even medication because they can’t afford it.
It worried her so much, she secured an Association of University Radiologists GE Radiology Research Academic Fellowship (GERRAF) and a Radiological Society of North America (RSNA) award in 2018 to investigate the impact of surprising and rising costs of care on MS patients. Her research team included colleagues from the Department of Radiology and Imaging Sciences and the Department of Neurology in the Emory School of Medicine; the Department of Epidemiology in Emory’s Rollins School of Public Health; the Department of Radiology of University of Michigan; The Harvey L. Neiman Health Policy Institute; and the School of Economics at Georgia Tech. The results, published in the March issue of Multiple Sclerosis (available here) confirmed her fears.
“More than one-third of MS patients in our study were care non-adherent: not taking medications, not getting imaging studies to monitor their disease and they were doing so for financial reasons,” she says. “The problem is that non-adherence leads to worsening of the disease, which leads to emergency treatment and hospitalizations, which not only eats any short-term cost-savings, it worsened the patients’ financial situation.”
The term for such situations is financial toxicity. As Dr. Sadigh explains, “Out-of-pocket expenses related to treatment are akin to physical toxicity in that costs can diminish quality of life.”
Both objective financial burden and subjective financial distress are key components of financial toxicity. Once patients get sick, they often work less. Higher bills with less income to pay them force patients to drain their savings and, for some, declare bankruptcy. Escalating worry and anxiety damage emotional well-being, which in turn negatively affects physical wellness, compounding the deleterious effects of behavior intended to alleviate the financial pain: i.e., rationing medications, skipping imaging studies, etc.
Dr. Sadigh’s study of breast cancer patients, published in April in Cancer (available here), similarly correlated financial toxicity with early discontinuation of life-saving/-prolonging endocrine therapies. In this study patients without insurance or covered only by Medicaid and those living in zip codes with high neighborhood deprivation index scores were much more likely to discontinue endocrine therapies than patients living in higher wealth areas and with private insurance.
“This is what we mean by social determinants of health. These external forces are determining who can afford care and for how long.”
Dr. Sadigh now is studying potential interventions, especially those involving radiology. A major source of financial concern and confusion is billing for medical imaging. As Dr. Sadigh notes, the people patients most frequently ask about imaging costs—ordering physicians and radiology schedulers—are ill-equipped to provide such information. That leaves patients confused and frustrated.
The Centers for Medicare and Medicaid Services (CMS) is hoping to help. As of January 2021, CMS says providers must post negotiated rates for all medical services, including imaging studies, online so patients can avoid “sticker shock” or “surprise billing”. Hospitals are further encouraged to provide consumer-friendly price transparency tools that estimate personalized out-of-pocket costs. These tools, however, do not include quality metrics so patients don’t have a way to determine if they’re getting a good deal. Further, the accuracy of their estimates compared to patients’ bills is not clear. Finally, it is not clear whether communication of a high imaging out-of-pocket cost can improve patients' financial ability to cope with the cost or increases rate of cancelling or rescheduling the imaging appointments.
To assess the latter, Dr. Sadigh and Emory Radiology’s health economist Dr. Michal Horný recently received an Emory University Department of Radiology seed grant to evaluate patients’ awareness of price transparency initiatives and the psychosocial and behavioral impacts of such initiatives.
To highlight the significance of quality data for informed patient decision-making, Dr. Sadigh is currently leading a study in which patients were given different combinations of imaging out-of-pocket costs and quality metrics to determine how patients value cost vs. quality when choosing an imaging center. When given only price information, patients tended to choose the less-expensive provider. When given both pieces of information, patients were willing to pay more for providers with higher quality metrics.
Dr. Sadigh and other radiologists are working on standardized quality metrics that can be combined with user-friendly price transparency tools to make it easier for patients to make informed decisions about imaging services.
While such information is important, Dr. Sadigh says it’s not enough. “We also need to help patients with navigating the complexities of costs and payments and then we need to connect them with sources of financial assistance. Radiology is not a luxury. It’s essential to diagnosing, monitoring, and treating disease. We have to make it more affordable.”
Here, too, Dr. Sadigh sees an important role for radiology and imaging sciences professional associations, as she and her research partner Dr. Ruth Carlos of the University of Michigan Department of Radiology explain in a just-published piece in the American Journal of Radiology (available here). As part of a multidisciplinary approach to care, radiology encounters can be used to screen patients for financial fragility and refer those at risk for assistance with financial navigation. The professional associations can provide models and guidance to help radiology practices build financial navigation into their price transparency initiatives so patients can get the financial support for the care they need.