Radiation oncologist Fumiko Chino gives us a lesson on medical debt

Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care

By Fumiko Chino, MD; Jeffrey M. Peppercorn, MD, MPH; Christel Rushing, MS; S. Yousuf Zafar, MD, MHS; et al
JAMA Oncology, August 10, 2017

The financial burden of cancer treatment is a well-established concern. Owing to cost sharing, even insured patients face financial burden and are at risk for worsened quality of life and increased mortality. Underinsured patients (those spending more than 10% of their income on health care costs) are a growing population, and are at risk given the looming heath policy and coverage changes on the horizon.

From the Discussion

More than one-third of insured cancer patients receiving anticancer therapy faced out-of-pocket costs that were greater than expected, and patients with the most distress were underinsured, paying almost one-third of their income in health care-related costs. Patients at risk for unexpected costs had less household income and faced higher out-of-pocket costs.


Widowed Early, A Cancer Doctor Writes About The Harm Of Medical Debt

By Alison Kodjak
NPR, August 10, 2017

Ten years ago, Fumiko Chino was the art director at a television production company in Houston, engaged to be married to a young Ph.D. candidate.

Today, she's a radiation oncologist at Duke University, studying the effects of financial strain on cancer patients. And she's a widow.

"I think of him every day," Chino says of her late husband, Andrew Ladd. "It drives me to do the type of research that I do — that's looking at the financial toxicity of cancer care."

Chino is co-author of a research letter, published Thursday in JAMA Oncology, that shows that some cancer patients, even with insurance, spend about a third of their household income on out-of-pocket health care costs outside of insurance premiums.

In 2005, before they were married, Chino and Ladd were living together in Houston. She was working in entertainment, and he was on the verge of earning his doctorate in robotics at Rice University. Each had medical insurance – she through her job, he through the school.

Then he started to vomit and lose weight.

He was diagnosed with neuroendocrine carcinoma, an aggressive cancer of endocrine cells that can strike in a variety of places in the body and can be hard to treat.

It was a huge blow for the young couple, still in their 20s, with promising careers ahead of them. Still, they looked to the future and decided to go ahead with their wedding.

But as Ladd's treatment moved forward, a harsh reality hit. His student insurance didn't cover much.

Soon, his medical costs surpassed his insurance policy's $500,000 lifetime limit (before ACA). But the bills kept coming.

Even as insurance coverage has expanded (under ACA), deductibles and copays on many policies have risen, leaving patients to shoulder more of the financial burden for their health care.

"The stress and overwhelming crushing defeat of these bills that would come in every week — it had an effect on our quality of life," Chino says.

Despite his illness, Ladd landed a job as a professor at the University of Michigan. It came with health insurance, and he continued treatment there.

But he never moved into his office. Three months into his time at Michigan, he died.

Chino was left with an ocean of debt. She estimates it's in the hundreds of thousands of dollars.

That's when she found a new mission in life. She enrolled in Duke's medical school and teamed up with Dr. Yousuf Zafar, who has made a specialty out of studying and writing about "financial toxicity," which he describes as the toxic effects of financial strain from health care costs. He's lead author on the JAMA Oncology study that Chino worked on.

"Patients are frustrated," Zafar says. "They believe they've got insurance. They believe they paid for insurance and that insurance should fully cover their cancer care."

"We need to do a better job explaining to our patients how much benefit they can get from treatment," he says. "But also how much harm they can face, whether that harm is physical toxicity or financial toxicity."

Ten years after Ladd's death, Chino is still dealing with the aftereffects.

"I still owe the debt," she says. "I stopped answering phone calls from debt collectors."



By Don McCanne, M.D.

Health care professionals who are health reform activists can certainly identify with the plight of radiation oncologist Fumiko Chino. Not only did she face the almost unbearable tragedy of her husband’s lethal cancer, she has been left with overwhelming medical debt in spite of insurance coverage.

Helping all of us to better understand the financial impact of cancer, Dr. Chino has co-authored an article in JAMA Oncology, “Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care.” Her lead co-author, Dr. Yousuf Zafar, acknowledges what a problem “financial toxicity” is and suggests that we need to do a better job of explaining to patients not only the physical toxicity of cancer therapy but also the financial toxicity. (Pause…)

We certainly admire Dr. Zafar for his efforts to educate us on financial toxicity, but we really do need to move beyond just talking about it. Our health care financing system needs to be redesigned to remove financial barriers to care, and, further, when an individual is already suffering from impaired health, the last thing we need to do is to add financial hardship through medical debt.

It is no secret that a well designed single payer program would remove financial barriers to care and prevent medical debt. People would just get health care when they need it and not have to worry about how they would pay for it.

It will be a breakthrough when medical journal editors who publish articles on the problems of financing health care begin to request that the authors include a remedy for financial toxicity - one that has been proven beyond any doubt to be fully effective - a single payer national health program.

Stay informed! Visit to sign up for daily email updates.