Financial burden can affect healthcare utilization. Few studies have assessed the short-term associations between material (debt, trouble paying rent) and psychological (worry or distress about affording future healthcare) financial risks, and subsequent outpatient and emergency healthcare use. Worry was defined as concerns about affording future healthcare.
Examine whether worry about affording healthcare is associated with healthcare utilization when controlling for material risk and general anxiety
Longitudinal observational study
Kaiser Permanente members with exchange-based federally subsidized health insurance (n = 450, 45% response rate)
Survey measures of financial risks (material difficulty paying for medical care and worry about affording healthcare) and general anxiety. Healthcare use (primary care, urgent care, emergency department, and outpatient specialty visits) in the 6 months following survey completion.
Emergency department and primary care visits were not associated with material risk, worry about affording care, or general anxiety in individual and pooled analyses (all 95% confidence intervals (CI) for relative risk (RR) included 1). Although no individual predictor was associated with urgent care use (all 95% CIs for RR included 1), worry about affording prescriptions (relative risk (RR) = 2.01; 95% CI 1.14, 3.55) and general anxiety (RR = 0.38; 95% CI 0.15, 0.95) were significant when included in the same model, suggesting the two confounded each other. Worry about affording healthcare services was associated with fewer specialty care visits (RR = 0.40; 95% CI 0.25, 0.64) even when controlling for material risk and general anxiety, although general anxiety was also associated with more specialty care visits (RR = 1.98; 95% CI, 1.23, 3.18).
Screening for both general anxiety and financial worry may assist with specialty care utilization. Identifying these concerns may provide more opportunities to assist patients. Future research should examine interventions to reduce worry about cost of care.
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Irwin A, Valentine N, Brown C, et al. The commission on social determinants of health: Tackling the social roots of health inequities. Plos Medicine. 2006;3(6):749-751.
Heiman HJ, Artiga S. Beyond health care: The role of social determinants in promoting health and health equity. Kaiser Family Foundation;2015.
Goldstein D, Holmes J. 2011 Physicians' Daily Life Report. Robert Wood Johnson Foundation;2011.
Kennedy BP, Kawachi I, Glass R, Prothrow-Stith D. Income distribution, socioeconomic status, and self rated health in the United States: multilevel analysis. BMJ. 1998;317(7163):917-921.
Xiao Q, Berrigan D, Matthews CE. A prospective investigation of neighborhood socioeconomic deprivation and self-rated health in a large US cohort. Health Place. 2017;44:70-76.
Ota A, Yatsuya H, Nishi N, et al. Relationships among Socioeconomic Factors and Self-rated Health in Japanese Adults: NIPPON DATA2010. J Epidemiol. 2018;28 Suppl 3:S66-S72.
Sulander T, Pohjolainen P, Karvinen E. Self-rated health (SRH) and socioeconomic position (SEP) among urban home-dwelling older adults. Arch Gerontol Geriatr. 2012;54(1):117-120.
Koch CG, Li L, Kaplan GA, et al. Socioeconomic Position, Not Race, Is Linked to Death After Cardiac Surgery. Circulation: Cardiovascular Quality and Outcomes. 2010;3(3):267-276.
Valtorta NK, Hanratty B. Socioeconomic variation in the financial consequences of ill health for older people with chronic diseases: a systematic review. Maturitas. 2013;74(4):313-333.
Yabroff KR, Dowling EC, Guy GP, et al. Financial Hardship Associated With Cancer in the United States: Findings From a Population-Based Sample of Adult Cancer Survivors. J Clin Oncol. 2016;34(3):259-267.
Altice CK, Banegas MP, Tucker-Seeley RD, Yabroff KR. Financial Hardships Experienced by Cancer Survivors: A Systematic Review. J Natl Cancer Inst. 2017;109(2).
Gordon LG, Merollini KMD, Lowe A, Chan RJ. A Systematic Review of Financial Toxicity Among Cancer Survivors: We Can't Pay the Co-Pay. Patient. 2017;10(3):295-309.
Bestvina CM, Zullig LL, Rushing C, et al. Patient-oncologist cost communication, financial distress, and medication adherence. J Oncol Pract. 2014;10(3):162-167.
Zullig LL, Peppercorn JM, Schrag D, et al. Financial Distress, Use of Cost-Coping Strategies, and Adherence to Prescription Medication Among Patients With Cancer. J Oncol Pract. 2013;9(6S):60s-63s.
Khera N, Chang YH, Hashmi S, et al. Financial burden in recipients of allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant. 2014;20(9):1375-1381.
Jones S, Du YX, Panattoni L, Henrikson N. Development of a questionnaire to assess worry about affording healthcare in an international sample. Qual Life Res. 2019;28:S54-S54.
Jones SMW, Walker R, Fujii M, Nekhlyudov L, Rabin BA, Chubak J. Financial difficulty, worry about affording care, and benefit finding in long-term survivors of cancer. Psychooncology. 2018;27(4):1320-1326.
