One of the leading non-clinical attributes that affect how oncologists decide which therapeutic agent to prescribe over another is patient affordability. As more and more insurance benefit designs shift the costs of treatment to the patient, affordability will continue to grow as a significant factor that contributes to patient adherence.

“I was an oncology social worker for well over 10 years and I found that I was spending most of my time dealing with the patient’s financial distress,” said Daniel Sherman, MA, LPC, a licensed professional counselor. “The number 1 issue was financial.”

To emphasize that point, a recent survey of insured patients who were receiving treatment for breast, lung, or colorectal cancer demonstrated that financial distress and out-of-pocket costs have several consequences for patients: 70% of patients reduced leisure activities, 48% withdrew savings, and 18% sold possessions. This distress also may result in decreased compliance. As many oncologists can attest, the financial distress of cancer care can significantly affect quality of life and treatment compliance.

 were not part of a typical conversation between oncologist and patient 10 or 15 years ago, said Sherman. But with annual direct costs for cancer care projected to rise from $104 billion in 2006 to over $173 billion in 2020 and beyond, and the increased media attention to the financial burden of cancer care, stakeholders such as oncologists, patients, insurers, and the pharmaceutical industry are looking for ways to ease the financial burden that can accompany a cancer diagnosis.

If a practice is considering hiring a financial navigator there are some considerations. “Depending on the size of the practice and number of patients being seen, I would estimate that a full-time financial navigator can see about 800 new cases a year,” said Sherman.

For uninsured patients, navigators can (See Figure)

		Facilitate enrollment in health care exchange plans

		Help patients enroll in Medicaid/Medi-Cal programs

		Apply for social security and disability benefits on behalf of the patient

		Identify and aid the patient to apply for free medications

In many cases, according to Sherman, the biggest obstacle is convincing the practice’s management team that adding another full-time employee (FTE) is needed. He emphasizes that for patients, the main concern—after the fear of dying from the disease&mdash;is how am I going to pay for this treatment? “I have found that patients are eager to have this conversation,” he continued. “Especially if there are options to minimize their out-of-pocket responsibilities.”

Navigators can also identify external sources to help pay for treatment, including:

Hiring a financial navigator has a distinct effect on other employees within the practice, as well. “For the oncologist, it improves access to care for the patient. The nurses are thrilled because it decreases the patient’s distress. Oncology social workers are thrilled because it limits their case load.”

“I think the oncology community has finally caught up and recognizes this as a problem,” said Sherman. There are a number of financial assistance program options that a navigator can explore with his patient. This includes manufacturer-direct programs and programs that aid the underinsured or uninsured patient. Financial assistance programs are evolving and oncology practices place increasing value on them.

“Using patient assistance programs offered by the drug manufacturer can provide a temporary fix,” said Sherman. In addition to alleviating some financial distress, well-designed manufacturer-direct programs help keep prescriber decisions focused on clinical, rather than financial, considerations. “Another source of assistance are programs sponsored by foundations that can help with the patient’s out-of-pocket responsibilities.” Minimizing practice burden should be a key consideration in structuring program access, information, enrollment, and qualification. Developing strategies to support underinsured patients in the state exchanges will be essential to ensure continued access and adherence for this patient population.

For Medicare patients, helping them choose the Medicare plan that provides the best coverage is an important responsibility of the financial navigator. “It’s quite complicated to educate the patient about picking better Medicare plans,” Sherman said. The benefit, though, is that the patient has 100% of coverage and “is under so much less distress than what they were under before financial counseling.” In addition, oncology practices and hospitals aren’t forced to collect copayments or coinsurance from their Medicare patients.

Sherman points out that not every patient needs a financial navigator. Usually before the first consult, the navigator will review the patient’s insurance benefits package. If he notices a significant out-of-pocket responsibility or if the patient appears to be uninsured or underinsured, these are patients who might benefit from a discussion with a navigator. “It’s typically 25% of all patients who come through the door.”

Sherman would recommend bringing in the financial navigator on the day of the initial consult. “We know that our patients are coming with this concern, on the day of the consult they are concerned with diagnosis and prognosis. They quickly shift to ‘how am I going to pay for this?’ So you catch them immediately. And the earlier the financial navigator can get involved, the easier to find solutions by identifying appropriate aid programs, or educating the patient to choose better insurance. The faster you do this the better it is for the patient.”

