Defining Financial Toxicity

Financial toxicity is a term that originated in the field of oncology and is considered a major side-effect of seeking cancer treatment—analogous to the toxicities of physical symptoms of treatment [1]. The term was first coined to bring attention to the often high out-of-pocket costs of cancer treatments and the corresponding adverse impacts on patients and their families [1].

Fenn et al. (2014) conceptualize financial toxicity as a composite measure that encompasses several dimensions of financial hardship, including out-of-pocket costs, productivity loss, asset depletion, medical debt, and bankruptcy [12]. The National Cancer Institute defines financial toxicity as the financial distress or hardship experienced by patients due to the cost of medical care [13]. This includes direct medical costs (e.g., treatment, medications) and indirect costs (e.g., lost income, travel expenses) which lead to financial strain and can adversely affect the patient’s quality of life and treatment adherence [13].

Lueckmann et al. (2021) expanded these definitions by highlighting that financial toxicity not only includes actual financial burden but also the anticipation and worry about potential financial distress [14]. This subjective financial distress can significantly impact the patient’s mental health and overall well-being, emphasizing the psychological dimension of financial burden that extends beyond objective economic measures [14].

The concept of financial toxicity has gained recognition as a critical concern across various chronic conditions, and notably diabetes [15,16,17]. Diabetes management requires ongoing medical monitoring, medication adherence, lifestyle modifications, and often advanced technologies—all carrying substantial costs. These expenses can create significant financial strain, leading to cost-related non-adherence (CRN) behaviors, worsened clinical outcomes, and diminished quality of life [18,19,20,21,22].

Measuring Financial Toxicity in Diabetes

Financial toxicity in diabetes encompasses multiple dimensions: objective financial burden (direct and indirect costs), subjective financial distress (perceived hardship), and consequent behaviors including cost-coping strategies. Recent research has established metrics to quantify these dimensions, enabling more systematic analysis [23].

Patel et al. validated the COST-FACIT instrument for measuring financial toxicity, originally developed in cancer, in a clinical population with diabetes [23]. COST-FACIT demonstrated a two-factor structure with high internal consistency: general financial situation (7-items, α = 0.86) and impact of illness on financial situation (4-items, α = 0.73) [23]. In this study, the highest percentage of participants endorsed quite a bit/very much for “worry of financial problems in the future as a result of illness or treatment” (60%), and feeling that they “have no choice about money spent on care” (64%). Although nearly one-half endorsed quite a bit/very much for “I am able to meet my monthly expenses” (45%), just as many participants (42%) noted quite a bit/very much for “my out-of-pocket medical expenses are more than I thought they would be,” “I am financially stressed” (47%), and “I am frustrated that I cannot work or contribute as much as I usually do” (47%) [23]. Only 16% endorsed quite a bit/very much for “I am satisfied with my current financial situation [23].” These findings illustrate the multidimensional nature of financial distress that extends beyond simple ability to pay for care.

Patel et al. (2025) identified three distinct classes of financial toxicity (high, medium, and low) among people with diabetes, with a score of 26 on the COST-FACIT being the strongest threshold for distinguishing high versus medium/low financial toxicity [24]. This classification showed a positive predictive value of 76% and negative predictive value of 93%, providing a framework for identifying patients at greatest risk [24].

While validated instruments like COST-FACIT have been adapted for diabetes in Western contexts, different approaches to measuring financial burden have emerged in countries like India. Studies from India have focused on catastrophic health expenditure (CHE) thresholds, with research showing that 37.9% of Indian households with members who have diabetes experienced CHE at the 10% threshold, and nearly 10% fell below the poverty line due to diabetes-related out-of-pocket expenses [9].

The Global Landscape of Financial Toxicity in Diabetes

Looking at financial toxicity in diabetes from a global perspective reveals several key patterns. Approximately 30–60% of people with diabetes worldwide experience some form of financial toxicity, though the severity and specific mechanisms vary significantly by healthcare system, income level, and geography [9, 24,25,26,27,28]. Across diverse countries, families affected by diabetes typically spend between 5 and 40% of household income on diabetes-related expenses, with the burden falling disproportionately on lower-income households who may spend as much as half their income on diabetes care in the most severe cases [26,27,28].

