A patient-informed framework of financial strain among adults with multimorbidity

Abstract

Background:

Over one-quarter of adults have multimorbidity. Patients with multimorbidity are more likely to struggle to afford their care than patients without multimorbidity, but their experiences with financial strain have not been fully described.

Objective:

We qualitatively explored the lived experiences of adults with multimorbidity to develop a framework describing financial strain in this patient population.

Design:

Using semi-structured interviews, we asked participants to describe scenarios causing financial strain, any exacerbating or alleviating factors, and emotional/behavioral responses.

Participants:

Adults who had ≥2 of 5 pre-defined chronic conditions (heart failure, coronary artery disease, diabetes, chronic obstructive pulmonary disease, hypertension), took ≥5 medications, and received care at a safety-net primary care clinic.

Measurements:

We analyzed transcripts using rapid qualitative analysis.

Results:

Among 13 participants, age was 42-68 years, 7 were female, 7 had self-reported Black race, and 9 were enrolled in Medicaid. On average, participants had 3/5 pre-defined chronic conditions and were prescribed 10 medications. Financial strain was driven by complex cycles of chronic disease stability and exacerbations, high medical costs (e.g., medications), non-medical costs (e.g., transportation), and low financial reserve (e.g., income loss due to hospitalizations). Participants felt they had to prioritize certain health conditions over others due to cost. Protective factors included caregiver support, financial assistance programs, and assistance from community organizations. Responses to financial strain included rationing care and borrowing money, which negatively impacted disease control and credit scores.

Limitations:

All interviews were conducted at a single site.

Conclusion:

Financial strain in multimorbidity stems from a complex interplay between individual, health system, and community factors, some of which may not be ascertained in routine interactions with primary care providers.

Introduction

Over one-quarter of adults in the United States have multimorbidity, defined as ≥2 chronic conditions.¹ Patients with multimorbidity face numerous barriers to adequate care, including complex medication regimens, conflicting specialist recommendations, logistical hurdles to accessing and organizing care, and the need to prioritize care across multiple conditions.^2-9 The out-of-pocket costs of multimorbidity care in the US add up to thousands of dollars per year per person. Among Medicare beneficiaries in 2019, the estimated annual out-of-pocket costs for medications alone ranged from $893-1017 for type 2 diabetes, $744-858 for chronic obstructive pulmonary disease (COPD), and $929-1041 for heart failure with reduced ejection fraction.¹⁰

Patients with multimorbidity are more likely to experience financial strain compared to patients without multimorbidity,^11,12 in part due to high insurance cost-sharing requirements in the US,^13,14 but also because they are more likely to have lower incomes and little wealth.^15,16 Patients experiencing healthcare-related financial strain are at higher risk of cost-related nonadherence to medications, lower quality of life, and poorer disease control;^17-22 this risk increases with number of chronic conditions and number of medications.²³

As illustrated in a recent systematic review,^2-5,7,8,24 several qualitative studies have described the lived experience of adults with multimorbidity and financial strain, typically focusing on specific anchor diseases (e.g., diabetes)^25,26 or specific aspects of care (e.g., medications, care coordination).^7,27 Few studies, however, have fully explored the contributors, consequences, and lived experiences of financial strain among adults with multimorbidity in the US.

In this pilot study, we used existing literature and semi-structured patient interviews to develop a patient-informed framework of financial strain among adults with multimorbidity in the US. While several frameworks have been developed to describe financial strain among patients with one condition (e.g., cancer, cardiovascular disease),^28-30 none have described financial strain in the context of complex multimorbidity management. Our intention in developing a framework was twofold. First, improved knowledge about patients’ degree of financial strain and how they think about financial tradeoffs can help clinicians pursue more patient-centered management plans.³¹ Second, a framework can improve understanding of the factors that augment financial strain among patients with multimorbidity and highlight areas where change is possible, via interventions or government policy reform. This patient-informed framework could inform the design of financial strain screening interventions to be delivered in primary care clinics.

