Canadians may raise an eyebrow when reading U.S. news reports on exorbitant health-care costs, under the impression that the financial burden of medical care does not have as profound an impact on us individually.
However, as a Canadian medical student, I have witnessed the ramifications of this financial burden on patients every time I step foot in the hospital.
Financial toxicity, a term first tied to the cancer world in which expensive treatments are prescribed, is a concept that is being actively applied to all aspects of the health-care system; it refers to the financial hardship experienced by patients as a result of their medical treatment. In fact, a recent study showed that one third of Canadian patients experience financial toxicity as a side effect of their cancer treatments. This impact extends to caregivers and partners with more than 60 per cent of partners of colorectal cancer patients experiencing increased financial burden.
Financial toxicity also has been shown to transcend the world of cancer care. Most notably, the World Bank estimates that between two per cent and 23 per cent of individuals from middle-to-high income countries such as Canada are at risk of experiencing catastrophic expenditure as a result of surgical care. Cardiovascular and cerebrovascular events have also been shown to contribute to financial toxicity among Canadians with earning declines as much as $3,834 after an acute myocardial infarction, $11,143 after a cardiac arrest, and $13,278 after a stroke. The significant burden can also be seen in far less acute settings with food-allergic families across Canada incurring higher direct costs associated with travel, specialist appointment fees, lost wages and more compared to families without a food-allergic child. This divide is further exacerbated by the fact that certain treatments for food-allergic children such as oral immunotherapy, which has been shown to provide as much as 50-80 per cent effective short-term desensitization to accidental exposures, are not publicly funded and can cost as much as $7,000 out-of-pocket at some outpatient clinics.
While the concept of financial toxicity is most often equated with the stereotypical image of a privatized system with outrageous hospital bills, the reality is more complex. There are numerous indirect factors (e.g., over the counter and prescription drug costs) that continue to perpetuate financial toxicity within both private and public health-care systems. These factors, while tangible, are difficult to quantify, resulting in a significant gap in research on financial toxicity within the Canadian setting. I have personally come across countless Canadians who avoid or delay receiving medical care due to the financial implications associated with insufficient employment insurance benefits, sick days and more.
It is important to realize that the negative effects and social implications of financial toxicity extend far beyond the death of one patient.
One case that still weighs on me is that of a patient who presented to the emergency department with advanced lung cancer. She had started to recognize the signs and symptoms months earlier but had delayed seeking care because she could not afford to take even one day off work, let alone the time required to take part in long-term treatment. As a single mother, the additional costs of public transportation and childcare made her rethink the need to seek care. I later learned that she had passed away in hospital and I couldn’t help but think that her early death was preventable. If she hadn’t been financially restrained when her symptoms first presented or limited by her fears of the financial burdens associated with receiving care, she may have lived many more happy years with her children.
It is important to realize that the negative effects and social implications of financial toxicity extend far beyond the death of one patient. Financial toxicity has been shown to promote psychological distress and lower quality of life; it has been associated with poor medical compliance as well as worse health outcomes among all patients. Even something as simple as daily parking fees has been shown to place an additional financial burden on patients in cancer centres across Western Canada.
Unfortunately, despite increasing acknowledgment across Canada, we still have a long way to go when it comes to accepting the significance of financial toxicity within our publicly funded taxpayer system. In fact, organizations such as Canadian Doctors for Medicare have made it its mission to improve our publicly funded health-care system and advocate for equitable care such as through the adoption of universal pharmacare, which Ottawa has signaled is coming soon.
The need to continue advocating for equitable care is more important than ever, particularly in light of ongoing efforts to decentralize health care in Alberta. A recent attempt by a primary care clinic in Calgary to provide exclusive benefits and appointment slots to individuals willing to pay annual membership fees is just one example of a worrisome push toward a two-tiered health-care system. These efforts threaten to jeopardize universal health care for all Canadians by undermining the core tenants of medicare and exacerbating the financial strain experienced by individuals at the hands of our health-care system. Thus, we must make a concerted effort to safeguard individuals from financial toxicity and continue fighting against the myth that the Canadian health-care system is “free.” We must better protect patients in private and public health-care systems from both the direct and indirect/non-medical costs of treatment and follow-up care. We must step away from categorizing the implications of health-care costs as being solely system-wide or individual-based problems since the financial burden of medical care can and does impact both.
Health-care providers must also begin to take proactive steps to ensure that patients are not only aware of the medical side effects of their care and treatments, but the financial side effects, too. There is an urgent need to fight for policy changes and system-wide interventions to protect our most financially vulnerable from the risks of catastrophic health-care expenditure, as the continued failure to address financial toxicity in medicine will be the cause for many more preventable deaths.