Addressing Financial Toxicity With Patients and Health Systems

Financial toxicity in health care, particularly cancer care, has been a growing issue in the United States and the world that organizations are tackling across many formats, according to a panel at the Advanced Topics for Oncology Pharmacy Professionals Summit.

Patients are preoccupied with the financial burden of rising cancer care costs, Fumiko Chino, MD, radiation oncologist, Memorial Sloan Kettering Cancer Center, explained by highlighting the results of a 2018 survey in which slightly more people were worried about the financial burden of their cancer care than of dying from cancer (57% vs 54%).

“So, this is something that is really a concern for our patients,” she said.

The issue of financial toxicity in cancer care has become a more popular research topic, with findings appearing in the “upper echelons of research,” such as in New England Journal of Medicine, and in lay media.

Chino knows firsthand about the devastating effects of financial toxicity. After her husband received a cancer diagnosis and throughout his treatment, they experienced the overwhelming burden of bills for his cancer care. Even after he died, she was hounded by debt collectors for the cost of his treatment, “and it’s the reason why I went to medical school and the reason why I’m so passionate about the work.”

The common misconception is that financial toxicity is simply “high costs,” but it’s more than that. It is a patient-facing problem related to the cost of their care, and patients with cancer are more likely to face it. Even patients who have health insurance feel the burden and are left with debt.

Financial toxicity is driven by a few factors:

• Overall rising health care costs. In 1970, health expenditures were $74.6 billion, which climbed to $1.4 trillion in 2000 and $3.3 trillion in 2015, Chino pointed out, adding that it’s clearly “unsustainable.”
• More costs are pushed onto patients. While the median monthly price of new cancer treatments has sharply increased since 1995, patients' median monthly income has essentially stayed flat. In addition, many patients are underinsured, and the insurance they do have is not enough to pay for their treatment.
• More people are being treated in the United States for cancer. Sometimes this increased treatment is not for their benefit, Chino said. There is overdiagnosis and overtreatment of diseases that might not ultimately affect a patient’s mortality. Chino said she had an 80-year-old patient tell her that after catching her low-risk breast cancer, she had a double mastectomy, and it saved her life. “And in my mind, I’m like, ‘I’m not sure if that’s actually true,’” Chino admitted.
• Clinical and technological advances. New medical technology is very expensive but not always good quality or cost effective. The clinical benefit of some new medications is “stagnant or decreasing,” but the costs continue to rise. “Each new drug on the market is not adding a commensurate benefit for the cost,” Chino said.

Financial toxicity decreases quality of life (QOL), patient satisfaction with care, and even the quality of care, Chino said. While it may seem obvious that patients with a lot of financial problems are much less likely to rate their QOL as good, it’s also true that financial toxicity can shift a patient’s satisfaction with their care.

“Ultimately, costs erodes the quality of care that’s received,” Chino said. There becomes an adherence problem. A survey found that 22% of patients didn’t fill a prescription due to cost, 14% skipped doses to make medications last longer, and 5% skipped, took less, or didn’t fill their chemotherapy prescriptions.

When someone receives a cancer diagnosis, their risk of bankruptcy increases 2.65 times, and a bankruptcy after a cancer diagnosis is associated with a 79% increase in mortality risk. “Our treatments are causing quality-of-life decreases, quality-of-care decreases, huge financial burdens, and we’re actually killing some people,” she said.

Financial toxicity does not affect all patients equally, however. Research has shown that 1 in 20 Black or Latina women with early-stage breast cancer, which is completely treatable and curable, lost their home.

“Our treatments are making some people homeless,” Chino said. “That is untenable in the United States today.”

Financial navigator Daniel E. Sherman, MA, LPC, who is also a consultant with The NaVectis Group, followed Chino to discuss how to address financial toxicity. Treating financial toxicity needs to move to a place where it is part of the treatment plan for a patient instead of the patient just being referred to a financial counselor or social worker.

He has helped to implement a financial navigation program in more than 50 hospitals across the country and has seen that while hospitals usually have financial counselors, they don’t have clinical knowledge, don’t understand the diagnosis or the treatment plan, and their tools consist mostly of trying to get the patient on Medicaid or qualified for a hospital charity program.

The problem is that the majority of patients don’t quality, Sherman said. “What are we doing with the severely underinsured that doesn’t quality for charity or Medicaid?”