Methods

Development of a preliminary framework

We developed a preliminary framework based on three recently published disease-specific frameworks of financial strain.^28-30 Jones and colleagues describe the financial and psychological burdens of unaffordable healthcare among US patients with cancer. Biddell and colleagues focus on the public policy, organizational, interpersonal, and individual factors that positively and negatively influence financial barriers to health care among patients with cancer in the US. Campbell and colleagues illustrate the factors that protect from, modify, and predispose toward financial strain among patients with cardiovascular disease in Canada.²⁹ We then added domains from prior multimorbidity frameworks, including concordant/discordant conditions, disease and medication interactions, and prioritization.³²

In our initial framework, we hypothesized that the main causes of financial strain among adults with multimorbidity were high medical costs and low financial reserve (e.g., lack of wealth; Appendix Figure A1). Factors hypothesized to exacerbate or alleviate financial strain included: multimorbidity-associated challenges (e.g., disease and medication interactions, disease exacerbations), availability of caregiver support, stress related to finances, and the need to prioritize certain conditions and/or certain expenses over others. The framework then described how patients coped with insufficient finances (e.g., cost-related nonadherence) and the impacts of financial strain on financial well-being, clinical outcomes (e.g., disease progression, symptoms, hospitalizations), mental health, and quality of life.

Testing the framework via patient interviews

Sample

We recruited participants receiving care at Duke Outpatient Clinic (DOC), an academic primary care clinic that serves ~6000 patients who are predominantly low-income, with 58% enrolled in Medicaid alone, 29% enrolled in Medicare alone or dually enrolled in Medicare/Medicaid, 12% enrolled in commercial insurance, and 2% uninsured. Most patients identify as Black (52%) or White (39%) and 5% identify as Hispanic. DOC has considerable resources to assist patients who experience structural barriers to care, including two social workers, one pharmacist, a chaplain, and several financial counselors. Our objective was to describe patients’ experiences with financial strain and multimorbidity, despite availability of these supportive services. One co-author practices at DOC (CES).

All patients checking in for appointments were offered an informational packet and eligibility screener (Appendix). They could complete the form while waiting for their appointments. The screener asked about demographics (age, gender, race, ethnicity), contact information, chronic conditions, and number of prescribed medications. It also included two yes/no statements about healthcare-related financial hardship: “In the last year, my medical illness and/or treatment have caused me financial problems” and “In the last year, my medical illness and/or treatment have caused my family financial problems.” Financial hardship was not a requirement for inclusion, since one of our objectives was to learn about factors that protect from financial hardship. All clinical and demographic responses were verified in the electronic health record (EHR) prior to enrollment. We continued patient recruitment until we reached code saturation in interviews, meaning repetitive codes were identified in the data and new interview data did not contribute additional codes.^33,34

Inclusion criteria included age ≥18, prescribed ≥5 medications, seen at DOC ≥1 time in the last year, able to communicate in English, and diagnosed with ≥2 of the following chronic conditions: coronary artery disease, COPD, diabetes, heart failure, and hypertension. These diseases were selected because they are common, typically require treatment with multiple medications that may be expensive, often occur alongside one another, and may be associated with fluctuating periods of stability and exacerbations.³⁵ Participants were eligible regardless of whether they had additional chronic conditions. We did not restrict age to older adults, since 7% of adults aged 18-44 and 33% of adults aged 45-64 have multimorbidity and may have different access to insurance than adults.¹ Exclusion criteria included: belonging to CES’ patient panel (to reduce the risk of coercion) and diagnosis of dementia (to ensure ability to obtain accurate patient perspectives). We purposively sampled with the goal of achieving balance on race, gender, and insurance type to ensure a diversity of experiences both within and outside of the health system.

This study was part of a larger study whose objective was also to develop a patient-centered financial strain screening questionnaire, via focus groups and follow-up interviews, all conducted after the initial interviews described in this article. Results of the focus groups and follow-up interviews are forthcoming and not described here.

Interview design

The study team used concept mapping to understand the interconnections among preliminary framework domains and to develop interview questions. The interview guide asked questions about participants’ experiences with being unable to afford care, financial coping mechanisms, prioritization of conditions, financial tradeoffs, and role of caregivers (Appendix).

One author (CLM) called patients after their appointments to obtain consent and schedule the interview. All interviews were conducted by one author (CLM) via Zoom or telephone, for patients unable to access internet in their area. No in-person interviews were conducted, to mitigate any potential transportation or time-related barriers to in-person participation³⁶ and because participants may feel more comfortable offering sensitive information in telephone interviews.^37,38 Interviews were audio-recorded, then transcribed by a professional transcription service. Participants were compensated for their participation.

Human Ethics and Consent to Participate declarations

This study was approved by the Duke Health Institutional Review Board (Pro00113134). Consent was obtained from all participants.

