Makale
The price patients pay: A peek into the financial burden for breast cancer patients diagnosed with mental health comorbidities
-
Neel Vaidya, MS
-
Ali Bonakdar, PharmD, MPH, PhD
The intersection of mental health diagnosis with breast cancer treatment comes with a significant financial burden for patients, and the numbers tell a compelling story. To better understand this issue, we conducted a study using United States (US) national healthcare spending data collected over a five-year period.
Setting the stage
Out-of-pocket (OOP) expenditures, including deductibles, coinsurance, and direct payments for drugs and services, represent one of the most tangible financial burdens patients face in the United States (US). With the rise of high-deductible health plans and specialty drug costs, understanding the magnitude of these costs is essential for payers, manufacturers, and health technology assessment (HTA) professionals.
Breast cancer (BC), the most commonly diagnosed cancer among women in the US, imposes an estimated $3.14 billion in aggregate annual OOP costs. Compounding this burden, nearly one in three BC patients lives with a co-occurring mental health (MH) condition, such as depression or anxiety, a rate that surged during the coronavirus disease 2019 (COVID-19) pandemic. These comorbidities drive more complex treatment regimens, higher utilization, and potentially greater financial exposure.
Breast cancer (BC), the most commonly diagnosed cancer among women in the US, imposes an estimated $3.14 billion in aggregate annual OOP costs. Compounding this burden, nearly one in three BC patients lives with a co-occurring mental health (MH) condition, such as depression or anxiety, a rate that surged during the coronavirus disease 2019 (COVID-19) pandemic. These comorbidities drive more complex treatment regimens, higher utilization, and potentially greater financial exposure.
Yet a notable evidence gap persists: How do MH comorbidities specifically influence the OOP burden that BC patients bear? This research addresses that gap, leveraging five years of Medical Expenditure Panel Survey (MEPS) data (2018–2022) to quantify the differential OOP burden and identify where disparities are most acute.
What we set out to explore
This study examined the OOP burden at a key intersection: BC patients living with MH comorbidities. Specifically, this research set out to:
1. Compare OOP expenditures between BC patients with and without MH comorbidities using nationally representative MEPS data from 2018 to 2022.
2. Examine how OOP burden varies by income level, age group, insurance type, and specific chronic disease burden drivers such as arthritis, asthma, and cardiovascular disease.
3. Quantify the adjusted relative risk of higher OOP costs attributable to the presence of MH comorbidities, accounting for demographic characteristics and comorbidity burden.
Together, these analyses provide actionable evidence on the real-world cost burden faced by this dual-diagnosis population.
What the data revealed
The analysis included a weighted sample of 1,509,242 patients with BC, 30.9% of whom had at least one comorbid MH condition. The findings showed:
BC patients with MH comorbidities faced median annual OOP costs of $1,821 compared to $996 for those without, representing an 83% higher burden (P<0.05). As a share of household income, this represented 5.3% vs. 3.6%.
The gap was most pronounced among patients with household income between $30,000–$60,000, where the MH comorbidity group faced OOP costs of $1,159 vs. $687 — a 70% differential that consumed a significantly larger share of already limited income.
Patients aged 65 years and younger showed OOP costs of $1,932 vs. $884 (a gap exceeding 100%), while all BC patients with private insurance faced OOP costs of $2,186 vs. $1,045 — also a gap exceeding 100%.
Among other specific comorbid conditions, asthma drove the highest OOP costs ($3,252 vs. $1,394 in the MH group vs. non-MH), followed by arthritis ($2,489 vs. $1,305), suggesting a multiplicative cost effect when chronic conditions and MH comorbidities co-occur.
After controlling for age, income, insurance type, and comorbidity count, the adjusted rate ratio of higher OOP expenditures for BC patients with MH comorbidities was 31.2% higher (rate ratio; 95% confidence interval: 1.022-1.684), confirming that the association is not driven solely by demographic confounders.
Why this matters: Implications for HTA, payers, and policy
For HTA professionals and health economics and outcomes research (HEOR) researchers
These findings carry direct implications for how we assess value in oncology and MH. With BC patients bearing median annual OOP costs of $1,821 when MH comorbidities are present, and contributing 5.3% of their income to healthcare costs, the patient financial burden cannot be excluded from a holistic assessment of therapeutic value. HEOR professionals should consider stratifying cost outcomes by MH comorbidity status and number of chronic comorbidities to reveal hidden cost gradients invisible in traditional aggregate analyses.
For payers and benefit design decision-makers
- Formulary and tier design: The concentration of OOP burden among patients with arthritis and asthma comorbidities suggests current tiering structures may disproportionately penalise patients with the most complex care needs.a
- Private plan recalibration: Private insurance enrollees with MH face OOP costs exceeding $2,000 annually, more than double their non-MH counterparts, prompting a need for benefit design reassessment.
