Table 1.
The Subcomposites of the Objective Family Financial Stress (OFFS) Index
| Description | Relevance | Components |
|---|---|---|
| 1: Relative Objective Family Financial Stress due to Out-of- Pocket Medical Expenses | A measure of income adequacy that reflects situations of: a) high total out-of- pocket outlays and income losses (e.g., completely uninsured expenses); as well as b) low total out-of-pocket outlays that nonetheless represent financially catastrophic costs for low-income families (e.g., underinsured expenses). | Divides the total out-of-pocket costs in the past month due to medical expenses by a U.S. derived income equivalence scale (IES). This IES, which equals total family income divided by the 0.38 power of family size, converts income into a measure of income adequacy that reflects family size and economies of scale or consumption [24–25]. The incorporation of family size to adjust for economies of scale in consumption is an improvement over cruder indices of out-of-pocket costs adjusted solely for family income regardless of family size.* |
| 2: Objective Family Financial Stress due to Medical Bills Management | Broadly reflects the financial stress of surveilling, monitoring, organizing, and interpreting various medical bills and insurance coverage statements. | 11 dichotomous variables over the previous four months reflecting whether the patient incurred medical expenses pertaining to doctor bills, nursing home expenses, medications, private duty or hired nurses, home health aides, special equipment and supplies, special foods or supplements, hospital bills, ambulance services, health insurance premiums, and all other.† |
| 3: Extent of Wage Loss due to the Outpatient’s Illness(es) | A proxy for family stress due to The share of marital and household wages lost due to the outpatient’s illness(es). | The variable “number of weeks of lost patient wages over the past four months due to the patient’s illness(es),” a proxy variable for the share of lost outpatient wages (but not lost total family wages). |
| 4: Diversity of Financial Resources Tapped due to the Outpatient’s Illness(es) | Reflects the number of family instrumental coping strategies to limit the extent of illness-related objective financial stress (and, subsequently, strain). | These dichotomous measures of family instrumental coping strategies pertain to whether: 1) savings were used due to the illness; 2) money was borrowed due to the illness; 3) a house or property was sold due to the illness; 4) the patient acquired a second job; 5) application was made for unemployment compensation; 6) bills were not paid; 7) standard of living was reduced (doing without); 8) extras were sacrificed; and 9) other family instrumental coping strategies were adopted. |
| 5: Employment Status Changes by the Outpatient and Spouse Caregiver | Coded so that resumed employment reflects reduced objective financial stress (i.e. a positive stressor) and a job ending (quit, retired, laid off, terminated) reflects increased stress (i.e. a negative stressor). | Added z-scores from the variable, “change in patient’s employment status over the past four months,” and from a similar variable, “change in spouse caregiver’s employment status over the past four months.” |
| 6: Overall Finances Trend | Reflects overall change in financial stress in the previous subcomposites as well as the change in stress due to other sources of reduced financial resources, non-medical sources of financial stress, and positive stress (medical and non-medical) due to improvements in personal finances. | A global variable regarding overall change (positive, neutral, negative) in personal finances during the past four months. One of five questions within a survey section regarding stressful life events.§ |
In about one-quarter of the observations, an important confluence of missing data in the income variable affects the first subcomposite of the OFFS index. A missing data dummy variable for the first subcomposite is included as a control variable within the regression model. The model is estimated twice using 1) all 267 respondents and mean-substituted values for missing data; and 2) 200 respondents without missing data. The missing data dummy variable does not become statistically significant in either analysis. The age predictor is statistically significant only within the full-data run, however interpretation of Figure 1 is minimally affected.
The summation of these 11 dichotomous variables reflects the number of family financial stresses contributing to out-of-pocket illness expenditures. However, there is no theoretical rationale that the family financial stress of surveilling, monitoring, organizing, and interpreting financial statements is a linear function (and not a nonlinear function) of the actual number of sources of financial stress. Thus, cut points were imposed on the calculated, summative variable to create a new ordinal grouping variable, the variety of sources of objective financial stress, that classifies patients into three categories (low, moderate, and high) [26].
Very few spouse caregivers (less than 7) report that they lost wages over the past four months due to the patient’s illness(es). Thus, the measure of total family financial stress due to the share of patient wages lost should strongly overlap, and reflect, family stress due to the share of marital and household wages lost due to the patient’s illness(es).
The failure to reflect overall changes in personal finances could confound the curvilinear and moderator relationships between objective family financial stress and subjective patient financial strain.