Expert Urges Discussions with Patients About Treatment Costs

Patients with cancer are paying more now for treatment than they ever have before, and are draining retirement savings, selling homes, and cutting back on essentials such as food and clothing to make ends meet, according to a recent presentation by S. Yousuf Zafar, MD, MHS, at the Association of Community Cancer Centers 2015 Annual Meeting in Arlington, VA.

Studies have shown that these circumstances affect patient well-being, quality of life, and adherence, said Dr Zafar, Associate Professor of Medicine, Duke University Medical School, Duke Cancer Center, Durham, NC, and providers should be taking steps now to address this issue of financial toxicity with their patients.

“As you think about the physical toxicity of your patients, and how we engage our patients on physical toxicity, also consider their financial toxicity,” Dr Zafar told the audience. “The time has come to stop describing this problem of financial toxicity. Now we need to start intervening.”

To demonstrate his point, Dr Zafar shared a case study about a male patient who was diagnosed with localized rectal cancer at a young age. Although the patient was insured, he did not have prescription drug coverage, and had paid for his oral chemotherapy out of pocket. He tolerated treatment well, and did not demonstrate physical toxicities associated with his treatment. However, at the end of his treatment, his cancer had metastasized.

At first unaware of his patient’s coverage status, Dr Zafar discussed further treatment options with the patient, and was surprised and concerned when the patient expressed hesitation about moving forward. When pressed, the patient explained that he did not have prescription drug coverage, and had incurred substantial debt to pay for his oral chemotherapy.

“He had a job, and he had insurance, but he had no prescription drug coverage,” Dr Zafar said. “He paid for all that medicine fully out of pocket. Because I didn’t ask him the simple question of whether he has prescription drug coverage, I caused him to incur thousands of dollars in medical debt.

This patient taught me an impor­tant lesson, and that lesson is that it’s very difficult to identify patients who are at risk of financial toxicity.”

Dr Zafar cited 2 reasons why patients may be paying more now for their cancer therapies than they used to: the cost of treatment has increased substantially over the past several years, and the amount that patients are asked to pay toward the cost of their treatment (ie, cost-sharing) has also increased. More specifically, he noted that the price of 1 month of chemotherapy has jumped from roughly $100 in 1970 to $10,000 in 2010,1 and a survey from the Kaiser Family Foundation documented that deductibles, premiums, and worker contributions to premiums have been rising sharply since 1999.2 In addition, a connection between high out-of-pocket costs and nonadherence to prescription medicine—for example, patients not taking their drugs as prescribed, filling part of their prescriptions, or not filling their prescriptions at all, in order to save money—is documented in the literature, he said.

“Then there’s the form of cost-sharing that I think is most relevant to our patients, and that’s tiered formularies,” said Dr Zafar. “Cancer patients have no choice but to reach for that top-shelf drug. As a result, they incur more costs out-of-pocket for a drug that is potentially life-saving and that patients are on for years.”

A significant part of the remedy, he believes, involves educating the patient population; this includes educating them on basic concepts about health insurance and healthcare such as copays and deductibles; and educating them about their diagnosis, prognosis, and treatment options. It is also important, he said, to look at the costs of treatment as well as new payment models. Finally, it is essential for providers to open the discussion with patients about costs. Acknowledging that oncologists have a lot to cover during a patient’s appointment, he advised that referring the patient to assistance programs or a financial counselor may be enough to help reduce costs without affecting the course of treatment.

“The important thing I tell oncologists is that we’re not alone in this. We have a lot of people we can turn to who can help patients find the resources,” he said. “But it is often our job to take that first step and let patients know that this is okay to talk about. Otherwise they may never do it.”

Dr Zafar also described a system he helped design called FinANCE—Financial Assistance, Navigation, and Communication Education—that focuses on educating patients about healthcare and finances. This includes video-based and interactive content on how patients can talk to healthcare providers about cost containment and resources for financial assistance, as well as a screening tool for financial distress. A pilot test of 15 patients with cancer who were randomized to use FinANCE and another 15 controls showed that the majority of those using FinANCE found it helped with their financial concerns, reported Dr Zafar. Furthermore, almost all of those using the system reported that it improved their knowledge about financial aspects of cancer care and what can be done about it. His team aims to engage financial counselors as well as more providers in the discussion of costs.

Dr Zafar urged the audience to consider financial toxicity as an important part of the treatment discussion, and to be open to broaching a discussion with patients about the costs of care. Noting conversations he has had with financial counselors and social workers who help patients with cancer, he said, “It is much easier to help a patient find financial resources before they incur medical debt than it is to dig them out of that debt. We need to identify patients, and we need to identify them early.”




References

  1. Memorial Sloan Kettering Cancer Center. Center for Health Policy & Outcomes. Cost of cancer drugs. www.mskcc.org/research/health-policy-outcomes/cost-drugs. Accessed April 8, 2015.
  2. The Henry J. Kaiser Family Foundation. 2013 Employer Health Benefits Survey. http://kff.org/private-insurance/report/2013-employer-health-benefits/. Published August 20, 2013. Accessed April 8, 2015.

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