Berggren U. General and specific fears in referred and self-referred adult patients with extreme dental anxiety. Behav Res Ther. 1992;30(4):395-401.
Buss C, Davis EP, Hobel CJ, Sandman CA. Maternal pregnancy-specific anxiety is associated with child executive function at 6-9 years age. Stress. 2011;14(6):665-676.
Reck C, Zimmer K, Dubber S, Zipser B, Schlehe B, Gawlik S. The influence of general anxiety and childbirth-specific anxiety on birth outcome. Arch Womens Ment Health. 2013;16(5):363-369.
Eastin MS, Guinsler NM. Worried and wired: effects of health anxiety on information-seeking and health care utilization behaviors. Cyberpsychol Behav. 2006;9(4):494-498.
Norris L. Will you receive an Obamacare premium subsidy? How the Affordable Care Act's subsidies are calculated, and who is eligible to receive them. HealthInsurance.org. https://www.healthinsurance.org/obamacare/will-you-receive-an-obamacare-premium-subsidy/. Published 2018. Accessed June 1, 2019.
Collins SR, Bhupal HK, Doty MM. Health insurance coverage eight years after the ACA. The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2019/feb/health-insurance-coverage-eight-years-after-aca. Published 2019. Accessed.
Barlow DH. Anxiety and its disorders: The nature and treatment of anxiety and panic. 2nd ed. New York: The Guilford Press; 2004.
Jones SM, Amtmann D. Differential item function analysis of a scale measuring worry about affording healthcare in multiple sclerosis. Rehabil Psychol. 2016;61(4):430-434.
Jones SM, Amtmann D. Health care worry is associated with worse outcomes in multiple sclerosis. Rehabil Psychol. 2014;59(3):354-359.
LaForge K, Gold R, Cottrell E, et al. How 6 Organizations Developed Tools and Processes for Social Determinants of Health Screening in Primary Care: An Overview. The Journal of ambulatory care management. 2018;41(1):2-14.
Adler NE, Stead WW. Patients in context--EHR capture of social and behavioral determinants of health. N Engl J Med. 2015;372(8):698-701.
Puterman E, Haritatos J, Adler NE, Sidney S, Schwartz JE, Epel ES. Indirect effect of financial strain on daily cortisol output through daily negative to positive affect index in the Coronary Artery Risk Development in Young Adults Study. Psychoneuroendocrinology. 2013;38(12):2883-2889.
Hall MH, Matthews KA, Kravitz HM, et al. Race and financial strain are independent correlates of sleep in midlife women: the SWAN sleep study. Sleep. 2009;32(1):73-82.
Lowe B, Wahl I, Rose M, et al. A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord. 2010;122(1-2):86-95.
Zeger SL, Liang KY, Albert PS. Models for longitudinal data: a generalized estimating equation approach. Biometrics. 1988;44(4):1049-1060.
Lesaffre E, Marx BD. Collinearity in Generalized Linear-Regression. Commun Stat-Theor M. 1993;22(7):1933-1952.
Lewis CC, Wellman R, Jones SMW, et al. Comparing the performance of two social risk screening tools in a vulnerable subpopulation. Journal of Family Medicine and Primary Care. In press.
Horst P. The role of predictor variables which are independent of the criterion. Social Science Research Council. 1941;48:431-436.
Jones SMW, Litwin P. Association of healthcare utilization with financial worry and anxiety in a general population sample. Psychol Health Med. 2020:1-8.
Collins JM, Olive P, O'Rourke CM. Financial Coaching's Potential for Enhancing Family Financial Security. Journal of Extension. 2013;51(1).
Shankaran V, Leahy T, Steelquist J, et al. Pilot Feasibility Study of an Oncology Financial Navigation Program. J Oncol Pract. 2018;14(2):e122-e129.
Henrikson NB, Tuzzio L, Loggers ET, Miyoshi J, Buist DS. Patient and oncologist discussions about cancer care costs. Support Care Cancer. 2014;22(4):961-967.
Pinto AD, Bondy M, Rucchetto A, Ihnat J, Kaufman A. Screening for poverty and intervening in a primary care setting: an acceptability and feasibility study. Fam Pract. 2019;36(5):634-638.
The authors would like to thank the staff of Kaiser Permanente Washington, Southern California, and Colorado for contributing to this project.
Funding was provided by the Kaiser Foundation.
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Jones, S.M.W., Banegas, M.P., Steiner, J.F. et al. Association of Financial Worry and Material Financial Risk with Short-Term Ambulatory Healthcare Utilization in a Sample of Subsidized Exchange Patients. J GEN INTERN MED (2021). https://doi.org/10.1007/s11606-020-06479-6
- economic well-being
- financial toxicity
- financial burden
- financial hardship