Medical-financial partnerships for improving financial and medical outcomes for lower-income Americans: A systematic review

Limited evidence on the health and financial outcomes of medical-financial partnerships (MFPs)

MFPs lack sufficient evidence to conclusively demonstrate their effectiveness in improving financial and health outcomes within healthcare settings.

The problem, condition or issue

Despite social safety net programs such as Social Security and the Earned Income Tax Credit (EITC) that provide income to the lowest income Americans, poverty continues to be a widespread problem in the United States. According to the US Census Bureau (2022), about 12% of Americans, or 38 million people, have household incomes below the U.S. poverty line. Poverty is considered one of the social determinants of health (i.e., a broad range of social and environmental conditions that affect health and well-being) because of its association with significant health problems (Francis et al., 2018). Poverty affects adult and child physical health due to its impact on access to safe housing, healthy foods, employment and educational opportunities, healthcare services, clean air and water, and a safe neighborhood environment (US Department of Health and Human Services, n.d.). Poverty is a special concern for minoritized populations, as poverty disproportionately impacts racial and ethnic minorities (Board of Governors of the Federal Reserve, 2021). States with higher levels of services that ameliorate poverty have significantly better health outcomes (Bradley et al., 2016).

Financial stress and strain is often experienced for those living below and just above the federal poverty level ($31,200 annually for a family of four in 2023). Financial strain is experienced when unexpected expenses occur, such as a health bill or car repair, even for households that regularly meet daily and monthly expenses. About half of U.S. households have less emergency savings than the amount needed to cover expenses for 3 months in the absence of income, as recommended by financial planners (FINRA, 2022). In 2022, only 63% of adults could cover a hypothetical unexpected $400 expense using cash, savings or a credit card paid off at the next statement (Board of Governors of the Federal Reserve System, 2023). Households without savings often take on unmanageable debt, which can result in debt collection proceedings. Hassani and McKernen (2018) estimate that 32% of adults, or 71 million people, have debt in collections. The lack of savings is also critical for older adults; half of all adults nearing retirement have no personal retirement funds (King, 2022).

Financial stress and strain negatively affects health and well-being through several pathways. First, chronic financial and other types of stress lead to the acceleration of normal aging through the shortening of telomeres and increases in allostatic load, together called “weathering.” These processes lead to premature aging and earlier onset of unfavorable physical health conditions (Geronimus, 2023). Second, financial stress interferes with regular medical care due to foregone care as a result of lack of affordability of care or other poverty-related access challenges. Preventive medical care can decrease in priority for families facing financial stress, which in turn can result in conditions becoming more acute and requiring more intervention (Schickedanz et al., 2023). Racial and economic discrimination faced by people of color, people with disabilities and other groups can compound financial stress (Geronimus, 2023). Children in low-income households whose parents are under financial stress may suffer harm to their cognitive and social/emotional development due to harsh, inconsistent, and/or detached parenting resulting from the stress (National Academies of Sciences, Engineering, and Medicine, 2019).

Poverty interventions are often housed within the social services sector (e.g., Birkenmaier et al., 2022). However, healthcare settings are increasingly a topic of interest for poverty interventions that have health implications (Rosenberg & Sude, 2024). Primary and tertiary healthcare settings that target and/or serve primarily lower-income and communities of color are trusted healthcare settings that serve populations that could benefit from services that lower financial stress (South et al., 2022). Primary healthcare settings provide low- or no-cost preventive and primary healthcare, while tertiary healthcare settings provide hospital-based care. These settings often function as the first point of contact in the healthcare system because referrals are not needed to access care; therefore, they can provide a gateway to other services. Primary healthcare providers are focused on the comprehensive and interrelated aspects of physical, mental, and social health, and are thus particularly interested in the home environment and stressors from patients. Tertiary healthcare settings with hospital clinics and wellness centers can also incorporate financial services to reduce financial stress (Bell et al., 2020).

Health practitioners are also focused on improving health outcomes, particularly through finding ways to promote keeping appointments focused on preventative care (Rosenberg & Sude, 2024). Primary healthcare clinics that serve low-income families have high no-show rates for appointments – estimates range between 25% and 50% of all appointments (Samuels et al., 2015). A relatively recent arrangement called “Medical Financial Partnerships” (MFPs) often have the dual goal of improving “show” rates for appointments and improving financial stress (Schickedanz et al., 2023).