- MH parity: Despite the Mental Health Parity and Addiction Equity Act of 2008, these data suggest the financial burden of behavioral healthcare within oncology populations has not been equalised. Benefit designs separating medical and behavioral health cost-sharing may compound OOP exposure.b
- Income-sensitive interventions: The dramatic income gradient, with OOP costs up to 70% higher in lower-income groups, points to the need for income-adjusted copay structures, enhanced patient assistance integration, and proactive financial navigation services.
a For example, a patient with isolated asthma may only need a low-cost inhaler (i.e., a generic inhaler on a lower formulary tier), but an additional diagnosis of arthritis might also require treatment with a specialty biologic, which sits on a high-cost pricing tier. Payers encourage tiering of medications to maximise the use of low-cost, low-tier generics to curb excessive drug spending, but this approach tends to financially penalise patients with multiple comorbidities.
b This may be especially problematic if health plans do not integrate oncology and behavioral health into one bucket, potentially requiring patients to satisfy multiple deductibles before insurance coverage begins.
For policy stakeholders
- State-level OOP cap legislation and oncology-specific copay assistance programs are gaining momentum, and this evidence may help inform these efforts.
- The study's own conclusion, per data from 2018 to 2022, calls for further research to quantify OOP savings following the Inflation Reduction Act (IRA) enactment (passed in 2022), a call that policymakers should heed and fund. Our data serve as a benchmark against which more recent data (2022 and beyond) can be compared to further evaluate the effectiveness of the IRA and its intended impact on the US healthcare system.
A call to action
The data indicate that between 2018 and 2022, BC patients with MH comorbidities would have accumulated over $9,000 in total OOP costs over the five-year study window, an 83% premium over the $4,980 borne by patients without these comorbidities. Sustained financial exposure at this level is associated with medication non-adherence, delayed care, and poorer outcomes. With the IRA's $2,000 Medicare Part D OOP cap now in effect and the first negotiated drug prices taking hold in 2026, the HTA community has both the opportunity and the obligation to measure whether these landmark reforms have actually narrowed the disparities this study documents, and to quantify where gaps persist, particularly for the commercially insured and working-age patients who remain beyond the IRA's reach. The work ahead is where we can make a meaningful contribution to patient-centered oncology care.
Note: Sources listed below
Disclaimer:
The information provided in this article does not constitute legal advice. Cencora, Inc. strongly encourages readers to review available information related to the topics discussed and to rely on their own experience and expertise in making decisions related thereto.
Sources:
- Hicks C. PhRMA. The patient experience: Out-of-pocket costs are driving patients' affordability and access challenges. PhRMA. October 19, 2021. Accessed August 27, 2026. https://phrma.org/blog/the-patient-experience-out-of-pocket-costs-are-driving-patients-affordability-and-access-challenges
- Breastcancer.org. Cost of care report: The financial burden of breast cancer in the United States. Breastcancer.org. 2022. Accessed August 27, 2026. https://www.breastcancer.org/managing-life/covering-cost-of-care/cost-of-care-report
- Charles C, Bardet A, Larive A, et al. Characterization of depressive symptoms trajectories after breast cancer diagnosis in women in France. JAMA Netw Open. 2022;5(4):e225118. doi:10.1001/jamanetworkopen.2022.5118.
- Charos D, Andriopoulou M, Vivilaki V. Breast cancer and COVID-19: The need for enhanced psychological support for women with breast cancer during the pandemic. Eur J Midwifery. 2022;6:69. doi:10.18332/ejm/156899.
- Elliott K, Haworth E, Bolnykh I, et al. Breast cancer patients with a pre-existing mental illness are less likely to receive guideline-recommended cancer treatment: A systematic review and meta-analysis. Breast. 2025;79:103855. doi:10.1016/j.breast.2024.103855.
- Loving BA, Almahariq MF, Sivapalan S, et al. Newly diagnosed mental health disorders in patients with breast cancer receiving radiation therapy. Int J Radiat Oncol Biol Phys. 2024;120(2):508-515. doi:10.1016/j.ijrobp.2024.03.028.
- Dai D, Coetzer H, Zion SR, Malecki MJ. Anxiety, depression, and stress reaction/adjustment disorders and their associations with healthcare resource utilization and costs among newly diagnosed patients with breast cancer. J Health Econ Outcomes Res. 2023;10(1):68-76. doi:10.36469/001c.70238.
- Arthritis Foundation. Out-of-pocket costs. Accessed August 27, 2026. https://www.arthritis.org/advocate/issue-briefs/out-of-pocket-costs
- Mental Health America. Parity in health insurance. 2019. Accessed August 27, 2026. https://mhanational.org/position-statements/parity-in-health-insurance/
