Kristin Jenkins

June 06, 2017

CHICAGO — Escalating drug prices and fast-multiplying insurance copays and deductibles have put some patients with cancer in the untenable position of having to discontinue potentially life-saving care or otherwise face bankruptcy.

So why aren't more oncologists helping patients understand the financial implications of various treatment options by discussing out-of-pocket (OOP) costs? A new study shines some light on the complex social and ethical issues behind this deafening silence.

Clinicians need third-party support to provide patients with cancer accurate estimates of OOP costs and financial aid, first author, Erin Aakhus, MD, an instructor in the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, said in an interview with Medscape Medical News. They also need training on how to disclose personal and professional conflicts of interest so they can stop worrying about harming the doctor–patient relationship.

"The major recommendation is that practices need to increase the financial expertise that they employ," Dr Aakhus told Medscape Medical News. "Third-party experts need to be available to patients and physicians to help facilitate accurate OOP cost estimates and early referrals to financial support programs and financial support expertise."

Although the number of patients who actually stop treatment or take fewer drug doses than recommended is relatively low, millions of people are affected by the financial risks of treatment, Dr Aakhus pointed out. Studies have shown that increasing OOP costs are causing real physical and financial harm to patients and that almost half of patients on Medicare are spending 50% of their income on treatment.

"I interviewed patients who could no longer pay for their children's university, who had their children in high school get a job," Dr Aakhus said. "I talked to elderly patients who had to move in with their adult children because they could no longer afford to live in their own home."

More recent studies show patients with cancer and other chronic medical conditions are at increased risk for bankruptcy, and organizations such as the American Society of Clinical Oncology have encouraged members to discuss OOP costs with patients "for years" to help patients avoid financial hardship and choose higher-value care, she noted.

Study Details

The new study was presented here at a poster session on June 5 at the American Society of Clinical Oncology (ASCO) 2017 Annual Meeting.

To explore the barriers to discussing the financial risks of cancer treatment, the study authors interviewed 22 patients with cancer and 19 healthcare providers at the Abramson Cancer Center at the University of Pennsylvania and three affiliated community practices between August 2015 and May 2016.

The results show that although both patients and clinicians didn't want to make tradeoffs between financial and physical health outcomes, patients feared they would be "profiled" on the basis of their ability to pay. At the same time, physicians expressed concern that the doctor–patient relationship could be negatively affected if they disclosed personal or institutional conflicts of interest. More practical barriers for clinicians included time constraints and difficulty providing accurate cost estimates.

"I think that physicians need to disclose their conflicts of interest the same way they would with their colleagues or at a professional meeting," Dr Aakhus said. "Patients really want their relationship with their doctors to be open and honest and need to be aware of this."

With the exception of clinicians who are salaried (and thus have no disclosures to make), physicians aren't trained to make disclosures to patients in a comfortable way, she acknowledged. This needs to be integrated into residency and medical school training as part of physicians' overall communications skill set, Dr Aakhus said. "It's a complex field, and we need to increase training and exposure of younger physicians to having these discussions."

The issue of patients with economic vulnerabilities feeling "profiled" can be avoided by having routine conversations about ability to pay for treatment with each and every patient. "Being aware of some of these issues from both the patient and providers side is a start," she said. "I don't think we talk about it enough."

Meanwhile, patients' attitudes toward the doctor's role in discussing OOP costs varied substantially. Some patients said they had concerns about their physician being distracted by this additional responsibility, while others were eager to discuss various treatment costs with their doctor. Factors that increased the odds of an open exchange included a strong doctor–patient relationship and nearby support staff with financial expertise.

"With implementation of OOP cost transparency, oncology practices will need to consider patient/provider aversion to financial/health tradeoffs, patients' sensitivity to socioeconomic 'profiling,' provider- and practice-level financial incentives, time constraints, accuracy of cost estimates, and variability in patient preferences," Dr Aarkhus and colleagues conclude. "Meanwhile, strong provider-patient relationships and availability of support staff will facilitate OOP cost transparency."

The study was funded by the Young Friends of the Abramson Cancer Center and the Conquer Cancer Foundation. The study authors have disclosed no relevant financial relationships.

American Society of Clinical Oncology (ASCO) 2017 Annual Meeting. Presented on June 5, 2017. Abstract 6597.

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