Financial Stress a Key Factor in Cancer Patient Care Plan

Marcia Frellick

May 20, 2018

WASHINGTON, DC — Patients with cancer are at a high risk for "financial toxicity," and nurses need to be equipped to talk to them about the financial aspects of their care, according to Teresa Hagan Thomas, PhD, RN, from the University of Pittsburgh School of Nursing.

It is not only the cost of treatment that contributes to financial stress; copays, lost wages, tolls, gas, transportation, food, parking, and childcare also play a role, Thomas said here at the Oncology Nursing Society 2018 Annual Congress.

And the problem is amplified in cancer patients because of the convergence of several factors: the higher cost of care, higher deductibles (including soaring expenses for new targeted treatments and immunotherapies), and a shift in care from community hospitals to hospital-based academic practices, which are often more expensive.

In addition, because cutting-edge oral chemotherapy is considered a prescription drug benefit, whereas intravenous chemotherapy is a medical benefit, coinsurance rates are higher for patients taking oral chemotherapies, she explained.

When we're looking at strictly monetary measures, estimates suggest that between one-fourth and one-half of all adult patients with cancer experience financial toxicity.

Estimates of the number of cancer patients living with financial stress vary, depending on the measurement used. However, "when we're looking at strictly monetary measures, estimates suggest that between one-fourth and one-half of all adult patients with cancer experience financial toxicity," Thomas reported.

Women are at higher risk for financial toxicity, as are young patients not yet eligible for Medicare and who do not have a large pool of assets, people in ethnic or racial minority groups, and patients with high deductibles. Skipping medications, focusing on cost of treatment, and wanting to change insurance are all warning signs of financial stress, she explained.

Research has shown that there is an association between financial toxicity and poor outcomes.

Although only about 3% of patients declare bankruptcy because of cancer care, doing so can affect mortality rates, Thomas said.

One study demonstrated that cancer patients in the state of Washington were, on average, about 2.5 times more likely to declare bankruptcy than people without cancer (J Clin Oncol. 2016;34:980-986). And patients who did declare bankruptcy were 80% more likely to die.

Barriers to Talking About Cost

Another study showed that 52% of adults with cancer wanted to discuss out-of-pocket costs with their doctor and 51% wanted their doctor to take costs into account when planning treatment, but only 19% had had such talks (Am J Manag Care. 2015;21:607-615). And when those discussions did happen, they lasted only about 30 seconds.

Given the time constraints on appointments, some patients are reluctant to bring up financial concerns, and they can find it embarrassing if they cannot afford the recommended treatment. Other patients might feel that financial discussions are irrelevant and are willing to pay whatever it takes to survive.

But either way, the total cost of treatment is often not available when care decisions need to be made, Thomas pointed out.

Patient wellbeing, health-related quality of life, and quality of care must be taken into account when the effect of financial distress is being considered, said Margaret Rosenzweig, PhD, also from the University of Pittsburgh School of Nursing.

When measuring financial distress or toxicity, we must standardize the metrics so that one researcher can build upon another researcher's findings, she noted.

Strategies to Help Patients

Patient navigation has proven to be an effective strategy for reducing cancer mortality, said Rosenzweig. "Why not apply this to financial navigation?"

She described four things that work well: asking patients about their worries; being transparent about costs (which can be difficult when providers don't have that information, she acknowledged); assessing distress; and knowing the referral systems.

Additionally, providers should know the value of the care they are delivering and be well versed on what is considered low-value care, she said.

Choosing Wisely recommendations from the American Society of Clinical Oncology target low-value care to decrease costs.

One recommendation suggests that one-drug chemotherapy be used instead of combination chemotherapy for the treatment of metastatic breast cancer, unless the patient needs a rapid response to relieve tumor-related symptoms.

Another suggests the avoidance of routine screenings, routine PET scans, and the routine use of growth factors, which can drive up costs.

However, even when the concerns of the patient are addressed, the structural problems of poor coverage and the cost of treatment remain, Rosenzweig pointed out.

After 48 years of oncology practice, this is probably the most significant thing I have done — bringing everybody together and looking at the whole situation.

Representatives who help patients at infusion centers with financial matters have been hired at the Beaumont Health System, which serves the greater Detroit area, said Josie Garnoc, MSN, RN, who is director of infusion services there.

As part of the insurance verification process, for example, they can look for copay assistance for a patient's medications, which can amount to "thousands of dollars," she told Medscape Medical News.

Also at Beaumont, financial concerns, along with documentation on chemotherapy management and staging, are entered into the Beacon oncology module of the Epic electronic health records system, said Jeanne Parzuchowski, RN, a nurse navigator for survivorship at Beaumont. That gives all providers a broad picture of the patient in real time, before, during, and after treatment.

"If a social worker or financial adviser has evaluated the patient, it will go into one document and it will start a story, which will be built on as it connects with family practice and internal medicine," she told Medscape Medical News. All providers "can see the snapshot of that person and their family before the treatment even starts."

A healthcare provider can then see if a patient is missing treatment sessions or radiation appointments because of transportation or childcare issues.

"This is how we're identifying and closing gaps in the system," said Parzuchowski. "After 48 years of oncology practice, this is probably the most significant thing I have done — bringing everybody together and looking at the whole situation."

Thomas, Rosenzweig, Garnoc, and Parzuchowski have disclosed no relevant financial relationships.

Oncology Nursing Society (ONS) 2018 Annual Congress. Presented May 19, 2018.

Follow Medscape Nurses on Twitter @MedscapeNurses and Marcia Frellick @mfrellick

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