The intervention

MFPs, a relatively new and innovative intervention, are currently being piloted within healthcare settings that serve lower-income and Medicaid-insured patients. These partnerships aim to directly address issues of patient financial stress and poverty (Liu et al., 2021), and promote adherence to healthcare appointments (Schickedanz et al., 2023). Typically initiated by health delivery systems, such as clinics, hospitals, or broader health networks, MFPs involve collaboration with financial service organizations to offer services that enhance both community finances and health. Distinguishing themselves from previous models, MFPs integrate financial stability efforts into the healthcare provision, attempting to create a synergistic effect on community wellness (Bell et al., 2020; Hole et al., 2017). The purpose of this service delivery model is to foster a robust connection between healthcare and financial services, offering a spectrum of support from specific interventions such as free tax preparation to more comprehensive services (Marcil et al., 2021). The goal of MFP services is to provide a platform to enhance patient financial stability for patients through a variety of offerings, including but not limited to, free tax preparation, enrollment in savings accounts, employment assistance and workforce development, financial coaching, and/or assistance with applying for benefit programs. MFPs serve a wide demographic, including hospital and clinic patients, their employees, and the wider community. MFPs provide financial services both onsite and in the broader community through formal organizational partnerships (Marcil et al., 2021).

Several key factors are driving the development and offering of MFPs. The idea that financial stress is inherently a healthcare issue is gaining traction. Prominent professional and government entities, including the Academy of Pediatrics and the American Academy of Family Physicians, advocate for healthcare providers to address the social determinants of health, which includes financial stress (American Academy of Family Physicians, 2022; Gitterman et al., 2016). Additionally, the National Association of Community Health Centers and the Centers for Medicare and Medicaid Services have developed tools for screening for the social determinants of health (Center for Medicare and Medicaid Services, n.d.; National Association of Community Health Centers Inc. (NACHC), 2022). Academic research further supports the significance of such screening tools in recognizing the social determinants of health, including poverty (Gruss et al., 2021; LaForge et al., 2018; O'Gurek & Henke, 2018). News coverage of MFPs is also driving interest (Huang, 2023).

Moreover, primary healthcare settings have historically incorporated non-financial social resources. Initiatives addressing necessities such as food security (Adams et al., 2017; Palakshappa et al., 2017), as well as behavioral health and legal services (Beck et al., 2021) have become integral components of patient care. Notably, some healthcare settings have incorporated Medical-Legal Partnerships, which embed legal services addressing legal barriers to financial wellness, such as benefit or disability appeals, workplace discrimination, and family medical leave (Marcil et al., 2021). Furthermore, qualitative research findings suggest patients are interested in services integration, such as financial coaching and free tax preparation clinics (Liu et al., 2021). Individual studies suggest that the integration of financial services within healthcare settings could lead to improved financial outcomes, such as reduced debt and higher credit scores, and better health outcomes through reduced financial stress, increased adherence to healthcare appointments, and greater utilization of preventive healthcare services (Dalembert et al., 2021; Schickedanz et al., 2023).

How the intervention might work

MFPs are pioneering approaches that operate on- and off-site of healthcare facilities through partnership arrangements. This review distinguishes on-site MFP interventions from conventional social work services in healthcare settings, and will focus particularly on those interventions delivered on-site and through tele-consultations with financial service providers operating under a healthcare provider's service model. While social workers in healthcare settings typically refer patients to external resources such as financial counseling and coaching and emergency nutrition supplements (Browne, 2019), MFPs that are colocated are distinctly different from traditional social services, and provide unique features. First, colocation simplifies access to services for patients to access services, whether in conjunction with their healthcare visits or as standalone services. Secondly, these services are integrated into the healthcare framework, and emphasize a holistic approach to patient care (Marcil et al., 2021). On-site MFP interventions can offer a suite of financial services, including financial counseling, financial coaching, tax preparation services, credit counseling, debt consolidation and forgiveness, and employment assistance (Bell et al., 2020). Patients can access these services within the physical space of healthcare settings (Dalembert et al., 2021; San Francisco General Hospital, n.d.), or via tele-consultation.