The primary drivers of financial toxicity operate through four key mechanisms that manifest differently across healthcare systems (Fig. 1):

Fig. 1

Conceptual Framework of Financial Toxicity in Diabetes

1.

Direct out-of-pocket costs for medications, supplies, and services create immediate financial pressure, affecting 40–70% of patients globally [29,30,31].

2.

Indirect costs including transportation, lost productivity, and caregiver burden account for an often-overlooked 20–40% of total financial impact [11, 32–33].

3.

Coverage gaps in both public and private insurance systems leave critical aspects of diabetes management unprotected—notably, diabetes technologies and outpatient services in many middle and low-income countries [10, 34,35,36].

4.

System-level structural barriers including fragmented care delivery, complex eligibility requirements, and limited availability of affordable options compound these challenges [37,38,39].

Stark disparities characterize this landscape. Within countries, financial toxicity is consistently more severe among racial and ethnic minorities, women (particularly mothers of children with diabetes), rural residents, and those with multiple comorbidities [11, 40–41]. Between countries, the most extreme disparities are seen in years of life lost due to diabetes: approximately 22–23 years in high-income countries compared to 33–45 years in low-income settings [34]. Access to diabetes technology exemplifies these disparities, with adoption rates ranging from over 70% in some European countries to less than 3% in many African nations [34].

Meanwhile, the increasing cost trajectory of newer diabetes treatments and technologies threatens to widen existing gaps [22, 42–43]. This global landscape reveals financial toxicity not as an inevitable consequence of diabetes but as a systemic failure requiring coordinated policy, healthcare system, and individual-level interventions tailored to specific contexts [15, 44–45].

Geographic Variations in Financial ToxicityHigh-Income Countries

Even in high-income countries with robust healthcare systems, financial toxicity remains a significant challenge. Conway et al. (2024) examined disparities in diabetes technology uptake across countries and found that even among high-income countries, structural barriers such as stringent eligibility requirements by public and private insurers limited access to cost-saving technologies [34].

Low and Middle-Income Countries

Low and middle-income countries face unique challenges in addressing diabetes-related financial toxicity due to developing health insurance and coverage structures.

The financial burden of diabetes is especially pronounced in low-income countries where healthcare infrastructure may be limited and insurance coverage minimal [46,47,48,49]. Owusu et al. (2024) evaluated the effectiveness of Ghana’s National Health Insurance Scheme in providing financial protection to households with type 1 diabetes, concluding that the scheme steadily fails to meet the cost-reduction expectations of patients and their caregivers, particularly for non-insulin supplies like test strips and glucometers [10].

Conway et al. (2024) noted that in many low-income countries, particularly in Africa, diabetes technology market penetrance is negligible to nonexistent, with regions reporting among the highest years of life lost due to type 1 diabetes [30].

India presents a particularly stark case of financial toxicity in diabetes care despite recent government initiatives. The country’s healthcare financing structure exacerbates these challenges. While India has implemented large government-sponsored health insurance schemes like ‘Pradhan Mantri Jan Arogya Yojana (PMJAY),’ these primarily cover inpatient services and exclude outpatient care—a critical gap for diabetes management which relies heavily on ongoing outpatient services [9]. Additionally, poor availability of free or subsidized essential drugs in public health facilities compels individuals to purchase medicines from the open market, leading to higher out-of-pocket expenses or foregone treatments [9].

For advanced diabetes technologies like continuous glucose monitoring and insulin pumps, the situation is even more challenging. Only 10–15% of individuals with T1D in India use diabetes technology to manage glycemia [30].

Mechanisms of Financial Toxicity in DiabetesDirect Costs of Diabetes Management

Direct costs for diabetes management constitute a substantial component of financial toxicity and include expenses for medications (particularly insulin), glucose monitoring supplies, devices, and healthcare services for routine disease management and treating complications (Fig. 2). These costs represent a cumulative burden. Recent literature reveals significant variations in these costs across different healthcare systems and populations.

Fig. 2

Financial Toxicity across the Diabetes Care Continuum

Medication Costs

The cost and related insurance coverage of diabetes medications, particularly insulin, represents a major contributor to financial toxicity [50,51,52,53]. Julian et al. (2021) reported that out-of-pocket costs for insulin and diabetes-related supplies increased by 54% between 2005 and 2017 among privately insured patients in the United States, even after adjusting for inflation [29]. People with consumer-directed/high-deductible health plans experienced an even more dramatic 70% increase during this period [29].