Rapid qualitative analysis

We assessed transcripts using rapid qualitative analysis, an appropriate method when designing contextually appropriate frameworks and interventions in a limited timeframe such as in a pilot study.^39,40 Using the preliminary framework domains of interest, three authors (CES, MAL, CLM) developed an initial codebook in Microsoft Excel, which was iteratively refined in successive meetings. We summarized key quotes from interviews by domain, compiled the information to evaluate the data across interviews, and then used matrix analysis to examine themes relevant to financial strain.⁴¹ Three authors (CES, MAL, CLM) reviewed and coded the first 8 participant transcripts. All authors met regularly to review transcripts, reconcile coding discrepancies, and provide revisions to agree upon a final codebook. Two authors (CES, MAL) then reviewed and coded the last 5 participant interview transcripts, meeting regularly with CLM, who served as adjudicator for discrepancies.

Finalizing the framework

Once interviews concluded, the team used concept mapping to develop the final framework. All authors met to discuss the domains produced from interviews and the ways in which domains interacted with each other. The most commonplace domains were incorporated into the final framework and domains were rearranged to illustrate the interactions among domains as described by participants.

Results

We reached code saturation after completing 13 interviews. Overall, 53 patients completed the eligibility survey; 26 were ineligible; 2 declined to participate after telephone contact; and 12 could not be reached. Interview time averaged 28 minutes (range 17-47). Seven participants were female (54%), 7 identified as Black (54%), 9 were enrolled in Medicaid (69%), and average age was 59 (range 42-68) (Table 1). On average, participants had 3/5 of the predetermined conditions (range 2-4) and 5 total chronic conditions (range 4-7), as defined by the Department of Health and Human Service’s Office of the Assistant Secretary of Health.³⁵ Participants took an average of 10 prescription medications (range 5-19). Nine reported financial hardship on the pre-eligibility survey. In interviews, however, we found that even patients reporting no financial hardship had at least some experience with difficulty affording medical care.

Table 1. Patient Characteristics.

ID	Age, years	Gender	Race	Eligible chronic conditions a	Additional OASH chronic conditions b	Number of medications	Insurance c	Reports financial problems
1	63	Male	White	CAD, hypertension	Depression, schizophrenia, SUD	5	Medicaid	No
2	72	Male	White	CAD, diabetes, hypertension	Atrial fibrillation, hyperlipidemia, history of rectal cancer	9	Medicare + commercial	No
3	62	Male	Black	COPD, hypertension	Asthma, SUD	9	Medicaid	Yes
4	64	Female	White	CAD, hypertension	Hyperlipidemia, arthritis, asthma, depression	6	Medicaid	Yes
5	67	Male	White	Diabetes, COPD, hypertension	Arthritis	9	MA + Medicaid	No
6	53	Male	Black	Diabetes, hypertension	Schizophrenia, SUD	12	Medicaid	Yes
7	47	Female	Black	COPD, hypertension	Atrial fibrillation, CKD	9	Medicaid	Yes
8	67	Male	Black	CHF, CAD, hypertension	Hyperlipidemia, hepatitis C	6	MA	Yes
9	62	Female	White	Diabetes, hypertension	Asthma, depression, SUD	19	Self-pay	Yes
10	54	Female	Black	Diabetes, hypertension	Hyperlipidemia, arthritis, asthma	12	MA + Medicaid	No response
11	42	Female	Black	Diabetes, hypertension	Arthritis, depression, SUD	12	Commercial	Yes
12	68	Female	Black	Diabetes, hypertension	Hyperlipidemia, arthritis, asthma, CKD	9	MA + Medicaid	Yes
13	50	Female	White	Diabetes, hypertension	Hyperlipidemia, arthritis	13	Self-pay	Yes
Mean (range)	59 (42-72)			3 (2-4)	5 (3-7)	10 (5-19)

CAD: coronary artery disease; SUD: substance use disorder; COPD: chronic obstructive pulmonary disease; CKD: chronic kidney disease; MA: Medicare Advantage; Medicare: Fee-for-service Medicare

^aDefined as cardiovascular disease, chronic obstructive pulmonary disease, diabetes, heart failure, hypertension

^bThe 20 chronic conditions selected by the Department of Health and Human Service’s Office of the Assistant Secretary of Health (OASH) are: hypertension, congestive heart failure, coronary artery disease, atrial fibrillation, hyperlipidemia, stroke, arthritis asthma, autism spectrum disorder, cancer, chronic kidney disease, chronic obstructive pulmonary disease, dementia, depression, diabetes, hepatitis, HIV, osteoporosis, schizophrenia, and substance use disorders.³⁵

^cNone of the included patients received benefits from the Veterans Administration or Tricare.