Community partnerships are integral to these colocated services. Toward that goal, the American Academy of Pediatrics has created a model for developing and sustaining effective community partnerships. This framework aids healthcare providers in identifying and aligning with partners to ensure and sustain patient benefits while efficiently managing staff resources (American Academy of Pediatrics, 2021). In practice, various healthcare staff members inform patients about the available financial services and encourage their utilization.

Across the MFP models currently implemented, financial coaching and tax preparation services are most prominent (Dalembert et al., 2021; Marcil et al., 2021). Financial coaching has evolved into a standardized, evidence-based method that empowers low-income families toward financial well-being (Hall et al., 2022; Modestino et al., 2019). Financial coaches assist clients to set and pursue their financial goals, complemented by financial education, and strategies to enhance budgeting, savings, and credit. Financial coaches work one-on-one or in groups, and use motivational interviewing and financial planning techniques, as well as assist to apply for public benefits (Collins et al., 2021). Demonstrated outcomes of financial coaching include increased financial knowledge and confidence, reduced stress and debt, and improvements in income, savings, and credit scores (Collins et al., 2021; Silva et al., 2022). Some MFP models include financial counseling (Sadigh et al., 2022). Financial counseling, in contrast, is a service that provides assistance on a particular issue, such as debt management, and often includes financial education.

In MFP models that include financial coaching, coaches maintain communication with clients between medical visits, and focus on financial stress and progress toward client-specific goals. The aim is to foster supportive, trusting, and nonjudgmental relationships that bolsters patient financial capability and adherence to healthcare appointments by aligning services with the patient's financial objectives. This approach seeks to build trust with the healthcare team, encouraging engagement with both healthcare and financial services (Schickedanz et al., 2023).

Free tax preparation within the MFP framework addresses another vital need (Bell et al., 2020). Filing for federal income taxes, particularly for low-income families eligible for significant refunds through credits such as the EITC and the Child Tax Credit (CTC), represents a crucial annual financial opportunity. Yet, an estimated 20% of those eligible fail to claim these benefits (Internal Revenue Service, 2022), and Black and Latinx children in families that are disproportionately affected (Bruenig & Williams, 2021). Free tax preparation assistance through programs such as the Volunteer Income Tax Assistance (VITA) program and Tax Counseling for the Elderly (TCE) is available for those earning $60,000 or less annually, people with disabilities, and those with limited English proficiency (US Department of Housing and Urban Development, n.d.), potentially offsetting the $1.75 billion earned by the for-profit tax industry annually (Weinstein & Patten, 2016).

Additionally, MFPs provide a variety of other services, such as employment assistance, diaper distribution, assistance with food insecurity, Child Development Accounts, housing assistance, savings programs, benefits enrollment, FAFSA assistance, pre-k enrollment, and medical bill negotiation, enhancing the holistic support offered to patients (Marcil et al., 2021).

Why it is important to do this review

This review has significant relevance for both health and financial policy. First, health policy is increasingly focused on the crucial role of the social determinants of health, including financial factors, in influencing health outcomes (World Health Organization, 2023). By addressing the financial goals and needs of patients, which can enhance health outcomes, policy may shift due to the reduced healthcare costs that arise from increased preventative healthcare delivery, such as vaccinations and health screenings. The findings of studies in this domain could inform health policy, particularly in the context of primary healthcare. Furthermore, the existing body of evidence provides little support for the idea that financial services, such as financial coaching and free-tax preparation clinics, could increase their impact when integrated into familiar and trusted environments, such as health clinics (Alexander et al., 2022). The effectiveness of embedding financial services within such settings could inform policies related to these services. For instance, the demonstrated success of MFPs might motivate policymakers to integrate these services more comprehensively into health systems and establish funding mechanisms for financial services.

Despite recent interest in MFPs, research remains fragmented, and to date, no systematic review of the MFP intervention focusing on their financial and health outcomes has been published. While one scoping review (Parry et al., 2021) has explored financial interventions within healthcare systems aimed at addressing poverty in high-income countries, it did not adhere to systematic review methodologies. Bell et al. (2020) undertook a systematic review of various MFP models and described different organizational approaches, without focusing on financial and/or health outcomes. Thus, no systematic reviews, to date, have examined MFP financial and/or health-related outcomes.

