Hawai‘i patients spent $230M+ on out-of-state cancer care in 2021-2023, UH Cancer Center study finds

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Link to images, b-roll: go.hawaii.edu/Eui

HONOLULU - A new study led by researchers at the University of Hawaiʻi Cancer Center found that at least $230 million was spent on cancer care delivered outside Hawaiʻi between 2021 and 2023, highlighting the significant financial impact of geographic isolation on patients and the health care system.

The study, titled "Quantifying financial toxicity from cancer care travel in a geographically isolated U.S. health system," analyzed de-identified data from commercial insurance claims filed through Hawai'i Medical Service Association (HMSA) by Hawaiʻi residents receiving cancer treatment. HMSA is an independent licensee of the Blue Cross and Blue Shield Association and the largest health insurance provider in Hawai'i. The study found that certain patients - particularly those with complex cancers such as leukemia, lymphoma and brain tumors - were much more likely to require care outside the state. The findings point to opportunities to strengthen local cancer care capacity and reduce the need for patients to travel thousands of miles for treatment, the researchers said.

"Hawaiʻi represents the most geographically isolated health system in the country, located approximately 2,400 miles from the continental mainland," the study said. "Although comprehensive oncology services are available within the state, certain high-complexity subspecialty services, advanced therapeutics, and clinical trial opportunities may require patients to seek care outside Hawaiʻi. Such out-of-state (OOS) utilization reflects both patient need and structural constraints in oncology capacity."

"Patients who must leave the islands for specialized cancer care bear enormous burdens: On top of medical bills, they may face travel expenses, time away from work, and the emotional challenge of receiving treatment far from home and the support of their loved ones. For some patients, the enormous cost of out-of-state treatment puts that care out of reach," said Dr. Hideko Yamauchi, Director of Clinical Affairs at the UH Cancer Center, and the principal investigator for the study. "By understanding where and why patients seek care elsewhere, we can better identify opportunities to expand access, strengthen specialized services, and keep more patients connected to their support networks while receiving treatment."

"HMSA is proud to work with the UH Cancer Center on research that helps us better understand the health care needs of the people of Hawaiʻi," said HMSA Chief Executive Officer Mark M. Mugiishi, MD, FACS, and a co-author of the study. "These findings can help guide efforts to improve access to high-quality cancer care closer to home. Whenever possible, patients should be able to receive advanced treatment in Hawaiʻi while staying connected to their families, communities and support systems during one of the most difficult times of their lives."

'Financial toxicity' places strain on patients

The study found that out-of-state cancer care expenditures totaled approximately $58 million in 2021, rose to $94 million in 2022, and reached nearly $79 million in 2023. Total spending exceeded $230 million during the three-year period.

Breast cancer accounted for the largest total amount spent on out-of-state care at $59.5 million, due to its high prevalence, researchers said. It was followed by leukemia ($46.4 million), lymphoma ($21.5 million), prostate cancer ($14.9 million), and pulmonary cancer ($14 million).

However, leukemia exhibited the highest proportion of out-of-state spending for treatment, at 39%, followed by lymphoma (29%), central nervous system tumors (27%), multiple myeloma (21%) and breast cancer (21%).

The study examined only direct medical costs paid through insurance claims with HMSA. It did not include claims with other insurers. It also did not include additional expenses frequently borne by patients and families, such as airfare, lodging, meals, lost income, or caregiver time. Previous research has shown that these travel-related burdens can contribute significantly to what experts call "financial toxicity" - the financial strain associated with cancer treatment.

"A concern raised by these findings is that the patients we can see in the data are only the ones who successfully traveled," Yamauchi said. "The patients we worry about are the ones we cannot see in this data - those who did not travel and faced barriers to accessing specialized care. Understanding that hidden burden is an important next step for research and policy."

Although Hawai'i's isolation is unique among the states, similar challenges affect rural and underserved communities throughout the U.S. where specialized cancer services may be limited.

