At the 2017 ASCO Quality Care Symposium, Dan Sherman, MA, LPC, discussed potential solutions to the persistent challenge of financial toxicity in the oncology setting. Mr. Sherman is a clinical financial consultant and Founder and President of The Navectis Group, Caledonia, Michigan. Rather than focusing on the drivers of cost, Mr. Sherman stressed the importance of identifying the core material and psychological needs of the patient and how they are affected, on multiple layers, by financial toxicity.
Oncology Care Model
The Oncology Care Model is an innovative payment and delivery program developed by the Centers for Medicare & Medicaid Services, which is designed to improve the effectiveness and efficiency of care. Mr. Sherman displayed a slide of the 13 case management requirements designated by the Oncology Care Model, from diagnosis through survivorship plans, and noted that 12 of the 13 requirements will impact the patient from a financial standpoint. “Many patients have told me that they have more anxiety over the cost of treatment than over dying of their disease,” said Mr. Sherman.
According to Mr. Sherman, another important part of care is providing the patient with estimated costs. Some facilities do that well; others do not. “If we provide a patient with expected costs of their treatment but don’t have effective solutions for their financial burden, we need to begin thinking about the psychological ramifications as we move ahead with treatment,” said Mr. Sherman.
To illustrate the depth of the problem of financial toxicity, Mr. Sherman pointed to a study in which 42% of insured cancer patients experienced a significant or catastrophic financial burden,1 and another study found that patients with high copays (more than $54) were 70% more likely to discontinue treatment within 6 months.2 “And in the world of Medicare, the probability of experiencing an out-of-pocket burden that’s at least 20% of a patient’s income is 75% higher for Medicare oncology patients compared to beneficiaries without cancer,” said Mr. Sherman.
To identify a core problem behind financial toxicity, Mr. Sherman referenced Oncology Roundtable, a firm that uses research and technology to improve health-care organizations, which found that most individuals who provide financial navigation services in the hospital oncology setting only have a high school diploma. “We are expecting undereducated individuals to perform work that is highly complicated. Consequently, there is a widespread lack of competency among financial navigators, which impacts the vulnerable cancer patient who is looking for financial relief,” said Mr. Sherman.
Proactive vs Reactive
Mr. Sherman characterized our current financial navigation as a reactive process, one that begins when the invoice for treatment services goes out to the insurance company, taking up to 90 days before the patient has the bill in hand. At that point, he said, the patient is already in distress and struggling with financial toxicity. “We proactively deal with the toxic side effects of cancer treatments, but we often treat patients without regard to their financial toxicity, which in effect becomes an untreated side effect,” said Mr. Sherman.
Mr. Sherman told the audience that the oncology community needs to take a proactive approach to this situation by improving the skill levels of financial navigators, combining the clinical needs of the patient with his or her financial circumstances, improving communication between the provider and the patient, and optimizing insurance coverage and external assistance programs. “There is no certification process in place for financial navigators, and to me that is unacceptable,” he added.
Many patients have told me that they have more anxiety over the cost of treatment than over dying of their disease.— Dan Sherman, MA, LPC
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Mr. Sherman noted that while lecturing on financial toxicity, he uses a particular case history to demonstrate the intricacies of financial navigation: A 71-year-old married man was diagnosed with stage IV colon cancer. He and his wife had a monthly gross income of $1,590, with $10,000 in total assets. The treatment cost for 1 year was about $350,000, and the patient’s responsibility was approximately $40,000. He has Medicare A, B, and D only.
When he asks his audiences what this patient’s best option is, most people say that the patient should drop his $10,000 in assets and go on Medicaid with a cost-sharing program, which would be better than having Medicare A, B, and D only. Mr. Sherman agrees that Medicaid would offer a better solution, but he noted that the $10,000 in assets was the couple’s security and safety net, arguing that a financial navigator with expert knowledge of the Medicare system could develop an even better plan for the patient.
For instance, there is a low-income subsidy program that reduces out-of-pocket expenses for oral medications, but it also provides open enrollment into a Medicare Advantage Plan. Mr. Sherman explained that once the patient’s insurance has been optimized, then the advisor can look at the external assistance programs, such as co-pay assistance foundations that will reduce the out-of-pocket expenses for the patient. Furthermore, utilizing the Medicare Savings Program raises this couple’s income by $2,900, per year.
“Under this scenario, we have an estimated $43,000 saving to the patient and $40,000 for the provider. By putting the patient on Medicaid, we would have created additional financial toxicity by putting a Band-Aid on the sore instead of curing the patient’s problem,” he said.
Mr. Sherman emphasized that financial toxicity is on the rise, and the Oncology Care Model is going to force this issue into the oncology community’s conversation, urging providers to begin serious doctor-patient conversations about the costs of care and developing a plan to help patients address their financial concerns. “I’m going to argue that it is time for oncology providers to acknowledge the depth of this problem and begin to train high-quality financial navigators to address this issue with their patients. This is an opportunity for oncology providers to improve their patients’ experience and also capture better revenue flow,” said Mr. Sherman. ■
DISCLOSURE: Mr. Sherman is Founder and President of The Navectis Group, which educates health-care providers about patient financial navigation services.