The research in this area is emerging, with scholarly discussions starting around 2017. Our preliminary search yielded several quantitative studies (Marcil et al., 2018; Marcil & Thakrar, 2022a; Markowitz et al., 2022; Schickedanz et al., 2023) and qualitative studies (Bennett et al., 2021; Jaganath et al., 2018; Liu et al., 2021; Marcil & Thakrar 2022b; Quinn et al., 2018), but the evidence is dispersed across disciplines. Given the interdisciplinary nature of this research and the novelty of these interventions, conducting a systematic review is crucial for assessing the components of the intervention implemented, the outcomes measured, and the strength of the evidence to effectively inform policy and practice.

This study addresses knowledge gaps in several areas. While individual studies on certain MFP interventions have observed positive outcomes, such as financial coaching (Theodos et al., 2015), and tax-time saving interventions (Roll et al., 2020), recent systematic reviews on other interventions offered within MFPs, such as matched savings accounts (Birkenmaier et al., 2022), Child Development Accounts (Birkenmaier et al., 2022), tax-time saving interventions (Birkenmaier et al., 2023), and on financial services interventions broadly, including financial coaching (Birkenmaier et al., 2022) have reported mixed or modest effects on savings amounts or were inconclusive. Other reviews, including systematic reviews, have found that financial education, counseling, and coaching has little or no effects on subsequent behavior, including short-term saving (Birkenmaier et al., 2022; Fernandes et al., 2014; Kaiser & Menkhoff, 2020; Miller et al., 2015). Thus, further systematic reviews of financial services interventions are necessary.

Objectives

The purpose of this review is to inform policy and practice relevant to MFPs by analyzing and synthesizing empirical evidence related to their health and financial outcomes. The primary objectives of this review is to answer the following research questions using formal research studies: 1.

What is the extent and quality of MFP intervention research?

Criteria for considering studies for this review

Search methods for identification of studies

We conducted a comprehensive search for published and gray literature informed by Campbell's guide for searching for studies (Kugley et al., 2017). We searched multiple electronic databases, gray literature sources, reference lists of reviews and relevant studies, trial registries and relevant websites and contacted authors.

Data collection and analysis

Description of studies

Results of the search

The results of the search and selection process are illustrated in Figure 1. Electronic searches of bibliographic databases and searches of other sources yielded a total of 91,778 hits. Of the 91,778 hits, 91,776 were from database searching, and two were registered protocols. As part of the automatic deduplication process available in Rayyan outlined above, 5189 articles were removed as duplicates automatically. An additional 22,382 reports were manually identified as duplicates and removed. After deduplication, 64,207 titles and abstracts were screened for relevance and 64,182 were deemed inappropriate. The full text of the remaining 25 potential studies were reviewed and screened for eligibility by four independent coders. We excluded 20 reports that were deemed ineligible and included five reports that met the inclusion criteria. Of the five, one was a correction to an eligible report. This resulted in four unique studies (using unique samples) published in five reports that were included in this review. Published protocols were available for three of the four studies (Marcil & Thakrar, 2022a, 2022b; Sadigh et al., 2022; Schickedanz et al., 2023). We conducted forward citation searching and reference list searching on the included studies. None of the additional entries generated by these searches met the inclusion criteria for full-text review. No new studies were located from websites, clinical trial registries, or from included authors. See the references of included studies for a list of reports that reported on the included studies.

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Figure 1

PRISMA flow diagram: search process and results.

Risk of bias in included studies

The risk of bias varied across studies from “some concerns” to “critical.” None of the four studies had a low risk of bias. Three of the four included studies had pre-registered protocols, which was helpful in assessing several domains, including deviations from intended interventions, measurement of outcomes, and in selection of the reported result reporting bias. The studies that used an RCT design differed in their risk of bias on almost all of the domains, with both having a low risk of bias for measurement of outcomes. Alternatively, the studies that used a QED design had virtually identical assessments of risk of bias across all of the domains, with the exception of selection of reported results. Study authors recognized study limitations and recommended that research on intervention effectiveness continues, and that rigorous research be conducted on the MFP interventions.