Expansion of Hawai'i cancer care indicated

"The UH Cancer Center deeply appreciates HMSA - a member of our Hawai'i Cancer Consortium - for collaborating on this crucial research. This study demonstrates why continuing to expand cancer care in Hawaiʻi is so important," said Dr. Naoto T. Ueno, Director of the UH Cancer Center, and a co-author of the study.

The findings suggest that increased investments in Hawai'i in high-demand specialty services, advanced diagnostics, clinical trials, and innovative care models, such as tele-oncology, could help reduce the need for some patients to travel outside of the islands for treatment, Ueno said.

The opening in July of the UH Cancer Center's Ho'ōla Early Phase Clinical Research Center is one example of such an investment. "The launch of the UH Cancer Center's new Ho'ōla Early Phase Clinical Research Center represents a major step toward increasing advanced cancer care in Hawai'i," Ueno said. "Ho'ōla EPCRC will give qualifying Hawai'i patients the opportunity to receive cutting-edge, first-in-Hawaiʻi Phase I clinical trial treatments here at home, without leaving their families and communities to travel to the U.S. mainland.

"In addition, the UH Cancer Center's new statewide academic oncology initiative, Ka 'Umeke Lama, aims to support and grow Hawai'i's oncology workforce, and bring quality cancer care to underserved populations," Ueno continued. "Our goal is to ensure that Hawaiʻi residents have access to the newest advances in cancer treatment while remaining close to the people who support them most."

Read the study abstract in the Journal of Clinical Oncology. The study was selected as an electronic abstract for the American Society of Clinical Oncology (ASCO) annual meeting in May in Chicago. Co-authors also included Dr. Deborah Taira, Professor, Daniel K. Inouye College of Pharmacy, UH Hilo; and Dr. Jeffrey Tom, Clinical Systems Director for Corporate Strategy, HMSA.

About The University of Hawai ʻ i Cancer Center

The University of Hawai ʻ i Cancer Center is dedicated to saving lives in Hawai ʻ i and the Pacific. It is inspiring hope by working to conquer cancer. The flagship priority is to understand and address cancer health disparities. The center strives to achieve this through research, education, patient care, and community outreach, focusing on the unique and diverse ethnic, cultural, and environmental characteristics of Hawaiʻi and the Pacific.

The UH Cancer Center is one of only 74 institutions designated by the National Cancer Institute (NCI), representing a significant mark of excellence, and is the only NCI-designated cancer center in Hawaiʻi and the Pacific. The center contributes more than $57 million to Hawai'i's economy through scientific research, clinical trials, and other activities.

As part of the University of Hawaiʻi at Mānoa, the UH Cancer Center operates out of facilities located in Kakaʻako. The center directly employs more than 300 faculty and staff, with an additional 200 affiliate members and cooperative agreements with organizations that are part of the Hawaiʻi Cancer Consortium. The consortium includes The Queen's Health Systems, Hawaiʻi Pacific Health, Kuakini Medical Center, Adventist Health Castle, Hilo Benioff Medical Center, Hawaiʻi Medical Service Association (HMSA), and the John A. Burns School of Medicine (JABSOM), all working together with the UH Cancer Center to advance cancer research and treatment in the state.

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About HMSA

Caring for the people of Hawai'i is our promise and our privilege. Working together with employers, partners, and physicians and other health care providers, we promote well-being; develop reliable, affordable health plans; and support members with clear, thoughtful guidance. Established in 1938 by social workers, HMSA is the most experienced health plan in the state. Starting in 2025, HMSA is supporting TriWest Healthcare Alliance to administer the U.S. Department of Defense's TRICARE program, providing health care for uniformed service members, their families, and survivors locally. With the addition of TRICARE, HMSA provides health care to nearly 1 million people in Hawai'i. We embrace our responsibility as a recognized leader to strengthen the health and well-being of our community. Headquartered on O'ahu with centers statewide to serve our members, HMSA is an independent licensee of the Blue Cross Blue Shield Association.

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For more information, visit: http://UHCancerCenter.org