Facing financial barriers to healthcare: patient-informed adaptation of a conceptual framework for adults with a history of cancer

Background Cancer-related financial hardship is associated with negative clinical outcomes, which may be partially explained by cost-related delayed or forgone care in response to financial barriers. We sought to understand patient experiences facing financial barriers to medical care following a cancer diagnosis. Methods We conducted virtual, semi-structured interviews in Fall 2022 with 20 adults with a history of cancer who had experienced cancer-related financial hardship in the prior year. We used template analysis within a pragmatic paradigm, combining constructivist and critical realist theoretical perspectives, to analyze interview transcripts and adapt an existing conceptual framework of financial barriers to care. Results The majority of interviewees identified as women (70%), non-Hispanic white (60%), and reported an annual household income of <$48,000 (60%). As interviewees sought to overcome financial barriers, they described substantial frustration at the limitations and complexities of United States health and social care systems, resulting in a reliance on a fragmented, uncertain resource landscape. The administrative burden resulting from bureaucratic systems and the advocacy responsibilities required to navigate them ultimately fell on interviewees and their caregivers. Thus, participants described their ability to overcome financial barriers as being influenced by individual and interpersonal factors, such as social support, comfort asking for help, time, prior experience navigating resources, and physical and mental health. However, participants noted health system organizational factors, such as whether all new patients proactively met with a social worker or financial navigator, as having the potential to lessen the administrative and financial burden experienced. Conclusion We present an adapted conceptual framework outlining multi-level factors influencing patient experiences coping with financial barriers to medical care. In addition to influencing whether a patient ultimately delays or forgoes care due to cost, financial barriers also have the potential to independently affect patient mental, physical, and financial health

Assessing the pre-implementation context for financial navigation in rural and non-rural oncology clinics

BackgroundFinancial navigation (FN) is an evidence-based intervention designed to address financial toxicity for cancer patients. FN's success depends on organizations' readiness to implement and other factors that may hinder or support implementation. Tailored implementation strategies can support practice change but must be matched to the implementation context. We assessed perceptions of readiness and perceived barriers and facilitators to successful implementation among staff at nine cancer care organizations (5 rural, 4 non-rural) recruited to participate in the scale-up of a FN intervention. To understand differences in the pre-implementation context and inform modifications to implementation strategies, we compared findings between rural and non-rural organizations.MethodsWe conducted surveys (n = 78) and in-depth interviews (n = 73) with staff at each organization. We assessed perceptions of readiness using the Organizational Readiness for Implementing Change (ORIC) scale. In-depth interviews elicited perceived barriers and facilitators to implementing FN in each context. We used descriptive statistics to analyze ORIC results and deductive thematic analysis, employing a codebook guided by the Consolidated Framework for Implementation Research (CFIR), to synthesize themes in barriers and facilitators across sites, and by rurality.ResultsResults from the ORIC scale indicated strong perceptions of organizational readiness across all sites. Staff from rural areas reported greater confidence in their ability to manage the politics of change (87% rural, 76% non-rural) and in their organization's ability to support staff adjusting to the change (96% rural, 75% non-rural). Staff at both rural and non-rural sites highlighted factors reflective of the Intervention Characteristics (relative advantage) and Implementation Climate (compatibility and tension for change) domains as facilitators. Although few barriers to implementation were reported, differences arose between rural and non-rural sites in these perceived barriers, with non-rural staff more often raising concerns about resistance to change and compatibility with existing work processes and rural staff more often raising concerns about competing time demands and limited resources.ConclusionsStaff across both rural and non-rural settings identified few, but different, barriers to implementing a novel FN intervention that they perceived as important and responsive to patients' needs. These findings can inform how strategies are tailored to support FN in diverse oncology practices

Hearing health care in the United States: A multi-scale spatial & political economic analysis of health care policy and access to audiology services

This project addresses hearing health care workers (audiologists) in the United States and the ways that structural, top-down pressures shape their spatial behavior and practice, which cumulatively affects the availability and accessibility of their services at multiple scales. Hearing loss is the third most prevalent disability in the United States, affecting 20 percent of the U.S. population and nearly half of older adults (≥75) (Agrawal, Platz, and Niparko, 2009). Moreover, despite the rising prevalence of hearing loss as the population ages, access to hearing health care services is sharply constrained by economic and geographical barriers and inequalities. The services to diagnose and treat hearing loss⁠—audiology services⁠—are not covered under most insurance plans, nor are they covered beyond a physician-referred assessment under Medicare; moreover, coverage of audiological services for adults under Medicaid varies state-by-state (Arnold, Hyer and Chisholm, 2017; Center for Medicare and Medicaid Services, 2016). Elderly and disabled people experience the effects of these limitations most acutely, due to their lower average household incomes and higher prevalence of hearing loss compared with the general population (Jung and Bhattacharyya, 2012). Therefore, this project examines audiologists, focusing on how their scope of practice and autonomy as professionals are constrained by health policy at the federal and state levels and the broader political economy of inter-professional practice in health care, all of which hinge on the classification of audiologists as non-medical “non-physician” care providers. Subsequent structural factors, such as low reimbursement rates and low professional autonomy, may influence the spatial behavior of audiologists, shaping tendencies in where they choose to locate, thus shaping the accessibility of their services. Situated in the context of an aging national population with growing hearing loss prevalence, this project also examines consumer access to hearing healthcare in the absence of comprehensive commercial insurance, Medicare, and Medicaid coverage of audiology services and hearing prosthetics/devices, which results from the path dependence of a health system formulated to address the needs of a young and ‘working age’ population. Employing GIS, spatial epidemiological, and spatial analytic methodologies, I examine the spatial, structural, and behavioral dimensions of hearing healthcare access on the part of providers and consumers.LimitedAuthor requested closed access (OA after 2yrs) in Vireo ETD syste