Data and analysis

Summary of main results

The challenges of low income and poverty impacts both the financial well-being and the health of Americans (US Census Bureau, 2022; US Department of Health and Human Services, n.d.). Increasingly, healthcare systems are seeking to address financial stress as a social determinant of health by incorporating financial services within the healthcare delivery model (Francis et al., 2018; World Health Organization, 2023), called an MFP. The purpose of this systematic review was to determine the state of research and examine the health and financial outcomes of MFPs.

This review included a total of four unique studies reported on in five reports. The studies reported on a range of services provided within an MFP, and in several types of healthcare settings. Two of the four included studies provided free tax preparation services, public benefits screening and referral, and/or community resources benefits and referrals. The remaining two studies provided other services. One study provided financial counseling, and one provided financial coaching, including one-on-one case management, budgeting, and goal setting.

Overall, the evidence of the health and financial effects of MFPs is sparse, given the small number of studies using randomized or QEDs. Moreover, the lack of standardization of outcomes studied, measurement of the outcomes, or timing of measurement did not allow for synthesis of outcomes across studies. None of the studies examined effects of similar types of interventions on similar outcomes, and several were missing sufficient data to calculate effect sizes, thus we were not able to pool effects of studies to conduct a meta-analysis.

Results indicate small and nonsignificant effects of MFPs on financial outcomes reported, and some author-reported positive statistically significant effects on attending appointments and vaccination schedule adherence.

Overall completeness and applicability of evidence

We were able to calculate the effect sizes for all reported outcomes in only one study (Sadigh et al., 2022) and one outcome in a second study (Marcil & Thakrar, 2022a, 2022b). We requested missing outcome data from authors, but authors did not provide the missing outcome data. Due to the absence of data, we were unable to pool the data for meta-analysis. Collectively, the four studies lacked evidence for longer term financial effects (longer than 6 months), a variety of doses (beyond two visits), and varying length of treatment (length for 50% of the studies was unspecified). All studies suffered from methodological flaws that limit the validity of results. Thus, the evidence provided about the MFP intervention from the included studies lacks completeness to be generalizable related to the type of settings, intervention components, geography, and household income.

In terms of settings, three of the four studies resided in pediatric primary care settings, and one resided in specialty adult care clinic (neurology). Thus, non-pediatric primary care settings, other types of adult speciality care settings, and tertiary settings were not represented in these studies. Relative to MFP components, half of the included studies provided only on-site VITA free tax assistance (Marcil & Thakrar, 2022a, 2022b; Markowitz et al., 2022), one offered financial coaching with bundled services (Schickedanz et al., 2023), and the fourth offered a package of financial services that did not include financial coaching (Sadigh et al., 2022). Given the lack of standardization, generalization about MFP intervention components is difficult. Other potential financial services, or combinations of services, were not included among the studies. The lack of geographic representation across the United States also presents a challenge to generalization. Two studies were located on the east coast (Marcil & Thakrar, 2022a, 2022b in New Haven, CT, and Markowitz et al., 2022 in Boston, MA), one was located in Los Angeles, CA (Schickedanz et al., 2023), while the location of the fourth (Sadigh et al., 2022) was unknown. The lack of known representation outside of the U.S. east and west coast also limits generalizability.

Other aspects of the studies also provide challenges for generalization. The sample sizes among the studies were mostly small, with three of the four studies presenting sample sizes smaller than 100 total. Larger sample sizes are desirable to achieve sufficient power in the analysis to detect smaller effects that may be missed in smaller sample studies and for accuracy. The studies may have mostly targeted a low-income population, but information is limited. One study (Schickedanz et al., 2023) specified that subjects were from low-income backgrounds, but the Sadigh et al. (2022) article reported findings relative to $60,000 annual income, while the other two (Marcil & Thakrar, 2022a, 2022b) and Markowitz et al., 2022) did not specify (although the intervention featured in these studies – VITA free tax preparation – targets a lower-income population). The subjects of three of the four studies were predominantly African American, and therefore generalizability to other populations would be challenging.

