Financial Toxicity in Atherosclerotic Cardiovascular Disease in the United States: Current State and Future Directions

Abstract

Atherosclerotic cardiovascular disease (ASCVD) has posed an increasing burden on Americans and the United States healthcare system for decades. In addition, ASCVD has had a substantial economic impact, with national expenditures for ASCVD projected to increase by over 2.5-fold from 2015 to 2035. This rapid increase in costs associated with health care for ASCVD has consequences for payers, healthcare providers, and patients. The issues to patients are particularly relevant in recent years, with a growing trend of shifting costs of treatment expenses to patients in various forms, such as high deductibles, copays, and coinsurance. Therefore, the issue of "financial toxicity" of health care is gaining significant attention. The term encapsulates the deleterious impact of healthcare expenditures for patients. This includes the economic burden posed by healthcare costs, but also the unintended consequences it creates in form of barriers to necessary medical care, quality of life as well tradeoffs related to non-health-related necessities. While the societal impact of rising costs related to ASCVD management have been actively studied and debated in policy circles, there is lack of a comprehensive assessment of the current literature on the financial impact of cost sharing for ASCVD patients and their families. In this review we systematically describe the scope and domains of financial toxicity, the instruments that measure various facets of healthcare-related financial toxicity, and accentuating factors and consequences on patient health and well-being. We further identify avenues and potential solutions for clinicians to apply in medical practice to mitigate the burden and consequences of out-of-pocket costs for ASCVD patients and their families.

Keywords: catastrophic expense; cost-of-care; financial distress; financial toxicity; medical bankruptcy; medical bills; out-of-pocket costs.

Figure 1. Financial toxicity among adults with atherosclerotic cardiovascular disease in the United States.

A, Out‐of‐pocket spending on healthcare/post‐subsistence family income >20%. B, Out‐of‐pocket spending on healthcare/postsubsistence family income ≥40%. Data from studies by Khera et al ¹⁵ and Valero‐Elizondo et al. ²³ ASCVD indicates atherosclerotic cardiovascular disease; and CHE, catastrophic healthcare expenditures.

Figure 2. A, Mean annual out‐of‐pocket expenditures.

B, Overall annual expenses among low‐income families, stratified by financial burden category, by spending category among individuals with atherosclerotic cardiovascular disease. Data from studies by Khera et al ¹⁵ and Valero‐Elizondo et al. ²³ ASCVD indicates atherosclerotic cardiovascular disease; CHE, catastrophic healthcare expenditures; and OOP, out‐of‐pocket.

Figure 3. Factors associated with financial toxicity among individuals with atherosclerotic cardiovascular disease.

Data from studies by Khera et al, ¹⁵ Valero‐Elizondo et al, ²³ and Khera et al. ³¹ ASCVD indicates atherosclerotic cardiovascular disease; CHE, catastrophic healthcare expenditures; CRN, cost‐related medication nonadherence; and OOP, out‐of‐pocket.

Figure 4. Schematic overview of financial toxicity in atherosclerotic cardiovascular disease.

OOP indicates out‐of‐pocket.