What do we know about people with high out-of-pocket spending?


This chart collection explores the distribution of out-of-pocket spending among people with large employer coverage using the Truven Health Analytics MarketScan Commercial Claims and Encounters Database. We examine trends in out-of-pocket spending by people with employer coverage from 2005 to 2015, as well as spending on diseases most associated with high out-of-pocket spending.

The percentage of high out-of-pocket spenders has increased over time


The percent of people with large employer coverage who have high out of pocket spending has increased over the last 10 years. In 2005, slightly over 17% of enrollees spent more than $1,000 (inflation-adjusted to 2015 dollars) on medical care. In 2015, that amount had increased to over 24% of enrollees.

In 2015, 12% of private insurance enrollees had out-of-pocket spending greater than $2,000


In 2015, enrollees in large employer plans spent an averaged $778 out-of-pocket. Of people with large employer coverage, 24% of enrollees had out-of-pocket spending greater than $1,000, 12% had spending over $2,000, 6% had spending over $3,000, and 2% had spending over $5,000.

The majority of high out-of-pocket spenders are female


In 2015, nearly 6 in 10 high out-of-pocket spender were women. This proportion has been largely consistent over the past 10 years for inflation-adjusted to 2015 dollar out-of-pocket spending levels of over $1,000, $2,000 and $5,000.

Older enrollees are more likely to be among the highest out-of-pocket spenders


The likelihood of having high out-of-pocket spending increases with age. While only about 14% of patients under age 25 spend over $1,000 or more, that rate is over 30% for those aged 45-54 and nearly 40% for 55-64 year olds.

Out of pocket spending is highest for those with diseases of blood organs


Although average enrollees out-of-pocket spending is under $800, out-of-pocket spending for people receiving treatment for certain diseases tends to higher. Among major disease categories, out-of-pocket spending is highest for enrollees undergoing treatment for diseases of the blood and blood-forming organs ($1,953 on average), congenital anomalies ($1,697 on average), circulatory system ($1,508), and cancer ($1,510 on average). Across all payers nationally, people with a diagnosis of a serious or chronic health condition face higher average out-of-pocket costs.

Patients with heart and circulatory diseases are much more likely to see out-of-pocket spending over $5,000


Extremely high out-of-pocket spending is more common among people with circulatory diseases than most enrollees. On average, 12% of all patients spend more than $2,000 and 2% spend more than $5,000. However, more than a third of patients with heart, arterial, or vein and lymphatic diseases spend over $2,000 per year and 6% spend over $5,000.

Circulatory disease patients have average spending nearly twice as high as enrollees overall


Circulatory diseases affect a large number of people and are a leading cause of morality and disease burden in the US. Average out-of-pocket costs for people with a diagnosis of a circulatory illness are nearly double that of the average enrollee out-of-pocket expenditure ($1,508 compared to $778).

Among enrollees, out-of-pocket spending for common cancers was between $1,400-$2,400


Among enrollees undergoing treatment for cancer, colorectal cancer followed closely by lymphatic cancers and urinary organ cancer had the highest out-of-pocket spending. However, some of the people in cancer treatment are undergoing follow-up care. For those receiving active treatment, the most expensive outlay for all cancers was for chemotherapy and radiation treatment ($3,568 on average per enrollee in 2015). The average out-of-pocket expenditure for cancer was $1,510 which nearly twice that of average enrollee spending.

High out-of-pocket spending varies among cancer patients depending on their diagnosis


High out of pocket spending levels are not consistent across all forms of cancer. For example, while on average less than a quarter of cancer patients spend over $1,000 for medical treatment, a third of lung cancer patients do. Additionally, more than 1 in 10 patients with either lymphatic, urinary, ovarian, breast, lung, or colorectal cancer spend more than $2,000 a year.

Enrollees with cancer diagnoses are much more likely to have out-of-pocket spending over $5,000


Enrollees with a cancer diagnosis were twice as likely to have spending over $5,000 as all enrollees. Colorectal and lymphatic cancer enrollees were over six times more likely to have high out-of-pocket spending than the average enrollee.  

Suicide treatment patients have higher out-of-pocket costs than other mental health patients


Mental health and substance use disorders are the top cause of disease burden in the US and is estimated to affect approximately 1 in 5 adults.  Out of pocket spending for enrollees with any mental health issues as well as several conditions such as suicide treatment, Schizophrenia, and dementia are much more likely to be over $1,000, $2,000, and $5,000 than the average enrollee.