In our final framework (Figure 1), both internal and external factors can contribute to financial strain, similar to the socioecological model of health.⁴² Internal (or individual) factors included multimorbidity-associated challenges, high medical costs, and low financial reserve. Multimorbidity-associated challenges included acute disease exacerbations, the need to prioritize care for certain diseases over others, and disease-disease and/or drug-drug interactions. External factors that may exacerbate or alleviate financial strain included availability of caregiver support, health system policies, and community supports. Patients’ coping strategies impacted their psychological, physical, and financial outcomes. The framework represents one point in time, but given the fluctuating nature of multimorbidity, the relationships between domains should be understood to be dynamic and bidirectional. Results are organized by framework domain and subdomain. Additional representative quotations are in Appendix Table A1.

Figure 1. Patient-informed framework of financial strain in multimorbidity.

This framework was developed based on findings from patient interviews. The framework represents one point in time, but given the chronic and fluctuating nature of multimorbidity, the relationships between domains should be understood to be dynamic and bidirectional. Similar to the socioecological model of health, internal and external factors can contribute to the experience of financial strain. Individual contributors include multimorbidity, high medical costs and low financial reserve. External factors that can exacerbate or alleviate financial strain include caregiver availability and support, health system policies, and community supports. The model also describes financial coping behaviors, and individual outcomes of financial strain.

Multimorbidity-associated challenges in managing financial strain

Clinical tipping points

Some participants consistently struggled to afford their medical costs month-to-month, even when their diseases were well-controlled. Costs fluctuated depending on disease activity, making it difficult to make long-term financial plans. A disease exacerbation requiring hospitalization, progression of disease requiring new medications or equipment, or a new chronic disease diagnosis could act as a tipping point in their ability to manage their finances. The sudden increase in financial strain was due not only to an increase in medical bills, but also loss of income. Participants described working fewer hours due to their symptoms, or losing their jobs due to time spent in the hospital.

Prioritization

Participants prioritized specific medications, appointments, and other aspects of their non-pharmacologic management due to cost. They generally prioritized preventing life-threatening complications and maintaining quality of life. For example, one participant with diabetes, COPD, and arthritis prioritized avoiding life-threatening hyperglycemia: “Well, I'm a diabetic, so if I couldn't afford to get my medicine I might die” (Participant 5). He exerted himself as little as possible to reduce his COPD-related dyspnea and arthritis-related pain, thus reducing the need to take medications for these conditions. While this decision may have saved money in the short-term, it may have increased his risk of cardiovascular disease and COPD exacerbation in the long-term.

Financial challenges

Medical costs

Participants described unaffordable out-of-pocket medical expenses, often despite having insurance. For some, enrollment in Medicaid or receipt of financial assistance from the health system was enough to reduce financial strain. For others, Medicaid’s $4 copayment per medication or the remaining expenses after financial assistance were still unaffordable. For those enrolled in Medicare and private insurance, costs were often unpredictable, due to confusing coverage rules. Some participants also struggled to pay for essential non-medical expenses that were needed to get to appointments and/or follow treatment plans, including gas, rent, food, and utilities.

Financial reserve

Almost all participants had an income (via Social Security or employment) and insurance. Overwhelming health needs resulted in difficulties maintaining employment, leading to loss of both wages and employer-sponsored benefits. Participants who had minimal savings also worried about unexpected medical or non-medical expenses: “I just pray that nothing catastrophic happens where I would need to come up with money in a hurry” (Participant 9).

External factors that exacerbate or alleviate financial strain

Family and other unpaid caregiver availability and support

Many participants did not have consistent social support. Some caregivers were unable to provide direct social support but could provide financial assistance. In some cases, a multi-person support team across family members evolved: “Towards the end of the month [if] I need something refilled…my sister…she'll [help financially] when she can. I got some nieces that will also help out when they can” (Participant 7). Caregivers who worked in healthcare were an important asset, as they helped guide participants through the labyrinth of insurance and assistance programs in addition to providing more typical support like transportation.

Health system policies

Many participants described the health system’s role in exacerbating their financial strain. They shared being turned away from clinic appointments because they did not have money for their copayment; being asked to attend frequent, costly appointments; and receiving surprise bills for urgent or emergent care. Administrative barriers and delays in access to health system and pharmaceutical financial assistance programs also contributed to stress and uncertainty. Other administrative barriers to coverage and affordability included unclear Medicaid eligibility requirements in the state of North Carolina and lack of knowledge about health system financial assistance programs and medication coupons.

