Factors Associated With Oncologist Discussions of the Costs of Genomic Testing and Related Treatments

K. Robin Yabroff; Jingxuan Zhao; Janet S. de Moor; Helmneh M. Sineshaw; Andrew N. Freedman; Zhiyuan Zheng; Xuesong Han; Ashish Rai; Carrie N. Klabunde

Disclosures

J Natl Cancer Inst. 2020;112(5):498-506. 

In This Article

Abstract and Introduction

Abstract

Background: Use of genomic testing is increasing in the United States. Testing can be expensive, and not all tests and related treatments are covered by health insurance. Little is known about how often oncologists discuss costs of testing and treatment or about the factors associated with those discussions.

Methods: We identified 1220 oncologists who reported discussing genomic testing with their cancer patients from the 2017 National Survey of Precision Medicine in Cancer Treatment. Multivariable polytomous logistic regression analyses were used to assess associations between oncologist and practice characteristics and the frequency of cost discussions. All statistical tests were two-sided.

Results: Among oncologists who discussed genomic testing with patients, 50.0% reported often discussing the likely costs of testing and related treatments, 26.3% reported sometimes discussing costs, and 23.7% reported never or rarely discussing costs. In adjusted analyses, oncologists with training in genomic testing or working in practices with electronic medical record alerts for genomic tests were more likely to have cost discussions sometimes (odds ratio [OR] = 2.09, 95% confidence interval [CI] = 1.19 to 3.69) or often (OR = 2.22, 95% CI = 1.30 to 3.79), respectively, compared to rarely or never. Other factors statistically significantly associated with more frequent cost discussions included treating solid tumors (rather than only hematological cancers), using next-generation sequencing gene panel tests, having higher patient volume, and working in practices with higher percentages of patients insured by Medicaid, or self-paid or uninsured.

Conclusions: Interventions targeting modifiable oncologist and practice factors, such as training in genomic testing and use of electronic medical record alerts, may help improve cost discussions about genomic testing and related treatments.

Introduction

The costs of cancer care have been rising in the United States,[1–4] increasing concerns about medical financial hardship for cancer patients and their families. Many cancer survivors have difficulty paying medical bills, face high levels of financial distress, and delay or forgo medical care because of cost.[5–11] Recent trends in health insurance benefit design, including increasing patient cost-sharing, with higher deductibles, copayments, and coinsurance rates,[12,13] can increase financial burden even among those with health insurance. Uninsured patients can be responsible for the entire cost of cancer care.

High patient out-of-pocket costs for cancer treatment have been the subject of many discussions in the scientific literature[1,12,14–17] and popular press.[18–20] In 2009, the American Society of Clinical Oncology highlighted the important role of oncologists in discussions about the expected patient out-of-pocket costs of cancer care.[21,22] The Institute of Medicine later identified these discussions as an element of high-quality care,[22] and cost consciousness has been proposed as a core competency for medical education.[23] Although oncologists generally agree about their responsibility for cost discussions,[24] these discussions are rare.[24,25] Nevertheless, most cancer patients desire discussions about expected out-of-pocket costs,[24] highlighting an unmet need for informed treatment decision making in cancer care.

Discussions of patient out-of-pocket costs are especially relevant when considering the increasing availability of molecularly targeted therapies for specific tumor variants. As of 2016, more than 200 targeted therapies were available in the United States and more than 2000 are in late-stage development.[26] More than half are in oncology. Targeted therapies have high list prices, frequently in excess of $100 000 annually.[27–29] Genomic tests to identify targetable variants can also be expensive[30] and are not always covered by health insurance. Even with health insurance coverage, cancer patients face cost-sharing for genomic testing and treatment, as high as 30% of the list price for tests and treatments.[13] Discussions about expected costs of genomic testing and related treatments may inform treatment decision making and help cancer patients prepare for high expenses. However, little is known about how often oncologists discuss costs of genomic testing and related treatment with their patients or about the physician and/or practice factors associated with those discussions. In this study, we address these research gaps by analyzing data from a nationally representative survey of oncologists about their cost discussions with cancer patients and identify potentially modifiable factors associated with the frequency of cost discussions.

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