Financial Toxicity (Financial Hardship From Medical Care)

What financial toxicity includes

Financial toxicity has two parts:

• Material hardship: out-of-pocket costs (deductibles, copays, coinsurance, uncovered drugs), travel, parking, childcare, lost wages from time off work, job loss, and debt.
• Psychological burden: worry, stress and feeling overwhelmed about money.

It also includes coping behaviors that can harm health: delaying appointments, skipping tests, rationing or not filling prescriptions, and cutting back on food or utilities.

Who is most affected

• People with cancer, especially those receiving expensive oral or infused drugs
• Younger adults, who may have less savings and dependent children
• People with lower incomes or less savings
• People who are uninsured or underinsured, or have high-deductible health plans
• People who lose work or work hours because of illness
• People who live far from treatment centers
• Caregivers, who may reduce work hours

How financial toxicity affects health

Research links financial toxicity to:

• Lower adherence to medicines and treatment plans
• Delayed or skipped care
• Higher rates of depression and anxiety
• Poorer quality of life and symptom control
• In some studies of cancer, worse survival

It is now considered a side effect of treatment that clinicians should screen for and address, in the same way as nausea or pain. See also chemotherapy complications.

How it is assessed

Some cancer centers use standard questionnaires, such as the COST (Comprehensive Score for financial Toxicity) tool, to measure financial distress. Many simply ask: "Are you worried about the cost of your care?" or "Have you had trouble paying for medicines or bills?"

Ways to reduce financial toxicity

Talk early about costs

• Ask your care team about the expected costs of treatment and whether lower-cost options with similar benefit exist, such as generic or biosimilar medicines, different settings for infusions, or fewer visits.
• Ask to speak with a financial navigator, financial counselor or oncology social worker. Most cancer centers have them.

Review insurance

• Check what your plan covers, your deductible and out-of-pocket maximum.
• Use in-network providers and get prior authorization when required.
• Appeal denied claims. Many denials are overturned on appeal.
• During open enrollment, compare plans based on your expected care.
• If you lose employer insurance, consider COBRA, marketplace plans under the Affordable Care Act (with possible subsidies), or Medicaid if eligible.
• Medicare Part D now has an annual cap on out-of-pocket prescription drug costs and an option to spread costs over the year.

Get help with costs

• Hospital financial assistance (charity care): nonprofit hospitals are required to have financial assistance policies. Ask for an application.
• Patient assistance programs from drug manufacturers, and copay assistance foundations for specific diseases.
• Nonprofit organizations that help with transport, lodging, utilities and living costs during treatment.
• Disability benefits: short- and long-term disability insurance, and Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI).
• Employment protections: the Family and Medical Leave Act (FMLA) and the Americans with Disabilities Act may protect your job and allow reasonable accommodations.

Manage bills

• Request an itemized bill and check for errors and duplicate charges.
• Negotiate a lower price or an interest-free payment plan before bills go to collections.
• Be cautious about putting medical bills on high-interest credit cards or medical credit cards.
• Keep records of every call, letter and payment.

Look after your wellbeing

Financial stress is a real source of distress. Counseling, support groups and talking with your care team can help. Treating anxiety and depression improves coping.

Frequently asked questions

What is financial toxicity?

Financial toxicity is the financial strain and emotional distress caused by the costs of medical care, including out-of-pocket expenses, lost income and debt. It is most studied in cancer. It can lead people to skip treatment and is linked to worse health and quality of life.

Why is it called financial toxicity?

The term compares financial harm to the physical side effects of treatment. Just as chemotherapy can cause toxicity to the body, high costs can damage a person's finances and wellbeing, and can indirectly harm health by causing missed care and stress.

How can I get help paying for cancer treatment?

Start by asking your cancer center for a financial navigator or social worker. They can help review your insurance, apply for hospital financial assistance, find drug manufacturer and foundation copay programs, and connect you with nonprofits that help with travel, lodging and living costs.

Should I tell my doctor I cannot afford my medicine?

Yes. Your care team cannot help if they do not know. There are often lower-cost alternatives, generic options, samples, assistance programs or different dosing schedules. Stopping or rationing medicines without telling your doctor can be dangerous.