Predictors of Medical Debt Sent to Collections after Radiation Therapy

Patients undergoing radiation therapy (RT) often face substantial out-of-pocket costs (OOPC), putting patients at risk of going into debt. Unpaid medical debt sent to collections is a proxy for severe financial distress.

We identified patients treated with RT at a tertiary care center and its affiliated community sites in fiscal years from 2023 to 2024. Charges for physician and hospital fees for RT, billed OOPC, and unpaid debt (ie, billed OOPC that is not paid and sent to collections) were collected. Multivariable analyses were performed to assess factors associated with unpaid debt.

We identified 14,774 patients (mean age of 64 years [SD, 14.7], 55.6% women [n = 8212], 6.3% Hispanic [n = 932], and half were never smokers [55.2%, n = 7863]). Most paid OOPC (61.1%, n = 8711), with a mean of $1350.70 (SD, 2569.3) and median $182.80 (IQR, 29.7-1894.7). A minority had debt sent to collections (2.7%, n = 397), with a mean of $1109.90 outstanding (SD, 4215.5) after a mean of 9.3 months (SD, 3.9). On multivariable analyses, older patients (odds ratio [OR], 0.99 [0.98-1.00]; P = .005) were less likely to have debt sent to collections. Single patients (OR, 1.32 [95% CI, 1.06-1.64]; P = .012), current smokers (OR, 2.20 [1.56-3.05]; P < .001;), with commercial insurance (OR, 1.95 [1.50-2.54]; P < .001; referent government insurance), living in more disadvantaged neighborhoods, or with higher OOPC (OR, 1.08 per $1000 [1.05-1.12]; P < .001) were more likely to have unpaid debt. An OOPC threshold of $49.10 was associated with being twice as likely to have unpaid debt (receiver operating characteristic curve of 0.724; OR, 2.36 [1.31-3.14]; P < .001).

In patients undergoing RT, most patients pay OOPC for treatment and a minority of patients incur debt going to collections. Patients who are single, Hispanic, current smokers, or with non-government-issued insurance, and higher OOPC were more likely to incur unpaid debt.