CORR Insights®: What Factors Are Associated with Increased Financial Burden and High Financial Worry for Patients Undergoing Common Hand Procedures?

Where Are We Now?

For the past several years, hand surgeons from my institution (Vanderbilt University) have donated their time to treat underinsured patients in the local community [4]. We have found that there is a subset of uninsured patients with elective surgical conditions who do not fall into the category of emergent surgical care. Conditions like trigger fingers, ganglion cysts, and carpal tunnel syndrome—one of the diagnoses examined in the current study—are among those conditions that would not be routinely treated in an emergency department [1], and these elective operations would require substantial out-of-pocket costs. Our patients, whose financial resources are limited, represent one end of the financial spectrum. The patient population in Bernstein et al. [1], most of whom had either private insurance or Medicare, seems to represent the other end. Still, more than one-third of the patients in the current study report some degree of financial burden and worry [1]. Although we have not specifically asked our charity care patients about their financial concerns, patient satisfaction surveys and personal comments indicate their deep appreciation for their care, emphasizing the relief of that financial burden.

Health insurance has been a major area of concern for many years. In 2010, the Affordable Care Act (ACA), also referred to as Obamacare, was signed into law. The ACA required everyone to have health insurance and offered financial assistance to those who could not afford a plan. The original coverage requirement included a tax penalty for those who did not purchase a health insurance policy (called the individual mandate). In 2017, a tax bill was passed repealing the individual mandate. Under the ACA, there are subsidies, or tax credits, for lower-income individuals to cover the costs of their insurance plans. However, as this study shows, health insurance, while important, is not the only factor involved in patients’ feelings of increased financial burden and worry. Other associated factors studied by Bernstein et al included age, race, number of dependents, employment status, presence of prior loans, and national Area Deprivation Index, with findings demonstrating that number of dependents and disability status were associated with higher financial burden and worry [1].

Apropos to this topic, the current COVID-19 pandemic has added to the financial burden and worries that patients currently bear. One study found that job insecurity due to COVID-19 was related to greater depressive symptoms and that financial concern was related to greater anxiety symptoms [5].

Financial concerns often are not in the forefront of our considerations as physicians when counseling our surgical patients. Perhaps they should be. In light of current economic conditions, the financial burden upon our patients and their families has increased. One patient recently turned down helicopter transfer from an outside facility to our institution for a time-sensitive, emergency procedure because of concerns about the costs associated with the transfer and the treatment of his injury. If patients are declining emergent care due to cost concerns, how much more will they defer more elective procedures?

Where Do We Need To Go?

At my institution, while social services and financial counseling are readily available for inpatients, there are limited social service resources available for outpatient surgical patients, like those patients in this study [1]. In addition to assessing surgical indications, should we have financial advisors, social services, and psychologists in our clinical to assess financial, social, and psychological considerations when planning surgery [2, 3]? With decreasing reimbursements and increasing impetus to see more patients, do we have the time and resources in our busy clinics to adequately assess these factors? If identified, do we have the resources and staffing to address the financial concerns of patients, let alone the social and possible psychological issues of every surgical patient? If serious financial concerns are identified, how can we help limit these financial concerns or provide additional resources or support?

Although the present study did not find a major difference in financial burden and worry based on insurance type, the authors note that financial concerns are likely more related to insurance coverage quality rather than insurance type [1]. Consideration of individual patients’ financial worries requires nuanced attention to their particular coverage. As noted previously, the present study predominantly included individuals with private insurance or Medicare. Although it can be extrapolated that uninsured individuals would have even greater financial burden and worry, the disparity in these metrics between uninsured and insured patients has not yet been delineated in a population of elective hand surgery patients.

Finally, the ramifications of these financial worries and burdens warrant further investigation. Did patients with increased financial worry or burden choose to delay their care? How do financial worry and burden contribute to psychological factors, which may in turn impact postoperative outcomes?

How Do We Get There?

First, we need to verify that the findings of this study generalize well. How concerned are patients about their financial situation and do these findings apply across a variety of economic and societal settings? Validated financial burden and worry (like those used in this study) and psychological questionnaires can be used in these various settings and in diverse populations of orthopaedic patients contemplating both elective and nonelective orthopaedic surgery, as well as in patients with insurance and those patients without it. Further, financial and psychological questionnaires can be utilized in conjunction with validated patient-reported outcome measures (PROMs) to determine the potential impact on postoperative results.

Second, part of the solution is to increase physician awareness and recognition of the financial concerns that patients bear. We should keep in mind and factor-in the financial implications of our treatment options. Our institution, as do most, has financial counselors available to address financial concerns. Facilities should try to prioritize options to address financial, social, and psychological issues prior to and after surgical procedures. Institutions will need to determine how these resources will be allocated, financed, and incorporated into the surgical planning process.

Finally, outcome studies using validated PROMs are needed to determine whether these interventions or resources will help to alleviate patient concerns by decreasing their financial worries or burdens.