Knowledge of Health Insurance, Financial Literacy Fail to Prevent Financial Hardship Amongst Patients With Cancer


Financial hardship amongst patients with cancer was shown to be an ongoing issue even after they demonstrated high levels of medical insurance literacy and financial literacy, reports JAMA Network Open.

These cross-sectional study outcomes were investigated amongst 404 patients enrolled from Mayo Clinic in Phoenix, Arizona (n = 299), from December 2019 to February 2020 and August to October 2020, and University of Mississippi Medical Center (UMMC) in Jackson (n = 105) from September 2020 to February 2021. Fifty-four percent were women, 75% were non-Hispanic White, and the median (IQR) patient age was 63 (54-71) years.

Participants’ financial hardship was evaluated via COST-FACIT (Comprehensive Rating for Financial Toxicity–Functional Assessment of Chronic Illness Therapy) and specific domains of that hardship (material, psychological, and behavioral) via National Health Interview Survey (NHIS) questions; the electronic health records from each site provided age, sex, insurance type, and disease data, and sociodemographics were gathered via study surveys. The Health Insurance Literacy Measure (HILM) gauged “a consumer’s ability to pick out and use medical insurance,” and 5 questions from the National Financial Capability Study evaluated financial literacy.

Overall, 38% of their study enrollees had private insurance and 72% had solid tumors, 42% being metastatic disease.

Near half (49%; 95% CI, 44%-53%) of the study population reported financial hardship, and this result jumped almost 20 percentage points, to 68% (95% CI, 63-72%), when findings from the NHIS questions revealed participants had no less than 1 hardship domain. This was seen despite 66% (95% CI, 60%-69%) also self-reporting that they had a high level of economic literacy.

The mean (SD) overall medical insurance literacy rating via HILM was 64.9 (13.3), and in response to the study investigators, each 10-point increase equated to an 18% lower risk of economic hardship (odds ratio [OR], 0.82; 95% CI, 0.68-0.99; P = .04). Nevertheless, this result was negated when financial literacy was considered. A HILM rating below 60 indicated low medical insurance literacy and was related to overall financial hardship, in addition to material and behavioral hardship.

Fifteen percent of all respondents reported low levels of each medical insurance literacy and financial literacy; 50%, high levels of each; 14%, high financial literacy and low insurance literacy; and 21%, high medical insurance literacy and low financial literacy.

“Patient-reported financial hardship is an increasing challenge in cancer care delivery,” the study authors emphasized. “Medical health insurance literacy and its association with financial hardship in patients with cancer, especially after controlling for financial literacy, haven’t been well examined.”

With a lower COST-FACIT rating indicating greater financial hardship, 49% of the study cohort had a median rating of 27—the indicator of any financial hardship. As well as, material, psychological, and behavioral hardship were reported by 28%, 64%, and 13%, respectively.

Regarding financial knowledge, the median (IQR) rating was 5 (4-6) points, and 66% of respondents provided correct answers to no less than 4 financial literacy questions, which the study authors says indicates that they had high financial literacy. Lower odds of economic literacy correlated with being a UMMC patient (OR, 3.04; 95% CI, 1.67-5.55), having a monthly household income below $5000 (OR, 2.00; 95% CI, 1.17-3.44), classifying as “other race or ethnicity” (OR, 2.10; 95% CI, 1.13-3.90), and having lower than a university degree (OR, 3.44; 95% CI, 2.03-5.91). Further, there was a 26-percentage-point difference in incidence of low financial literacy reported between those that did and didn’t report financial hardship: 49% vs 23%.

“Financial hardship from treatment is an unlimited issue for patients with cancer that has been related to treatment nonadherence and better bankruptcy risk,” the authors wrote. “Efforts by health plans, hospitals, and the federal government to enhance medical insurance literacy can be certain that patients make financially sound decisions amongst different insurance products based on their financial condition and medical requirements, use their advantages optimally, and proceed their inexpensive coverage for advisable cancer care.”

An editorial accompanying the study echoed the investigators’ findings, noting that improving patient financial literacy through education-based interventions will help to empower patients and that financial navigators will help “decrease each patient and health system costs because navigators link patients to support and services which are designed to enhance access.”


Khera N, Zhang N, Hilal T, et al. Association of medical insurance literacy with financial hardship in patients with cancer. JAMA Netw Open. Published online July 25, 2022. doi:10.1001/jamanetworkopen.2022.23141


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