Financial Impact of Complex Cancer Surgery in India: A Study of Pancreatic Cancer

Abstract

PurposeThe rapidly increasing burden of cancer in India has profound impacts on health care costs for patients and their families. High out-of-pocket (OOP) expenditure, lack of insurance, and low government expenditure create a vicious cycle, leading to household impoverishment. Complex cancer surgery is now increasingly important for emerging countries; however, little is understood about the macro- and microeconomics of these procedures. After the Lancet Oncology Commission on Global Cancer Surgery, we evaluated the OOP expenditure for patients undergoing pancreatico-duodenectomy (PD) at a government tertiary cancer center in India.MethodsProspective data from 98 patients who underwent PD between January 2014 and June 2015 were collected and analyzed. The time frame for consideration of expenses, including all preoperative investigations, was from the first hospital visit to the day of discharge. Catastrophic expenditure was calculated by assessing the percentage of households in which OOP health payments exceeded 10% of the total household income.ResultsThe mean expenditure for PD by patients was Rs.295,679.57 (US$74,420, purchasing power parity corrected). This amount was significantly higher among those admitted to a private ward and those with complications. Only 29.6% of the patients had insurance coverage. A total of 76.5% of the sample incurred catastrophic expenditure, and 38% of those with insurance underwent financial catastrophe compared with 93% of those without insurance. The percentage of patients facing catastrophic impact was highest among those in semiprivate wards, at 86.7%, followed by those in public and private wards.ConclusionThe cost of PD is high and is often unaffordable for a majority of India’s population. A review of insurance coverage policies for better coverage must be considered.

The Out-of-Pocket Cost Burden of Cancer Care—A Systematic Literature Review

“…The systematic review identified 3639 records, of which 105 full-text studies were retrieved [ 8 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 ,…”

“…However, this study had a small sample size and contributed relatively little to the estimated 42% weighted average income spent as out-of-pocket expenses in LMICs. Additionally, four studies defined explicit thresholds for catastrophic health expenditure [ 27 , 68 , 69 , 101 ]. They defined a threshold of annual income spent as out-of-pocket expenditures and estimated the proportion of patients exceeding it.…”

“…In two studies, CHE was defined as 30% of the annual household income spent as non-reimbursed out-of-pocket costs in two studies conducted in different LMICs of South East Asia among an all cancer population [ 68 , 69 ]. This threshold was also defined at 40% in Haiti among breast cancer patients [ 101 ] and 10% in India among patients with pancreatic cancer [ 27 ]. The proportion of patients incurring CHE, however defined, ranged between 31% and 67%.…”

“…Furthermore, four studies estimated additional out-of-pocket costs among patients living in rural and remote areas mostly due to increased expenses related to travel and transportation [ 44 , 51 , 65 , 109 ]. In settings with private insurance schemes, like in the U.S., patients with limited insurance packages paid higher deductibles and co-payments, especially for treatment and medications [ 27 , 41 , 48 , 60 , 73 , 97 , 98 , 104 ]. Finally, lower-income patients and households had a greater burden imposed by out-of-pocket expenses, as measured by the proportion of the household income spent in the form of out-of-pocket costs [ 31 , 34 , 47 , 68 , 69 , 74 , 86 , 87 , 90 , 92 , 108 , 116 ].…”

“…For example, low-income households with pediatric cancer patients in India paid more than twice their monthly earnings to cover the associated out-of-pocket expenses, thus incurring considerable debt [59]. This trend was also observed among patients who were unemployed and those who lacked or did not have private health insurance [27,41,48,60,73,97,98,104]. Some ethnic minorities and Indigenous communities, who often reside in rural and remote areas, experienced higher levels of out-of-pocket costs in Australia-other communities reported no costs due to a reduced, and almost non-existent access to health care [28,36].…”