The burden of financial toxicity has become increasingly recognized in the US healthcare system over the past several years, according to Clara Lambert, BBA, Oncology Financial Navigator at Munson Medical Center in Traverse City, MI. “It has a huge impact, and it doesn’t only apply to people who don’t have insurance; now it applies to people who do,” she said at the 2017 Academy of Oncology Nurse & Patient Navigators (AONN+) West Coast Regional Meeting.
“This is a side effect of cancer care we’re very concerned is going to increase as time progresses,” said Lillie D. Shockney, RN, BS, MAS, ONN-CG, Program Director and Cofounder of AONN+. “Particularly with the recognition that the newer chemotherapy agents, targeted agents, and immunotherapies are going to be more expensive than what we’ve experienced in the past.”
The Underinsured and Uninsured
In 2014, 31 million people in the United States were underinsured, and 11% of privately insured adults had a deductible of $3000 or more, up from 1% in 2003. The underinsured have some health insurance, but not enough to cover medical expenses such as high deductibles, high out-of-pocket maximums, and large copays on specialty drugs.
Financial toxicity can be long lasting, and the extent to which patients are affected often depends on when in the time of their benefit year they are diagnosed. Out-of-pocket costs tend to display a strong seasonal effect, peaking in January when many patients face new calendar year deductibles. And as patients enter the survivorship phase and go through continuous testing and monitoring of their disease, the burden carries over.
“With the implementation of the Affordable Care Act (ACA), we saw a decrease in the uninsured and an increase in underinsured,” said Ms Lambert. In 2010, when the ACA passed, 20% of Americans were uninsured. As of 2016, that number was down to 12%.
Factors Driving Financial Toxicity
Patients and caregivers often live in and provide income to the same household. When both the patient and caregiver must take time off of work for cancer treatment, the household income is depleted. Even if the patient decides to work through treatment, he or she will likely suffer concern and anxiety about repeated time away from work, limited time off, potential job loss, and in the case of short-term or long-term disability payments, insufficient funds.
As of late, political uncertainty is adding to patients’ financial worries. Premiums are increasing, insurance providers are pulling out of the marketplace, and the fates of the ACA and the American Health Care Act are unknown. “Patients are concerned,” Ms Lambert said, stressing the importance of staying current on political topics pertaining to healthcare.
The Revenue Cycle
According to Ms Lambert, institutions should cultivate revenue cycle relationships. This initiates important communication concerning distress screening, financial programs, and referrals, thereby reducing rework and allowing for the revision of processes. “We’re always revising our processes, because everything is changing so much with patient finances,” she said.
Financial toxicity has actually started to affect clinical decision-making. Patients often push back on a treatment decision when they find out the cost might be more than they think they can afford, she noted. In one study of patients with cancer, 42% of participants reported a significant financial burden. When they experienced that burden, they made choices often detrimental to their health, such as partially filling prescriptions, taking less than the prescribed amount of medication, or using their savings to help cover out-of-pocket expenses.
“I think it’s important that healthcare providers know about the financial process and refer their patients to someone who can help,” she said. Compared with patients aged 55 years and older, research has demonstrated that younger patients (aged 25-54 years) are more often referred to patient support services for help with their financial distress. “This is a huge disparity, and I think one of the reasons for that is a lot of people over 55 grew up with more traditional health insurance,” Ms Lambert said. “It was provided and almost entirely paid by their employer, and out-of-pocket costs were significantly less. So they don’t even know they need to ask these questions about their financial burden.”
Implementing Financial Navigation
According to Ms Lambert, implementing a system of financial navigation can help patients significantly with the burden of financial toxicity. Because of oncology financial navigation, her cancer center has seen cost savings, increased revenue, and “very high” patient satisfaction. “The patient assistance we offer is more complex than what a financial counselor does,” she explained. Her team offers insurance optimization and education, financial assistance and advocacy, and transportation and lodging assistance. She encourages financial distress screening and advocates the use of the National Comprehensive Cancer Network Distress Tool.
Insurance education is important—particularly for the older generation—to help patients know and understand their benefits, she said. “At open enrollment time, it’s important to host community learning sessions about such topics as prescription plans and ACA marketplace programs,” Ms Lambert said. “It’s also important to have a Certified Application Counselor at your cancer center, and it’s pretty easy to become one.”
It is not always easy for financial navigators to provide patients with price transparency because prices so often fluctuate and insurance companies pay at different rates. “But I make an effort to include the patient’s benefit information in their price estimate, because it tends to make it less traumatic,” she said. “They can actually see what their insurance will cover, and if they wish, we can estimate their transportation and lodging costs for them.” Finally,
Finally, continuous investigation into new patient and community resources is vital to the role of the oncology financial navigator, Ms Lambert added.