In addition, on the day of the consult, “it’s typical that other family members are present as well,” said Sherman. “I love it when the family is present because I’m educating everyone at the same time.” And while educating the patient about the different benefits and plan designs, it might come to light that the patient cannot afford to pay an additional $50 or $100 a month. At this point, another family member, whether it’s a son or daughter, or if it’s the son or daughter with the diagnosis, the parent, might offer to help pay for the added premium. “That removes the financial burden from the discussion and the patient can focus on just receiving the treatment,” he said.

Another consideration is in this age of health reform, patients enrolled in “bronze” health plans have about a $6300 out-of-pocket responsibility says Sherman. “Many patients still don’t know that if they are below 250% of the federal poverty level, they can receive subsidies,” said Sherman. “But this only applies to silver plans. I’ve had patients who say they’ve picked the gold plan, thus reducing their out-of-pocket costs, only to discover that if they had picked a silver plan, they would have had an even smaller deductible because of the subsidies.”

He said, “There are some patients who are much better off because of reform. But there are some who are not better off. The majority are better, especially if they were uninsured.”

With the many advances being made in research and treatment, some types of cancers are being chronically treated. With that comes copayments, coinsurance, and other out-of-pocket expenses for patients. The role of the financial navigator is growing.

“It is a ‘must have’ service within oncology,” said Sherman. “Patients who don’t seek our help can suffer needlessly. There are so many things that can be done to decrease the distress to the patient. Patients are experiencing more financial distress than they have to,” he said.

Oncologists Respond to Financial Toxicity

Unfortunately, along with the distress that comes with a cancer diagnosis and the discomforts of treatment, more patients now have to deal with “financial toxicity,” the expense, anxiety and loss of confidence confronting those who face large, unpredictable costs, often compounded by decreased ability to work. Financial pain may extend beyond treatment. A recent study from the Centers for Disease Control and Prevention found that 30% of cancer survivors are not able to return to work, or have decreased ability to work. Annual medical expenditures increase by more than $4,000 for males who have had cancer and by nearly $3,300 for females.

Oncologists are helping their patients cope in a number of ways. For example, in the July issue of Cancer, a team of University of Chicago cancer specialists describe the first tool—11 questions, assembled and refined from conversations with more than 150 patients with advanced cancer&mdash;to measure a patient’s risk for, and ability to tolerate, financial stress. The researchers named their patient-reported outcome measure COST (COmprehensive Score for financial Toxicity).

Lead author, Jonas de Souza, MD, said, “We need better ways to find out which patients are most at risk. Then we can help them get financial assistance. If patients know what to expect, they may want their physicians to consider less costly medications.”

Souza is a head and neck cancer specialist at the University of Chicago School of Medicine. Medication cost is the prime contributor to financial toxicity and at the recent 56th Annual Meeting of the American Society of Hematology (ASH) held this past December, an expert panel came together for a frank discussion about this aspect of cancer care. Hagop M. Kantarjian, MD, professor, department of leukemia, University of Texas MD Anderson Cancer Center, Houston, kicked off the discussion with a provocative talk about drug pricing, squarely identifying the pharmaceutical industry. Kantarjian went on to point out that high out-of-pocket costs of cancer treatments are leading patients to personal bankruptcy, adherence issues, and mental stress. See our coverage of the panel discussion, “Healthcare Costs in Need of Solutions: Experts at ASH Agree.”

			de Souza JA, Yap BJ, Hlubocky FJ, et al. The development of a financial toxicity patient-reported outcome in cancer: The COST measure. Cancer. 2014 Oct 15;120(20):3245-53.

			Mariotto AB, Yabroff KR, Shao Y, et al. Projections of the cost of cancer care in the United States:2010-2020. J Natl Cancer Inst. 2011;103:117-128.

Articles

One of the leading non-clinical attributes that affect how oncologists decide which therapeutic agent to prescribe over another is patient affordability. 

When the Patient Can't Afford His Cancer Treatment

 To date, enthusiasm for bundled pricing has been associated with the Medicare Bundled Payments for Care Improvement (BPCI) initiative, which has consisted principally of cardiac and orthopedic procedures with a hospital inpatient component. But what about modifying the payment methods for oncology/cancer care? Is oncology next in line for alternate/bundled payment?

It now appears that, in fact, oncology is next up. In August 2014, the Center for Medicare & Medicaid Innovation (CMMI) released its preliminary design description for the Oncology Care Model (OCM), which is expected to be formalized in the form of a major new CMMI initiative in alternate payment for chemotherapy services provided to Medicare fee-for-service beneficiaries. This CMMI initiative can be expected to be a “call to action” in the transformation from fee-for-service to alternate payment methodologies in oncology.

