The Financial Impact of Cancer Care: Implications and Potential Solutions
Veena Shankaran, MD, MS
A 56-year-old insured woman with metastatic colorectal cancer presents to you for consultation. She has received multiple prior therapies since her diagnosis 2 years ago, but has continued to experience progression of disease and deterioration in functional status. She sees you in consultation and is eager to “try anything” that might allow her to have more time with her children. You recommend an oral multikinase inhibitor, which has been shown to improve median survival by close to 6 weeks in a randomized phase 3 study of patients with refractory metastatic colorectal cancer. She agrees to this approach, and you prepare a prescription. Unbeknownst to you, the pharmacist, or your clinic staff, she goes to fill the prescription and discovers that her out-ofpocket responsibility for a month’s supply of medication is $1870. She charges the initial payment to 3 different credit cards, including one belonging to her 24- year-old son. After 3 months of treatment (and $5610 paid out-of-pocket), she develops significant toxicities and progressive disease, at which point she is enrolled in a hospice care program.
This clinical vignette highlights many flaws with the way treatment cost information is handled in most oncology practices in the United States. First, this example illustrates a failure of the shared decision-making model. Neither the patient nor the treating physician was aware of the high out-of-pocket cost associated with the prescribed drug; therefore the treatment decision was made in the absence of complete information. Next, lack of transparency about costs may have led to missed opportunities for financial assistance. While upfront knowledge of the $1870 per month coinsurance may not have changed the physician’s recommendation or the patient’s decision, it might have prompted the care team to look for patient assistance resources to reduce or eliminate the out-of-pocket payment. Finally, lack of a mechanism to identify and address this patient’s financial concerns, in real time, may have prevented the patient from planning in advance for her bereaved children’s financial well-being.
In this article, we will address the growing problem of “financial toxicity” in cancer care, the impact of financial toxicity on a patient’s well-being, and potential strategies at the patient and clinic or hospital level to mitigate the financial burden of cancer treatment.
RISING COST OF CANCER CARE
As the cost of cancer care in the United States continues to rise at an unprecedented rate, cancer patients are strug-gling to pay their share of the bill. Cancer care represents one of the fastest growing segments of healthcare spending; median cancer drug prices alone have risen from $962 in 1989 to $7112 in 2009.1,2 In response to rising cancer care costs, many health plans have shifted some costs to patients in the form of higher co-payments, deductibles, and premiums. The proportion of employee health plans with multitiered prescription formularies (3 or 4 tiers) has steadily increased from roughly 25% in 2000 to nearly 80% in 2013.3 Estimates from the 2014 Commonwealth Fund Biennial Health Insurance Survey indicate that 23% of adults aged 19 to 64 years were underinsured, meaning that out-of-pocket costs (excluding premiums) equaled 10% or more of household income.4 The 2010 Patient Protection and Affordable Care Act (ACA) has increased access to quality health insurance, but has not removed financial risk in the context of a major health shock like cancer.
With respect to rising cancer treatment costs, increased cost-sharing schemas, and economic instability in recent years, many reports have shown that patients with cancer are facing a variety of financial challenges following diagnosis. In a recent study investigating financial outcomes of 550 colon cancer patients in western Washington state, nearly 40% reported experiencing at least one of the following after-cancer diagnosis: borrowing money from family or friends, a minimum of 20% income decline, accrual of debt, or selling their primary residence.5 In another study linking US Bankruptcy Court records with records from the Western Washington Surveillance, Epidemiology, and End Results registry, patients with cancer were found to file for bankruptcy at significantly higher rates than similar patients without cancer (hazard ratio [HR], 2.65; 95% CI, 2.51-2.80).6
Importantly, financial problems following diagnosis may be critical, but underappreciated drivers of observed disparities in treatment adherence and health outcomes among cancer patients. In a follow-up to the bankruptcy study discussed above, bankruptcy filing was associated with a higher risk of death among cancer patients, after adjusting for age, gender, cancer stage, and treatment using propensity score matching (HR, 1.79; 95% CI, 1.64-1.96).7 Studies have also shown an association between high co-payments for cancer drugs and lower adherence to therapy. Among Medicare Part D enrollees, a $10 incremental increase in oral cancer drug co-payment was associated with a 13% to 20% increased likelihood of treatment discontinuation.8 High monthly co-payments for tyrosine kinase inhibitors have also been shown to be associated with a greater risk of treatment discontinuation compared with low co-payments (relative risk [RR], 1.42; 95% CI, 1.19-1.69).9 While not specifically addressed in these studies, nonadherence likely translates into poorer clinical outcomes.
Addressing the problem of financial toxicity requires a comprehensive approach with commitment from multiple stakeholders. In recent years, the oncology community has come together to lobby for lower pharmaceutical prices, a crucial step in addressing the growing financial burden faced by cancer patients and their families.10,11 We propose several other potential strategies at the patient and clinic or hospital level to address the problem, focusing on missed opportunities highlighted in the earlier clinical vignette.
Improve Cost Transparency
The shared decision-making model is based on full disclosure of risks, benefits, and alternatives to a particular treatment strategy.12,13 In oncology, patients are often given very thorough information about physical side effects and clinical benefit (usually in terms of median survival). However, patients are often unaware of their financial liability for treatment until well after a clinical decision has been made, often at the pharmacy window or after receiving a bill in the mail. We argue that upfront information about out-of-pocket treatment costs might help patients make more informed decisions, including decisions to forgo subsequent-line palliative chemotherapy when clinical benefit is low and financial burden is high. True cost transparency requires engagement from payers and a system, not only to generate real-time cost estimates, but to deliver these estimates in an appropriate context to physicians and/or patients.
Improve Access to Financial Assistance
Identification of high copayments and coinsurance before a prescription is filled or a treatment is administered not only informs the clinical decision-making process, but may also allow the clinic staff and pharmacy billing specialists to identify sources (through foundations or pharmaceutical companies) for copayment assistance or provision of free drug.14,15 Opportunities for assistance should be identified early and should be offered to all patients regardless of their perceived ability to pay, as financial circumstances can change quickly during the course of treatment.
Measure Financial Burden in Real Time
Patients who face major financial hardships, such as personal bankruptcy during cancer treatment, typically exhibit some earlier signs of financial vulnerability or strain. Yet, financial strain is rarely measured in clinical oncology practice on a routine and prospective basis. We argue that a proactive approach of measuring financial status, early and often, can help align patients with appropriate resources before they face more devastating financial consequences. In the era of widespread mobile phone and smartphone use across all racial and income groups, leveraging mobile technology to measure out-of-pocket expenses and financial vulnerability would be an appealing approach.
Provide Access to Financial Planners
Some of the strategies (eg, asset management, debt consolidation), which could help prevent cancer patients from facing devastating financial consequences, fall outside the purview of the healthcare profession. Oncology practices can help by connecting patients with trained financial planners who can help them budget for upcoming out-ofpocket expenses or plan for their family’s financial future.
Addressing the financial burden of cancer treatment requires efforts at the policy, payer, and clinic level to control soaring drug prices, improve cost transparency, measure financial toxicity, in real time, and align patients with financial assistance or counseling. Implementation of these strategies, in clinical practice, requires commitment from various stakeholders and a recognition that addressing the problem of financial toxicity is as important as addressing other side effects of cancer treatment. EBO