Despite the barriers imposed by the healthcare system, participants also felt appreciative of individuals working within the system who made efforts to help, including social workers who provided information on local resources and clinicians who did their best to consider costs in their medical decisions. Some specialty clinics provided additional supports. For example, one participant with a history of cancer shared that a patient advocate in the cancer center helped guide her to available medication manufacturer coupons and assistance programs.

Community supports

Participants received support from their churches, local food banks, and local medication assistance non-profit organizations. However, some programs were disease-specific. For example, one participant with a history of cancer shared that a cancer-focused community organization had helped with transportation and other indirect medical costs when her cancer was active. Once her cancer went into remission, she lost access to the program despite a continued need for services related to her other chronic conditions.

Financial coping behaviors

Financial tradeoffs

Participants’ financial priorities often determined whether they elected to undergo recommended testing and treatment. Some participants prioritized essentials like food and housing and pursued treatments that aligned with their anticipated budget. Others were willing to spend more than they could afford on healthcare, knowing they might incur medical debt. Several participants were frustrated about how difficult it was to determine whether a particular treatment would be covered by insurance and what their costs would be ahead of time, hindering their ability to make informed decisions about financial tradeoffs.

Other financial coping behaviors

Other common coping strategies included avoiding medical appointments, skipping meals, borrowing money from family, and begging for money on street corners. Patients also described skipping medications to stretch out prescriptions: “Well sometimes I just took half a dose…because I didn't have enough money to go buy it” (Participant 5).

Outcomes of financial strain

Psychological and physical outcomes

Participants worried about how they would access medical care and about the impact of avoiding care on their overall health. One participant described the direct impact of poor financial reserve on her ability to manage her obesity: “I think I was like 229[lb] down to 186[lb]. And then when I lost my home, I gained it all back” (Participant 4). When financial reserve improved, health outcomes improved: “I take my medicine regular now [that I'm on Medicaid]. Every day. And makes me feel - I feel better. I got a little more energy. I do a few more things than I could before” (Participant 5).

Financial outcomes

Some participants used credit cards to pay for their recurring medical expenses, but the bills soon became insurmountable. Multiple participants shared the stress of having aggressive bill collectors request money they simply did not have. “You constantly have the bill collectors calling you. And you tell them, ‘I’m unemployed. There’s nothing I can do’” (Participant 11). One participant described losing her house and moving in with family, though it is unclear whether this event was specifically linked to healthcare-related financial strain.

Discussion

The objective of this study was to develop a framework to describe experiences with financial strain and approaches to financial tradeoffs among adults with multimorbidity. Similar to the socioecological model of health, we found that financial strain is influenced by individual and external factors. Patients described the individual-level impacts of financial costs associated with managing multiple chronic conditions and recurring cycles of acute disease exacerbations, as well as the physical and emotional toll of having to prioritize certain diseases over others due to cost. Some external factors alleviated financial strain, such as caregiver availability and support from community organizations. In contrast, participants described healthcare organizations like hospitals and pharmaceutical companies as putting up administrative and financial barriers to care. As shown in prior studies,^20,43 financial strain led to damaging individual coping behaviors and negative health and financial outcomes. Our final framework identifies areas that can be targeted by clinicians (e.g., shared decision-making about financial tradeoffs), health systems (e.g., simplifying financial assistance applications), and policymakers (e.g., Medicaid access) to lessen financial strain and improve individual outcomes.

Our findings are consistent with the limited research available on the financial burden of multimorbidity care in the US. One recent review of qualitative studies conducted in the US and internationally found that financial strain often results from medication expenses; transportation and parking; appointments; and loss of income related to frequent appointments.²⁴ Similar to prior findings, patients in our study coped with unaffordable expenses by borrowing money from family and friends, sacrificing food and other essentials, and prioritizing the treatments that were most likely to prolong their life and improve their quality of life.^24,44

Our findings build on the prior literature by delving into the external factors that exacerbate and/or alleviate financial strain. Many of the patients we interviewed had minimal social support and few people to turn to for financial assistance, consistent with research showing that social networks can act as mediators of health and economic inequities.^45-47 Patients acknowledged that financial assistance from government and healthcare organizations were available, but the administrative barriers to receiving assistance sometimes felt insurmountable. While all participants lived in North Carolina and received their care at a single clinic, many patients across the US are similarly left out of programs intended for underserved populations, due to lack of knowledge or burdensome applications. For example, 18% of patients meeting criteria for Medicare’s low-income subsidy program are not enrolled.⁴⁸ In most states, patients must know about and apply for hospital financial assistance programs to benefit from them, rather than getting auto-enrolled if eligible.⁴⁹ Future research could evaluate whether auto-enrollment in hospital financial assistance and/or government-based supports leads to reductions in financial strain.

