Out-of-pocket-payments and the financial burden of 502 cancer patients of working age in Germany: results from a longitudinal study

  • Matthias BüttnerEmail author
  • Hans-Helmut König
  • Margrit Löbner
  • Susanne Briest
  • Alexander Konnopka
  • Andreas Dietz
  • Steffi Riedel-Heller
  • Susanne Singer
Original Article



Cancer patients in Germany often face payments related to their disease or treatment which are not covered by their health insurance. The aim of this study was to analyze the amount of out-of-pocket payments (OOPPs) among cancer patients in Germany, to explore potential socioeconomic determinants of OOPPs, and to identify how cancer patients are burdened by these payments.


Cancer ptients were consecutively enrolled in 16 clinics in Leipzig, Germany. Data on OOPPs for the past 3 months and on socioeconomic status were obtained at the end of their hospital stay (t0) and 3 (t1) and 15 months (t2) after t0. Financial burden was calculated by dividing the monthly OOPPs by the midpoint of the income category, and the perceived burden was assessed by using the financial difficulties scale of the EORTC QLQ-C30. A two-part regression model was used to estimate the determinants of OOPPs.


At baseline (t0), 502 cancer patients participated in the study and provided data on OOPPs and socioeconomic status. The mean 3-month OOPPs were the following: €205.8 at baseline, €179.2 at t1, and €148.1 at t2. Compared to the lowest income group (< €500 monthly), all other income groups (€500–999, €1000–1499, and ≥ €1500) had higher 3-month OOPPs of €52.3 (p = 0.241), €90.2 (p = 0.059), or €62.2 (p = 0.176). Financial burden at t0 was 6.4% (SD 9.2%) on average, 5.4% (SD 9.9%) at t1, and to 3.9% (SD 7.0%) of monthly income at t2.


German cancer patients face relatively high OOPPs during their cancer journey. These payments may burden cancer patients, especially certain subgroups like low-income groups.


Out-of-pocket-payments Cancer Financial burden Germany Financial toxicity 



This work was supported by German Pension Insurance (#8011-106-31/31.81).

Compliance with ethical standards

Conflict of interest

The authors confirm that they have full control of all primary data and agree to allow the journal to review the data if requested.

Matthias Büttner has nothing to disclose.

Hans-Helmut König has nothing to disclose.

Margrit Löbner reports grants from German Pension Insurance, during the conduct of the study.

Susanne Briest has nothing to disclose.

Alexander Konnopka has nothing to disclose.

Andreas Dietz has nothing to disclose.

Steffi Riedel-Heller reports grants from German Pension Insurance, during the conduct of the study.

Susanne Singer reports grants from German Pension Insurance, during the conduct of the study; grants and personal fees from Pfizer, personal fees from Bristol-Myers Squibb, personal fees from Boehringer-Ingelheim, personal fees from Lilly, outside the submitted work.


