While past studies have explored how cancer patients’ financial health influenced their risk of mortality, new research digs in deeper by zeroing in on objective data: credit scores. It found that when a cancer patient’s credit score drops — regardless of where it started pre-diagnosis — odds of survival decrease drastically. The findings were presented earlier this month at the American College of Surgeons Clinical Congress and have not been peer-reviewed.

Previous research relied on self-reports of financial burden, according to study author Benjamin James, chief of general surgery at Beth Israel Deaconess Medical Center and an associate professor of surgery at Harvard Medical School. While helpful for understanding patients’ subjective experiences, such reports are prone to recall bias. It’s incredibly difficult to gather objective measures, James says, because clinical and financial data are housed by separate institutions with different privacy rules.

After years of negotiation, James and his team received deidentified clinical data from roughly 90,000 cancer patients in the Massachusetts Cancer Registry alongside financial information from a national credit bureau. The researchers adjusted for mortality-dependent variables, such as cancer type and stage, socioeconomic status, and race, and divided the credit scores into tiers (300-600, 600-660, 660-780, and 780-850). They found that patients who experienced a drop of two tiers within a year were 29 percent more likely to die. For those who experienced a two-tier drop within six months, that number increased to 63 percent.

In this conversation edited for clarity and length, James explained the implications of his team’s findings.

You focused on credit scores — why is that?

A credit score is a really good marker of somebody’s overall financial health. And, crucially, it changes over time. The crux of the question that we’re asking in this study is: What is the impact on patients’ long-term survival if they’re experiencing financial toxicity? If you get a medical bill that you can’t pay, or you can pay it but it means you’re going to have to refinance your home, is that more likely to cause you to die of your cancer than if you didn’t have that debt?

So, what did you find?

We looked at three main things. First: What is somebody’s mortality from their cancer diagnosis based on where their credit score started? What we found is that patients with a lower credit score at baseline were more likely to die. Now, that’s actually not very surprising, because that relates to social determinants of health. The literature has shown time and again that patients that are in lower economic status, that are of minority race — in general, they’re more likely to die. Sadly, that’s not a new finding.

The second question, though, was new: Regardless of where the credit score starts, if that score drops or increases in the 12 months after diagnosis, how does that impact their mortality? We adjusted for all those social determinants of health and just looked at the credit score. What we noted was that when a patient’s credit score dropped by two tiers, their mortality increased by nearly 30 percent.

And finally, when we looked at how the credit score changed over time on the six-month timescale, we actually saw an even bigger change. In this case, a two-tier drop was associated with a 63 percent increase in mortality. In other words, somebody getting the exact same cancer diagnosis has a 63 percent higher likelihood of dying just based on how their credit score is dropping.

You found an association between credit score declines and mortality. What might be the reason for the link?

I think there are lots of potential reasons. The obvious one, which may or may not be true, is that somebody is obtaining less care because they can’t afford it. And if they’re obtaining less care because they can’t afford it, they may be more likely to die of that diagnosis. The assumption is that if somebody is sick and they have cancer, we’re going to treat them. And that’s just not true. There are plenty of people out there who have to make financial choices that ultimately impact their survival. They may look at a family of four and say, I can either get this additional chemotherapy to improve my survival, or, you know, decide that I can’t cause this amount of financial hardship to my family. 

“The assumption is that if somebody is sick and they have cancer, we’re going to treat them. And that’s just not true. There are plenty of people out there who have to make financial choices that ultimately impact their survival.”

The other explanation, which I’m less convinced by, is that, as somebody is more likely to die, their credit score is more likely to go down — say, you stop pursuing treatment and you’re in palliative care, not paying anything, and then your credit score goes down. It’s chicken or egg: Are you more likely to die because your credit score is going down, or is your credit score going down because you’re dying? I don’t believe the latter is the main cause of what we’re seeing, however, because the vast majority of patients in the study do not have end-stage disease.

We can’t tease out the causes in this current data set, but we’re currently doing a prospective study where we’re surveying patients over time and collecting their financial data at the end of the study. So it’s a combination of both objective and subjective financial toxicity, in order to understand how they correlate with each other. We’re at the very beginning stages of that research, but that’s ultimately the way we’ll find out what’s really going on.

What about if a person’s credit score increases? Does that have a protective effect, where a person is less likely to die?

No, it doesn’t. The way I view it: Those who are able to pay things are able to pay things. So regardless of whether their credit score goes up, they’ll just continue to be able to pay for treatment. But at this point, we don’t really have a good explanation for why improving somebody’s financial health, particularly if they started at a lower tier, doesn’t seem to make a difference in their survival.

How can cancer patients protect themselves from this huge increased mortality risk? Are there any ways to intervene?

I think it all comes down to policy reform. That’s ultimately what we can do about this. I don’t personally believe that when people have medical debt that they can’t pay, that that should translate into an impact on their credit score. And so, there’s legislation out there about saying that medical debt shouldn’t be included in credit health. I think we also need to stop the aggressive, predatory collection agency practices of coming after you for your medical debt. There’s a bill that’s sitting with the Massachusetts legislature right now that makes the argument that we should not allow hospitals to sell medical debt to collection agencies. They should have to negotiate that on their own with the patient, as opposed to selling it.

“I think it all comes down to policy reform. That’s ultimately what we can do about this.”

Also, providing people with financial navigators at the start of their diagnosis is important. It’s very hard as a provider to have cost conversations with patients when they get diagnosed. We as providers don’t feel comfortable doing it because it’s a hard conversation to have, and it can feel like it’s not our responsibility; plus, we don’t know what the financial implications of their diagnoses are. But if I published this study, and a provider can look at this and say, “Wow, my breast cancer patient is more likely to die if their credit score goes down,” they may use that information as an awareness tool for their patients moving forward, which might allow patients to plan better for their diagnosis. You walk into the office, you get a cancer diagnosis, and you’re told that you have to start thinking about the finances of this as well, because it will impact your long-term survival.

This research was conducted in Massachusetts, where 97-98 percent of the population has healthcare insurance coverage — one of the highest coverage rates in the country. Could these associations between financial health and mortality look even worse in other states where more people are uninsured?

Whatever our findings are in Massachusetts, we have to assume that they would be substantially worse in most other states. If we are showing that patients are more likely to die as their credit score goes down, in a state where the majority of patients have health insurance, you can only imagine what would happen in other states that don’t have that kind of coverage.

That’s especially pertinent right now as we’re on the verge of 25 million Americans losing their health insurance coverage, depending on which way things go. These 25 million are the exact patients who are already at risk given their socioeconomic status, and most won’t be able to afford private insurance.

Even being insured doesn’t mean you don’t have out-of-pocket costs. Co-payments are going up dramatically. We know that 11 percent of people’s spending is on healthcare costs. And we know that of the $200 billion spent annually on cancer care, $21 billion of that is paid out of pocket by patients. People are making choices: Are they going to go into debt, or are they going to choose to not have the medical care that they need?