Financial advocacy that uses co-pay assistance and patient assistance program aren’t actually fixing the problem of financial toxicity—they’re just putting a band-aid on the problem, he said. These programs often focus on a treatment modality, but that doesn’t address all the other costs patients are faced with.

“We know that when patients come in, there are a lot of things that need to be put in place first before the interventions are done,” he said. For instance, they need a biopsy, surgery, to be hospitalized, etc.

Financial navigation looks at the issue differently and tries to educate patients on the extremely complicated health care system in the United States so they can move from being underinsured to more fully insured. Successful financial navigation services require a deep understanding of the health care system, which consists of:

• Government safety net programs, like Medicaid and the Medicare Low-Income Subsidy
• Health insurance policies, such as Medicare parts A, B, C, and D; the insurance marketplace; and commercial insurance
• External assistance programs, such as patient assistance, co-pay assistance, premium assistance, basic needs assistance, and transportation

In addition, financial navigators need to have disease knowledge and treatment process, including progression, treatment modalities, treatment plans, length of treatment, and toxicities.

As a financial navigator, Sherman sees the patient on the day of their consult, because research has shown the patient is already coming into the system highly anxious about cost of care.

“I can count on 1 hand—maybe 4 times—when the patient said, ‘This is not a good time,’” Sherman said. “Most patients want to talk about this.”

He provided a case scenario of a 45-year-old single woman with 2 minor children making $58,000 annually who received an ovarian cancer diagnosis. She would need 6 months of chemotherapy, during which she cannot work. She has 3 months of short-term disability and is enrolled in a silver marketplace plan that costs $653 a month with a $6800 deductible and $17,100 maximum out-of-pocket (OOP) cost.

“What do you think that’s like?” Sherman asked. “Can you imagine the level of stress that this person is experiencing?”

He knows that marketplace insurance is based on a projected income, and her income was about to go to $0, so he called up and was able to get her monthly premium to $149 a month. In addition, her children went onto Medicaid. Her new maximum OOP costs was $2500 and her deductible was $400.

In addition, he found a foundation for ovarian cancer that paid health insurance premiums and he was able to bring it down to $0 a month, plus get her a little charity assistance on OOP.

“It’s fixing the insurance for the individual,” Sherman said. “That’s what financial navigation does.”

Finally, Ryan Haumschild, PharmD, MS, MBA, director of pharmaceutical services, Winship Cancer Institute, Emory University, explained that financial toxicity also plays a huge rule for institutions, not just patients. “There’s a ton we can do for the patients, but how do we focus on decreasing costs in the system?”

There are strategies to reduce expenses that have been around for a while, such as formulary management, medication use evaluations, inventory management and medication carrying costs, and manufacturer programs.

“Pathways, to me, are the future of care delivery,” he said. This is a shared decision-making framework that provides evidence-based care for similar outcomes and a predictable drug spend.

Emory treats patients in a large geographical area, and pathways were crucial to ensure patients were seeing different practices of care after different sites of care. For a patient, they were left with a challenging decision: travel the 50 miles to the academic medical center, where they had to find parking, navigate the building, and wait at a clinic that’s probable running behind schedule or go to a local practice that’s a lot easier for them to get to.

The center tried to “blow up the model” and “give the best outcomes possible regardless of where you’re treated,” Haumschild said.

He also highlighted the use of electronic medical records (EMRs), which can be used to drive care with a few features:

• Order sets that drive best practice treatment protocols. EMRs allow Emory to build out pathways that align with the prior authorization and precertification team and links out to foundation support for patients, as well as steward patients along the way during their treatment.
• Product selection. The cost-effective therapy can be the primary treatment option. If there is an available biosimilar, then they can provider “great efficacy at a reduced cost,” Haumschild said.
• Exceptions process. With documentation of process, when a lot of exceptions are requested, they can go reevaluate the pathway to determine if it’s the right one.

There are ways health systems can decrease cost without compromising clinical efficacy, such as through incorporating a pharmacoeconomic review when discussing formulary additions, understanding payer preferences, optimizing treatments when there are multiple indications, and considering the use of biosimilars.

Moving toward value-based care requires creating consistent practices; providing better or best outcomes to patients; incorporating evidence-based practices; considering the total cost of care, and not just the acquisition cost of the drug; providing innovative contracting; aligning prescribing with a strategic approach instead of one-off preference; and aligning the financial for patients and the organization to reduce spend across the health care system, Haumschild said.