		The goal is to utilize appropriately aligned financial incentives to bring about improved health outcomes, higher quality of care, and lower expenditures (“triple aim”).

		Financial incentives are associated with total medical cost of Medicare fee-for-service beneficiaries undergoing chemotherapy treatment over a six month episode.

		Two-part financial incentives are monthly per-beneficiary per month (PBPM) care management payment plus retrospective performance-based payment (“shared savings”), both in addition to traditional fee-for-service (FFS) payments.

		Participants will be “physician practices that furnish chemotherapy.”

		To be a “multi-payer model” to include other (commercial) payers working in tandem.

		Significant data and quality reporting requirements must be met (“Appendix A. Practice Requirements”).

		Is the definition of participant to be taken literally, that is, only private medical practices with a chemotherapy service can qualify for the OCM program? If so, what about the approximately 40% of community oncologists that are “practicing” in relationship to a hospital, or those that are employed by a hospital or by a hospital affiliated/captive medical group? Or those practicing in a contractual relationship with a hospital, such as professional services agreement (PSA), master services agreement (MSA), comanagement?

		In preliminary discussion with representatives from CMMI, it has been clarified that CMMI did not intend to exclude physicians/practices other than traditional private medical practices and welcome OCM applications from other forms of practice (hospital employed or contracted). And further, practices that do not furnish chemotherapy directly on their own account would not be precluded. The threshold determinant is only that the Medicare FFS patient can be “attributed” to the tax ID/provider number of the physician/practice.

		The amount of the PBPM payment to an OCM participant is to be based on the OCM participant’s estimated practice costs to furnish the OCM enhanced services. So, it appears that the PBPM payment will not be consistent across all OCM participants, but will vary by the participant’s cost structure.

What might be the range of acceptable PBPM payment?

		Two recent (summer 2014) program announcements may be instructive. First, WellPoint/Anthem announced its new “Cancer Care Quality Program” which pays a $350 PBPM amount for cancer care management and drug pathways compliance. CMS has proposed a new payment for Chronic Care Management of $41.92 per month effective in 2015. These two programs might establish a theoretical floor and ceiling for the range of OCM PBPM payment: $42 to $350, documented by the OCM participants actual costs.

Shared savings benchmarked to historic data

		OCM proposes to establish benchmark expenditure targets for a participant based on the participant’s historic data. Benchmarking based on a look-back to a participant’s historic cost performance will will not benefit those participants who have already been active in care management process re-design, such as oncology medical home and oncology ACO practices. But benchmarking based on historic claims data does benefit higher cost programs — there is theoretically a higher benchmark amount on which to achieve savings.

		In oncology, with the risk of the ever increasing costs of drug and new technologies, it would be preferable to benchmark against a regional or national norm for like services, not benchmark against oneself. There is some reference in the OCM that CMMI would “leverage regional or national data to increase precision for target prices for practices with a low number of episodes,” so perhaps there is some room for further deliberation of benchmarking based on market norms rather than benchmarking against oneself.

		The OCM program envisions that in addition to their arrangement with OCM, participants will also have a commitment for a similar alternate pay arrangement in effect with a commercial health plan. This multipayer requirement is intended to bring about payment transformation across the broader population (Medicare plus commercial). Many health plans have in place some form of alternate payment program in oncology (for example, UnitedHealthcare, Aetna, Humana, WellPoint/Anthem, most Blue Cross plans), so incorporating this multipayer element into an OCM application should be achievable.

Significant data and quality reporting requirements

		Appendix A to the OCM provides a rather comprehensive list of process and quality monitoring “Practice Requirements” that must be satisfied in order to participate in OCM. The Practice Requirements are similar to those of existing oncology accreditation/recognition programs, such as Commission on Cancer (CoC) accreditation (of hospital cancer programs), Quality Oncology Practice Initiative (QOPI) and the new NCQA Patient-Centered Specialty Practice recognition program.

		Adherence to the Appendix A requirements may prove to be too burdensome to implement and manage for many private practices. However, these types of process and quality monitoring activities are right in the wheelhouse of hospital programs.

		Is there a potential synergy between oncologist and hospital joint participation in OCM? For example, hospital assumes responsibility for the Appendix A Practice Requirements in exchange for a portion of the shared savings generated? What, if any, are the regulatory implications (Stark, anti-fraud & abuse or otherwise) of hospital and physician participation in the OCM shared savings?     

OCM “double dipping” with ACO shared savings program?

