Financial Hardship, End-of-Life Health Care Use, and Costs in Patients With Cancer.

Abstract

Patients with cancer are at higher risk of adverse financial events (AFEs) compared with individuals without cancer. However, little is known about how personal finances affect cancer care, particularly at the end of life (EOL). To investigate the association between AFEs and health care use and costs at EOL among patients with cancer. In this cohort study, Western Washington Surveillance, Epidemiology, and End Results cancer registry cases were linked to claims from commercial payers and Medicare and to credit records from TransUnion. Patients with American Joint Committee on Cancer stage I to IV solid tumors who died between January 1, 2013, and December 31, 2019, were identified. Data analysis was performed from January 2023 and June 2025. Emergency department (ED) and inpatient visits in the last 3 months of life, place of death, and mean adjusted health care costs per patient were compared between patients with vs without new AFEs in the 2 years preceding EOL (charge-offs, third-party collections, tax liens, delinquent mortgage payments, foreclosures, or repossessions). A multivariate logistic regression analysis evaluated the association between AFEs and the outcomes of ED or inpatient visits and inpatient death. Health care costs in the last 3 and 6 months of life were analyzed using 2-part models to account for zero costs and right-skewed positive expenditures; adjusted average treatment effects were estimated. A total of 10 826 patients (median [IQR] age, 75 [69-83] years; 5877 [54%] male; 932 [8.6%] with AFEs) were included. Patients with AFEs were more likely to have multiple ED or inpatient visits (odds ratio [OR], 1.41; 95% CI, 1.22-1.62; P < .001) and die in a hospital (OR, 1.50; 95% CI, 1.30-1.75; P < .001). Mean (SD) adjusted total health care costs were higher in patients with AFEs than those without in the last 3 months ($35 115 [$1415] vs $31 031 [$389]) and 6 months ($57 401 [$2181] vs $51 602 [$581]) of life, yielding a mean adjusted incremental costs in the AFE group of $4084 (95% CI, $1287-$7087; P = .006) and $5799 (95% CI, $1235-$9996; P = .01), respectively. In this cohort study, AFEs were associated with greater ED and inpatient use, higher risk of inpatient death, and higher care costs at EOL. These findings point to the need for future studies investigating whether interventions that mitigate financial hardship could improve the EOL experience and decrease health care costs for patients with cancer.