  1. 1.
    Jonsson B, Hofmarcher T, Lindgren P, Wilking N (2016) The cost and burden of cancer in the European Union 1995-2014. Eur J Cancer 66:162–170CrossRefGoogle Scholar
  2. 2.
    Tambor M, Pavlova M, Woch P, Groot W (2011) Diversity and dynamics of patient cost-sharing for physicians’ and hospital services in the 27 European Union countries. Eur J Pub Health 21(5):585–590CrossRefGoogle Scholar
  3. 3.
    Beske F, Goldbach U (2009) Zuzahlungen im Gesundheitswesen: Grundlagen, internationaler Vergleich und Konzepte für die Gesetzliche Krankenversicherung. Schriftenreihe des Fritz Beske Instituts für Gesundheits-System-Forschung 111Google Scholar
  4. 4.
    Bodeker W, Moebus S (2015) Conflicting rules and incentives for health promotion and prevention in the German statutory health insurance (GKV). Gesundheitswesen 77(6):397–404PubMedGoogle Scholar
  5. 5.
    Lauterbach KW, Stock S, Brunner H (2006) Gesundheitsökonomie – Lehrbuch für Mediziner und andere Gesundheitsberufe. Hans Huber, BernGoogle Scholar
  6. 6.
    Mielck A, Kiess R, von dem Knesebeck O, Stirbu I, Kunst AE (2009) Association between forgone care and household income among the elderly in five Western European countries - analyses based on survey data from the SHARE-study. BMC Health Serv Res 9:52CrossRefGoogle Scholar
  7. 7.
    Sambamoorthi U, Shea D, Crystal S (2003) Total and out-of-pocket expenditures for prescription drugs among older persons. Gerontologist 43(3):345–359CrossRefGoogle Scholar
  8. 8.
    Crystal S, Johnson RW, Harman J, Sambamoorthi U, Kumar R (2000) Out-of-pocket health care costs among older Americans. J Gerontol B Psychol Sci Soc Sci 55(1):S51–S62CrossRefGoogle Scholar
  9. 9.
    Piette JD, Heisler M, Wagner TH (2004) Cost-related medication underuse among chronically ill adults: the treatments people forgo, how often, and who is at risk. Am J Public Health 94(10):1782–1787CrossRefGoogle Scholar
  10. 10.
    Huang J, Zhou S, Groome P, Tyldesley S, Zhang-Solomans J, Mackillop WJ (2001) Factors affecting the use of palliative radiotherapy in Ontario. J Clin Oncol 19(1):137–144CrossRefGoogle Scholar
  11. 11.
    Mathews M, Buehler S, West R (2009) Perceptions of health care providers concerning patient and health care provider strategies to limit out-of-pocket costs for cancer care. Curr Oncol 16(4):3–8CrossRefGoogle Scholar
  12. 12.
    Corrieri S, Heider D, Matschinger H, Lehnert T, Raum E, Konig HH (2010) Income-, education- and gender-related inequalities in out-of-pocket health-care payments for 65+ patients - a systematic review. Int J Equity Health 9:20CrossRefGoogle Scholar
  13. 13.
    Bock JO, Matschinger H, Brenner H, Wild B, Haefeli WE, Quinzler R et al (2014) Inequalities in out-of-pocket payments for health care services among elderly Germans--results of a population-based cross-sectional study. Int J Equity Health 13:3CrossRefGoogle Scholar
  14. 14.
    Arsenijevic J, Pavlova M, Rechel B, Groot W (2016) Catastrophic health care expenditure among older people with chronic diseases in 15 European countries. PLoS One 11(7):e0157765CrossRefGoogle Scholar
  15. 15.
    Valtorta NK, Hanratty B (2013) Socioeconomic variation in the financial consequences of ill health for older people with chronic diseases: a systematic review. Maturitas 74(4):313–333CrossRefGoogle Scholar
  16. 16.
    Gordon LG, Merollini KMD, Lowe A, Chan RJ (2017) A systematic review of financial toxicity among cancer survivors: we can’t pay the co-pay. Patient 10(3):295–309CrossRefGoogle Scholar
  17. 17.
    Singer S, Szalai C, Briest S, Brown A, Dietz A, Einenkel J et al (2013) Co-morbid mental health conditions in cancer patients at working age--prevalence, risk profiles, and care uptake. Psychooncology 22(10):2291–2297PubMedGoogle Scholar
  18. 18.
    Singer S, Meyer A, Wienholz S, Briest S, Brown A, Dietz A et al (2014) Early retirement in cancer patients with or without comorbid mental health conditions: a prospective cohort study. Cancer 120(14):2199–2206CrossRefGoogle Scholar
  19. 19.
    Bundesministerium der Justiz und für Verbraucherschutz (2017) Einkommensteuergestz §9 Werbungskosten. Accessed 03.01.2017
  20. 20.