Quality of the evidence

While each of the four included studies provide evidence of the effectiveness of the intervention, the evidence across the studies is incomplete due to outcome reporting issues, methodological weaknesses and important concerns regarding risk of bias. While two of the four included studies used random assignment, and three of the four studies had registered protocols, there was little consistency in the outcomes measured, given that each collected data on a different set of health and financial outcomes.

While two of the studies used random assignment, all of the studies contained important methodological weaknesses. For example, two of the four studies assessed for fidelity, but none of the studies reported the outcome of the fidelity assessment. Although three of the four studies had registered protocols, all of the studies were assessed as “non-low” risk of bias due to various factors. In addition, two studies did not assess for pretest differences on outcomes. Given the lack of data to calculate effect sizes, inability to perform a meta-analysis, risk of bias issues, and methodological weaknesses, we conclude that evidence is sparse about the effectiveness of the MFP intervention on health and financial outcomes.

The studies included here have important strengths. Research design is a strength for several studies. For instance, two of the four studies are RCT's (k = 2), and Sadigh et al. (2022) study examines five financial and health outcomes across 3 months. In addition, all of the studies used a manualized intervention. Another strength is related to training – three of the four studies provided training for the staff providing the intervention, either from the IRS (Marcil & Thakrar, 2022a, 2022b; Markowitz et al., 2022) or an organization (LIFT) (Schickedanz et al., 2023). Both RCTs and one QED had registered protocols.

The risk of bias varies across studies. Two different tools were used to assess the risk of bias – the RoB 2 tool for the two RCT studies, and the ROBIN-I for the two QED studies. One RCT study was assessed as “some concerns” due to the randomization process, and the second was assessed as“high risk” due to deviations from the intended intervention, missing outcome data and selection of reported result. Two QED studies were assessed as “critical” risk of bias due to confounding, selection of participants, and missing data, and in addition, one of the studies had concerns about selection of reported results. While the number and quality of studies included in this review precludes providing a clear answer on the health and financial effects of MFPs, this review provides a good indicator of the state of the evidence for this intervention and identifies important gaps to inform future research.

Potential biases in the review process

The conduct and reporting of this review were guided by Campbell's standards and policies for the conduct and reporting of systematic reviews to ensure a rigorous and transparent review designed to minimize bias and error (Campbell Collaboration, n.d.). To limit bias in the review process, we conducted a thorough and transparent search for published and unpublished studies and conducted a rigorous process for screening and selecting studies and extracting data using at least two independent reviewers. We also included and reported all financial and health outcomes relevant to this review per the protocol. This review is not without its limitations, however, and the findings must be interpreted in light of the study's limitations. While we made every attempt to search for published and unpublished studies, all of the studies that met inclusion for this review were published journal articles. Because we limited studies to those conducted in the United States and were published in English due to the uniqueness of the U.S. healthcare and financial systems, our findings are limited to the United States context.

Despite these limitations, this review provides a comprehensive summary of MFPs that combine financial services and healthcare services. This is the first systematic review examining health and financial outcomes of MFPs, and therefore sheds early light on the promise and limitations of the body of evidence of MFPs on financial and health outcomes, as well as gaps to inform future MFP interventions development and research.

Agreements and disagreements with other studies or reviews

This is the first systematic review of MFP interventions on health and financial outcomes.

Therefore, we are unable to comment on the degree to which this review agrees with similar reviews or studies.

Implications for practice and policy

Due to the small number of included studies, the lack of sufficient data to calculate the effects on health and financial outcomes, the diversity of components and services offered and the non-low risk of bias across the studies indicates a lack of strong evidence about the effectiveness of MFP interventions. Although MFP interventions are increasingly offered, the lack of strong evidence suggests that, while many see these as promising interventions, more evidence is needed to fully support more wide-scale implementation.

The lack of strong evidence about the effectiveness of MFP interventions has implications for practice and policy in several ways. First, the diversity of components of MFP interventions results in challenges to comparing processes and outcomes across studies. The diversity of components also results in interventions being delivered by practitioners from various professional backgrounds and in different types of healthcare settings with various target audiences and goals. However, practitioners seek evidence on the effectiveness of their choice of components with MFPs so they can deliver the most effective and efficient intervention towards their healthcare and financial goals. The lack of evidence across MFPs points to the need to develop a more definitive evidence base about the components that provide the desired outcomes.