Lin et al. (2023) found that while insulin usage remained stable over the past decade, total insulin expenditure almost doubled per person per year after the implementation of the Affordable Care Act in the US, regardless of insurance status [37]. For the uninsured, out-of-pocket insulin costs increased from $1,678 per person per year to $2,800 per person per year [37].

Non-insulin medications also contribute significantly to financial burden with diabetes. Quach et al. (2024) highlighted that median annualized out-of-pocket spending for SGLT2 inhibitors and GLP-1 agonists was higher than for insulin or DPP-4 inhibitors among commercially insured individuals in the US [42]. People with diabetes taking three or more classes of diabetes medications faced particularly high costs, with the top decile spending nearly $3,000 annually out-of-pocket for medications alone [42].

In middle and low-income countries, medication costs represent an even greater relative burden [49, 54–55]. Mohammed et al. (2024) found that in Ethiopia, none of the lowest-priced generic diabetes medicines were affordable in either public or private healthcare settings, with prices in private pharmacies significantly exceeding reference prices [30].

While insulin costs have risen dramatically in the United States, medication affordability represents an even greater relative burden in India. Rawat et al. (2024) found that families in Delhi with a family member managing diabetes may lose 10–40% of their gross family income to diabetes care expenses [26]. Moreover, a recent study examining affordability of essential medicines found that 51.4% of Indian households with diabetes members were unable to afford insulin and 24.6% couldn’t afford metformin, with the highest unaffordability reported in rural areas and among the lowest income tertile [9]. Perhaps most alarmingly, among 2,972 surveyed diabetes patients in India, 71.5% reported taking no diabetes medication at all due to cost barriers [9].

Monitoring Supplies and Devices

Beyond medications, costs for glucose monitoring supplies and devices constitute a significant portion of direct expenses [22]. Fauzi et al. (2024) detailed the costs associated with self-monitoring blood glucose (SMBG) devices in Indonesia, noting that glucometers cost between 19.21 and 38.40 USD, with a pack of 25 glucose strips ranging from 3.84 to 7.68 USD [35]. With a minimum requirement of four glucose tests per day, this totals approximately 38.40 USD per month—a substantial burden in a country where the monthly average household income was 203.52 USD in 2023 [35].

Lin et al. (2023) found that in China, approximately 89.5% of older adults with diabetes were reluctant to have their blood glucose monitored for economic reasons [56]. Blood glucose test strips were not covered by medical insurance, requiring patients to bear these costs themselves [56].

Healthcare Services

Costs for healthcare services—including consultations, laboratory tests, and hospitalizations—also contribute significantly to financial toxicity among people with diabetes worldwide [57]. Rawat et al. (2024) examined out-of-pocket direct costs of ambulatory care for type 2 diabetes in Delhi, India, finding that families who have a member managing diabetes may lose 10–40% of their gross family income to diabetes care expenses [26].

For people with complications, these costs escalate dramatically [58,59,60,61,62]. Seshadri et al. (2024) reported that among patients with diabetic foot ulcers in South India, the median total annual out-of-pocket expenditure was ₹29,775 ($378.14), with 68.8% of participants facing catastrophic expenditure (> 10% of annual income) for management of these complications [33]. India has been described as ‘the most expensive country for diabetic foot ulcer care,’ with an estimated 5.7 years (68.8 months) of an average patient’s income required to pay for complete DFU therapy [33, 61].

Phrommintikul et al. (2022) found in Thailand that the average total out-of-pocket outpatient cost for diabetes was THB 22,874 ± 38,066 ($759 ± 1,264) for the first year, while out-of-pocket inpatient expenditure averaged THB 160,790 ± 411,607 ($5,338 ± 13,666), with complications dramatically increasing costs [57].

Indirect Costs and Broader Economic Impact

Beyond direct healthcare expenses, indirect costs significantly contribute to the overall financial toxicity of people managing diabetes [15]. These indirect expenses include productivity losses due to missed work or reduced capacity, substantial caregiver burden affecting family finances, and transportation expenses to healthcare facilities. These factors often receive less attention in policy discussions but can substantially impact household finances [32].

Productivity and Employment Impacts

Diabetes-related financial toxicity significantly affects employment and productivity [