As the cost of cancer care continues to rise, it’s not just the patients’ finances that are affected. Recent research has linked high out-of-pocket costs to nonadherence and early discontinuation of treatment.
Disclosing the financial risks of cancer treatment to patients, however, may be easier said than done. According to a study from Penn Medicine, patients’ fear of socioeconomic profiling and doctors’ conflicts of interest are barriers to routine bedside conversations about cost.
“Despite the clear financial toxicity that patients are experiencing, they have many concerns about how increased knowledge about cost could influence how their prescribers make clinical decisions,” said Erin Aakhus, MD, an instructor in the Perelman School of Medicine at the University of Pennsylvania.
“There was also a concern about socioeconomic or sociodemographic profiling,” Dr Aakhus observed. “Patients worried that increased awareness or frequency of discussions about out-of-pocket cost might lead to discrimination that would result in worsening disparities.”
For this qualitative study, Dr Aakhus and colleagues conducted interviews with 22 cancer patients and 19 providers at Penn’s Abramson Cancer Center and 3 affiliated community practices between August 2015 and May 2016. As Dr Aakhus reported at the 2017 ASCO Annual Meeting, analysis of interviews revealed several pragmatic barriers to cost transparency, with time constraints a major concern. Physicians acknowledged the difficulty in providing accurate cost estimates to patients in a timely manner due to the complexity of billing and insurance design, said Dr Aakhus, who emphasized that physicians’ schedules are already constrained as it is.
“Trying to get accurate cost estimates for patients can be a burdensome process, and it’s not something that a lot of physicians feel is feasible in a workday,” she explained. “Furthermore, compared to efficacy and toxicity, cost transparency was not the highest priority for either patient or provider.”
In addition, analysis showed an aversion to making financial/health trade-offs. Especially with regard to a life-threatening disease, said Dr Aakhus, patients worried that considering the value between 2 regimens might lead to inferior care. Both patients and providers also expressed concerns about financial conflicts of interest (ie, the underlying motivation of the cost discussion).
“I was surprised by how often I heard that,” said Dr Aakhus. “Providers were worried about patients misinterpreting their intentions and assuming that there was a direct financial benefit to a given recommendation.”
This fear was not necessarily misguided, however, as several patients cited drug kickbacks and improper prescriber incentives as a cause for concern.
“If the first thing on the doctor’s mind is cost, that gives me the impression that’s all he’s interested in—the money part of it,” one patient noted.
“I know that there are drugs that the doctor will prescribe and get a kickback,” another patient mentioned.
So, in an ideal world, how would cancer patients like to receive cost information? According to Dr Aakhus, it depends on the patient. The researchers identified substantial variability in patient preferences for the timing and context of cost discussions. Some patients preferred to discuss financial concerns with their oncologist, Dr Aakhus said, but many shared a preference to discuss them with a third-party financial expert or advocate.
“Although some patients felt that learning about the costs of treatment during an initial consultation might be overwhelming mentally or emotionally, many others indicated that they would prefer to know as soon as possible to help them plan their budgets,” the authors noted.
Given these differences of opinion, said Dr Aakhus, a 2-pronged approach is needed to facilitate out-of-pocket cost transparency: having both a strong patient-provider relationship and knowledgeable support staff on hand to ease some of the burden for physicians.
“Few oncologists discuss these costs routinely with their patients,” she reported. “However, we found that doctors who had good support—nurses or financial navigators—felt more comfortable having the conversation because they could rely on a third party to follow up with specific numbers.”
Dr Aakhus and colleagues plan to follow up this qualitative study with more quantitative analysis, namely, a survey of a larger patient population.
“We’d like to identify those factors that stand in the way of making cost transparency acceptable and feasible for providers of cancer care and then use this framework to develop and test practical, scalable interventions that improve communication about costs between patients and their providers,” she concluded.