Policy actors in the healthcare system that seek to facilitate improved health outcomes through the MFP intervention can seek a stronger evidence foundation for the effectiveness of MFP interventions. Policy related to the MFP intervention in each type of setting (primary, specialty care, and tertiary), component set, and outcomes measured, resides within healthcare organizations that govern healthcare sites. These organizations, collectively, can promote standardization of component sets within specific types of settings, as well as outcome measures. Standardization of measurement time points post-intervention, as well as other aspects of the intervention, would assist in the development of an evidence base. Organizational policy work can facilitate additional research on MFPs using strong methodology, manualized MFP interventions, and common outcomes to assist in building a strong evidence base.

Gaps in practice settings

All four studies included in this review took place in outpatient clinic settings. Little research has explored whether individuals may benefit from MFPs located in other settings, such as inpatient and home settings. Due to the nature of the privatized healthcare system in the United States, financial stress may be a concern for those experiencing inpatient hospitalization. There may be an opportunity to explore the benefit of an MFP designed to assist individuals who are hospitalized, especially for those with chronic illness and their family members. Individuals who experience chronic illness may experience frequent hospitalizations that can lead to reduced income due to the physical symptoms of having a chronic illness, lost wages from employment due to absence, and medical bills from treatment (Ghazal et al., 2023). Current care as usual for these patients includes outside resource referral to community resources and to hospital financial services, which may alleviate the financial stress related to medical care and costs. However, hospital staff often do not have specific skills tailored to addressing the full scope of financial needs of their patients. MFP providers would have the opportunity to build long-term relationships with these patients and their caregivers, given the nature of repeated or long-term inpatient hospitalization, and therefore MFP interventions may provide the financial benefits desired.

Likewise, little research has been conducted on the use of MFPs combined with home health and visiting nurse settings. Home visits by nurses and other trained medical personnel have had positive health and social outcomes for medically and socially vulnerable populations, including low-income families and seniors (Lizano-Díez et al., 2022; Minkovitz et al., 2016). Typically, these services provide minimal material assistance such as infant or adult diapers, infant care supplies, and/or basic home health monitoring equipment. All other services, including financial assistance or coaching, are provided as referrals. MFPs made in conjunction with an established home health or visiting nurse model may achieve the desired financial benefits from the established ease of client access (due to previously established routine of home visits) and increased levels of trust and engagement afforded by associating with a client's known healthcare team.

Implications for research

The systematic review highlights several gaps in the evidence base for MFPs, pointing to important implications for future research. The limited number of studies, combined with the diversity of MFP components and services and the lack of consistent outcomes, underscores the need for a more rigorous and comprehensive approach to MFP intervention research. Future research should prioritize the clear description of MFP components and consider assessing different components separately within research designs to identify what works most effectively. This approach will enable a more nuanced understanding of how specific components contribute to health and financial outcomes. One of the key challenges in MFP research we identified is the lack of consistency in the outcomes measured across different studies. Developing a common core of outcomes for MFP interventions is essential to enable meaningful comparisons and meta-analyses. This core set of outcomes should include both health-related and financial measures that are universally relevant across diverse healthcare settings. By standardizing outcome measures, researchers can generate more robust evidence on the effectiveness of MFPs and identify the components that yield the most significant benefits. Another notable issue that could be addressed in future research is the lack of diversity of settings in which MFP interventions were implemented. This review found that all included studies were conducted in outpatient clinic settings, leaving a significant gap in understanding the potential benefits of MFPs in other healthcare environments. Future research should explore the implementation of MFPs in inpatient and home-based care settings, where financial stress may be more acute due to chronic illness and prolonged hospitalization. Investigating the impact of MFPs in these settings could provide valuable insights into how such interventions can be adapted to meet the needs of diverse patient populations and healthcare contexts. Finally, more and better research is needed in this area. Enhancing methodological rigor, including the use of RCTs and standardized time points for outcome measurement, will be crucial to building a strong evidence base.