The framework presented here is the first to describe multimorbidity-related financial strain. It differs from prior disease-specific frameworks by including challenges in management and affordability that may not be seen in patients who do not have multimorbidity, including disease-disease interactions, cycles of disease stability and exacerbation, and the need to prioritize the conditions that are most active at a given time.⁵⁰ Further work is needed to explore whether our framework can be applied to a broader range of ages, insurance types, incomes, chronic conditions, and geographies. Our framework could also be used to develop a national survey aimed at assessing financial strain across a more generalizable population. The perspectives of family caregivers and clinic staff caring for patients with multimorbidity should also be considered, as their actions may alleviate or exacerbate patient financial strain.

Our framework could also be used to develop a financial strain screener for use in clinical settings, similar to an existing survey that has been validated for use in cancer⁵¹ and diabetes.⁵² The screener could incorporate aspects of the Age-friendly 4Ms model of care, which encourages clinicians to consider “what matters most” to patients in shared decision-making discussions. A multimorbidity-centered financial strain screener could allow clinicians to create individualized, patient-centered care plans that account for both clinical and financial preferences. A positive financial strain screen could, for example, prompt a clinician to refer a patient to a social worker, or deprescribe an expensive medication.⁵³

In the last three years, state and federal policymakers made significant strides towards addressing the financial barriers to care described in our patient interviews. First, the 2022 Inflation Reduction Act placed a $2000 cap on out-of-pocket medication costs for Medicare enrollees.⁵⁴ Second, North Carolina expanded Medicaid eligibility in December 2023, leading to >675,000 new enrollees in less than 2 years.⁵⁵ Third, in January 2025, the Consumer Financial Protection Bureau (CFPB) finalized a regulation removing medical bills from most credit reports.⁵⁶ Finally, in August 2024, North Carolina hospitals agreed to forgive medical debt that was ≥2 years-old for people who were enrolled in Medicaid, had incomes ≤350% of the federal poverty limit, or had debt amounting to >5% of their income.⁵⁷ Unfortunately, some of these reforms may be short-lived due to recent federal legislative and regulatory action. The One Big Beautiful Bill Act drastically reduces federal funding for Medicaid beginning in 2026, putting Medicaid expansion and medical debt forgiveness reforms at risk in North Carolina and other states.⁵⁸ Additionally, federal courts recently blocked the CFPB’s regulation removing medical bills from credit reports.⁵⁹ As federal support for patients facing health-related financial strain declines, it will be up to state governments, health systems, community organizations, and individual clinicians to intervene whenever possible to minimize costs and maximize access for the most vulnerable patients.

Our study has several limitations. First, all interviews were conducted at a single safety-net primary care clinic that has extensive resources available to assist patients encountering structural barriers to care. Financial strain may be higher for low-income patients receiving care at clinics where these resources are not available. Second, one author (CES) is a primary care physician at this clinic. None of the patients on her panel were included in the study to reduce the risk or appearance of coercion. Third, our inclusion criteria limited our ability to explore all perspectives. In particular, our study included patients with a subset of five highly prevalent chronic conditions who spoke English and were predominantly low-income. Some of our findings may not extend to other patients with multimorbidity, patients with higher incomes, or patients facing language barriers. Additionally, while we excluded patients with dementia, we did not screen patients for other causes of cognitive impairment. This pilot study represents formative work that should be confirmed in a larger, mixed-methods study. Fourth, while study participants had diverse genders, races, and ages, our interviews did not address the role that individual and/or systemic discrimination may play in the experience of financial strain. We also did not explicitly collect information on disabilities. Future work should evaluate the role of discrimination in financial strain, for example by evaluating our framework in the context of the National Institute on Aging’s Health Disparities Framework.⁶⁰

Conclusion

Multimorbidity presents unique challenges to patients that contribute to both risk for and consequences of financial strain. Moving forward, it will be important to further refine our understanding of financial strain in multimorbidity by gaining the perspective of clinicians, social workers, and caregivers. It will also be important to evaluate financial strain in a larger sample of patients with varying income levels, insurance coverage, and disease combinations. Future work should put these findings into action by devising, testing, and implementing interventions that address each framework domain and aim to make comprehensive multimorbidity care more financially accessible in the US.