		Hmmm…what if a Medicare cancer patient attributed to an OCM program is already attributed by the patient’s PCP to a Medicare Shared Savings Program (MSSP) accountable care organization (ACO)? Wouldn’t that result in Medicare sharing the savings for the same patient twice?

		It would appear so and apparently CMMI has become aware of this dynamic and will be addressing it in the final form of the OCM program announcement.

		CMS/CMMI has received a number of responses to the OCM preliminary design from professional associations and individual stakeholders. On September 18, 2014 the American Society of Clinical Oncology (ASCO) issued a letter to CMS commenting that the CMMI-OCM was consistent with a number of important policy goals of ASCO’s payment reform model, Consolidated Payments for Oncology Care (CPOC). In its letter, ASCO offered observations and recommendations with regard to a number of CMMI-OCM features concluding that “to be meaningful, the incentives embedded in the OCM must reflect decisions that are under the control of the oncology practice, performance measures must be robust and applicable to the patient population and the overall system must reflect the variability in labor and resources required to treat individuals with cancer.” (See the ASCO in Action news item dated 10/1/14).

		We can expect that these and other nuances of the OCM program will be reconciled during the OCM Letter of Intent period (expected to commence by late October 2014). And regardless of the ultimate features of the OCM program, we expect that it will receive significant response from the oncology/cancer care sector and that it will represent a “call to action” in the transformation from fee-for-service to alternate payment methodologies in oncology.

Ronald Barkley, MS, JD, is President of the Cancer Center Business Development Group (CCBD Group) and National Co-Chair of the Cancer Center Business Summit.  He can be reached at rbarkley@ccbdgroup.com.

To date, enthusiasm for bundled pricing has consisted principally of cardiac and orthopedic procedures with a hospital inpatient component. Is oncology next in line for alternate/bundled payment?

Key Features of the CMMI Oncology Care Model (OCM)

In today’s age of health reform, more patients are finding themselves on the hook for out-of-pocket medical expenses. Helping cancer patients manage the costs of their treatment can improve adherence. Consequently, oncology practices can ease their patients’ financial concerns by connecting them to financial counseling services, as seen in the cover story this month, “

When the Patient Can’t Afford His Cancer Treatment

The Advisory Board Company, a global research, technology, and consulting firm, has provided tactics to help patients understand and manage their financial responsibilities. According to the company, the ideal financial navigation program helps patients understand the basics of health insurance and their own specific benefits. More than two-thirds of patients with cancer say they want to know their out-of-pocket costs before treatment. It’s this transparency that usually decreases their anxiety and increases the chances that they will pay for at least a portion of their care.

Practices should also identify and reach out to their patients who are eligible for new or improved health coverage. Coordinating the start of treatment with the start of coverage should be a goal in patient financial counseling.

Dan Sherman, the President and Founder of the NaVectis Group, which provides financial counseling services, says that even patients who have comprehensive coverage may struggle with out-ofpocket costs. But there are many external sources of financial support, with potential assistance coming from nonprofit organizations, pharmaceutical companies, and even individual donors.

An outcome measure to consider when providing financial counseling to patients with cancer is the COST (Comprehensive Score for Financial Toxicity) tool created by researchers from the University of Chicago. The 11-question tool measures a patient’s risk for, and ability to tolerate, financial stress. Researchers published their findings in the journal 

Lead author Jonas de Souza, MD, said, “Few physicians discuss this increasingly significant side effect with their patients.” The rationale for developing the tool was simple: “Physicians aren’t trained to do this. We believe that a thoughtful, concise tool that could help predict a patient’s risk for financial toxicity might open the lines of communication. This gives us a way to launch that discussion.”

The tool originally consisted of 147 questions but was eventually pared down to 11 short and easy-to-understand statements that are brief enough to avoid annoying patients but thorough enough to obtain the needed financial information. Learning how a patient responds may help clinicians determine who is likely to need education, financial counseling, or referral to a support network. The tool also can help predict who is likely to have problems and require some interventions. The University of Chicago researchers report that a larger study to validate these findings is underway, which will correlate the newly developed scale with quality of life and anxiety in patients with cancer.

The cost burden to patients with cancer is an outcome that requires assessment, and “measuring this toxicity is the first step towards addressing this issue,” said de Souza. “It’s another important piece of information in the shared decision-making process.”

Oncology practices can ease their patients' financial concerns by connecting them to financial counseling services.

January 2015 | Special Issues

When the Patient Can't Afford His Cancer Treatment

Key Features of the CMMI Oncology Care Model (OCM)

Cancer Treatment Has a New Side Effect- Patient Financial Toxicity