    Hagenaars A, de Vos K, Zaidi MA (1994) Poverty statistics in the late 1980s: research based on micro-data. Office for Official Publications of the European Communities, LuxembourgGoogle Scholar
  21. 21.
    Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ et al (1993) The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 85(5):365–376CrossRefGoogle Scholar
  22. 22.
    Fayers PM, Aaronson NK, Bjordal K, Groenvold M, Curran D, Bottomley A, on behalf of the EORTC Quality of Life Group (2001) The EORTC QLQ-C30 scoring manual, Brussels, 3rd edn. European Organisation for Research and Treatment of CancerGoogle Scholar
  23. 23.
    Manning WG, Basu A, Mullahy J (2005) Generalized modeling approaches to risk adjustment of skewed outcomes data. J Health Econ 24(3):465–488CrossRefGoogle Scholar
  24. 24.
    Le Cook B, McGuire TG, Lock K, Zaslavsky AM (2010) Comparing methods of racial and ethnic disparities measurement across different settings of mental health care. Health Serv Res 45(3):825–847CrossRefGoogle Scholar
  25. 25.
    Baili P, Di Salvo F, de Lorenzo F, Maietta F, Pinto C, Rizzotto V et al (2016) Out-of-pocket costs for cancer survivors between 5 and 10 years from diagnosis: an Italian population-based study. Support Care Cancer 24(5):2225–2233CrossRefGoogle Scholar
  26. 26.
    Céilleacher AO, Hanly P, Skally M, O’Leary E, O’Neill C, Fitzpatrick P et al (2017) Counting the cost of cancer: out-of-pocket payments made by colorectal cancer survivors. Support Care Cancer 25(9):2733–2741CrossRefGoogle Scholar
  27. 27.
    Longo CJ, Bereza BG (2011) A comparative analysis of monthly out-of-pocket costs for patients with breast cancer as compared with other common cancers in Ontario, Canada. Curr Oncol 18(1):e1–e8CrossRefGoogle Scholar
  28. 28.
    Pisu M, Azuero A, Benz R, McNees P, Meneses K (2017) Out-of-pocket costs and burden among rural breast cancer survivors. Cancer Med 6(3):572–581CrossRefGoogle Scholar
  29. 29.
    Hajek A, Bock JO, Brenner H, Saum KU, Matschinger H, Haefeli WE et al (2017) Which factors affect out-of-pocket payments for health care services among elderly Germans? Results of a longitudinal study. Gesundheitswesen 79(2):e18–e25PubMedGoogle Scholar
  30. 30.
    Lang HC (2010) Willingness to pay for lung cancer treatment. Value Health 13(6):743–749CrossRefGoogle Scholar
  31. 31.
    Bremer P (2014) Forgone care and financial burden due to out-of-pocket payments within the German health care system. Health Econ Rev 4(1):36CrossRefGoogle Scholar
  32. 32.
    Giorgi Rossi P, Beccaro M, Miccinesi G, Borgia P, Costantini M, Chini F et al (2007) Dying of cancer in Italy: impact on family and caregiver. The Italian survey of dying of cancer. J Epidemiol Community Health 61(6):547–554CrossRefGoogle Scholar
  33. 33.
    Azzani M, Roslani AC, Su TT (2016) Financial burden of colorectal cancer treatment among patients and their families in a middle-income country. Support Care Cancer 24(10):4423–4432CrossRefGoogle Scholar
  34. 34.
    Ubel PA, Abernethy AP, Zafar SY (2013) Full disclosure--out-of-pocket costs as side effects. N Engl J Med 369(16):1484–1486CrossRefGoogle Scholar
  35. 35.
    Tucker-Seeley RD, Yabroff KR (2016) Minimizing the “financial toxicity” associated with cancer care: advancing the research agenda. J Natl Cancer Inst 108(5)CrossRefGoogle Scholar
  36. 36.
    Statistisches Bundesamt (2018) Gesundheitsausgaben in Deutschland. Accessed 20.06.2018

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), Division of Epidemiology and Health Services ResearchUniversity Medical Center MainzMainzGermany
  2. 2.University Cancer Centre, University Medical Center MainzMainzGermany
  3. 3.Department of Health Economics and Health Services ResearchUniversity Medical Center Hamburg-EppendorfHamburgGermany
  4. 4.Institute of Social Medicine, Occupational Health and Public Health (ISAP)University Medical Center LeipzigLeipzigGermany
  5. 5.Leipzig Breast Cancer CenterUniversity Medical Center LeipzigLeipzigGermany
  6. 6.Clinic for Otolaryngology, Head and Neck SurgeryUniversity Medical Center LeipzigLeipzigGermany

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