Supplements Improving Patient Access to Critical Therapies in the Age of Cost Sharing
Practical Solutions When Facing Cost Sharing: The American Cancer Society's Health Insurance Assistance Service
The American Cancer Society (ACS) has been a leading voice for healthcare reform and an informed advocate for effective health insurance reforms. Since the implementation of the Affordable Care Act (ACA), the ACS has observed a shift in inquiries to its Health Insurance Assistance Service (HIAS) from individuals seeking coverage, to a growing problem of individuals presenting issues from being underinsured. Underinsured patients with cancer face serious financial challenges due to large co-pays and coinsurance costs. HIAS was created to help these patients identify potential options for insurance coverage while tracking patient trends.
The types of calls received by HIAS have been captured as part of an internal database that allows for the analysis of trends and emerging issues. By evaluating several case studies that illustrate common issues faced by underinsured individuals, we identified solutions ranging from exploring financial assistance programs, such as co-pay relief and providing appeal information, to searching for more adequate or affordable insurance options. Additionally, the ACS has worked to find strong partnerships with other nonprofit organizations to aid in cost relief.
Although the ACA has made plans available to many patients and their families, the maximum for an individual’s in-network out-of-pocket costs are still too high for many individuals. New approaches are needed to improve the cost protection of health plans. By documenting access problems faced by patients with cancer, the ACS is better positioned to tell policy makers about the concerns of real patients and work toward policy solutions.
Am J Manag Care. 2016;22(4 Suppl):S92-S94
Our nation’s healthcare system is one of the most expensive in the world, yet the quality of care we deliver to our citizens continues to lag behind that of other industrialized nations. The financial impact of a cancer diagnosis is often longer-lasting than the disease itself. Millions of Americans, with and without health insurance, face tremendous financial obstacles in paying for the direct and indirect costs associated with cancer treatment. To improve healthcare quality and reduce costs, the Affordable Care Act (ACA) takes steps to change the way we pay for and deliver healthcare in this country.
The American Cancer Society (ACS) has been a leading voice for healthcare reform and an informed advocate for effective health insurance reforms. Since 2005, the ACS has sponsored the Health Insurance Assistance Service (HIAS), a unique initiative to help patients with cancer navigate the private coverage system and to educate policy makers about how coverage works for patients with this serious and chronic condition. For patients who call the ACS National Cancer Information Center, HIAS offers a free resource that connects them with health insurance specialists who work to address their needs. Callers younger than 65 years who have insurance questions or problems talk to specialists who gather detailed information about each caller’s circumstances and offer information about options in his or her state. The program began with a limited number of states, but it now covers all 50, plus Washington, DC.
HIAS provides health insurance information and resources to over 2700 callers per year. The demographics of those served by HIAS disproportionately reflects the characteristics of more vulnerable or disadvantaged populations. Callers tend to be older, unmarried, under-/unemployed, and have very low incomes. Among unemployed callers, most are not working due to health reasons. Current insurance coverage for those contacting HIAS shows that 57% are uninsured, 26% are underinsured, and 17% are in transition. The resolution rate—that the individual was able to obtain insurance within 3 months (including Medicaid)—is only 20% for these individuals. The resolution rate was somewhat higher for callers who were younger, married, and working full time, and had higher incomes.
One of the lessons learned from our experience with HIAS was the power of using the “cancer lens” to explain and assess the nation’s healthcare delivery system to the media, policy makers, and the general public. Cancer is extremely complex and diverse; its detection, treatment and remission can test the limits of the medical system. Nevertheless, cancer resonates publicly because so many families and communities have been affected by the disease. Although the intricacies of the health system are easily lost on the general public, this group can readily understand that the delivery system should work for a cancer patient, and if it does not, then it is falling short of what it should be doing.
Since the implementation of the ACA, the ACS has observed a shift in inquiries to HIAS from individuals seeking coverage to a growing problem of individuals presenting issues with being underinsured. Underinsured patients with cancer face serious financial challenges due to large co-pays and coinsurance costs. It is worth noting the current trends in calls being received. Specifically, people contact HIAS for the following reasons:
They are unable to afford co-pays, monthly premiums, and deductibles to obtain and/or maintain health coverage.
- Facilities request cash up front before they will treat an uninsured patient.
- They have experienced the loss of employer coverage due to a layoff.
- They have coverage that is less adequate, less affordable, or unavailable.
- They think they have “good” insurance, but find they have huge out-of-pocket expenses and/or high deductibles. In some cases, the insurance plan is not adequate in covering one aspect of their cancer treatment.
Below are 2 examples of patients from HIAS, which highlight some of these cost-sharing issues:
Sandie. Sandie is a patient with breast cancer, and she contacted us regarding her coverage. Her breast cancer has recurred and her husband’s company pays toward the cost of health insurance for the family; however, she is experiencing frequent co-pays of $65 a visit. The family is enrolled in a PPO Silver plan with the Advanced Premium Tax Credit; they are over the income limit for cost-sharing reductions. Although Sandie was interested in exploring a different plan that might help her avoid some of the cost sharing she is experiencing, changing plans would result in a new annual deductible and could be more expensive than keeping her current plan. Staff focused on assisting Sandie’s needs around financial assistance for her co-pays and other costs associated with the breast cancer diagnosis. Our Cancer Resource Connection contains local and national organizations that can provide additional assistance to patients, depending on their needs. In this case, staff worked with Sandie to identify financial resources so that she could continue to go to her doctor and receive the care she needs.
Tammy. Tammy was diagnosed with breast cancer in July 2015. She faces several issues, including a cumbersome physician referral process, a limited network, a $4000 deductible, and high out-of-pocket costs. Her current plan may not cover a much-needed PET or MRI scan up front and may require her to pay the full cost until she meets her high deductible. Her plan has confirmed that certain bills will require payment prior to treatment while others will be billed at a later date; however, the plan is unable to give her guidance on what to expect regarding billing each treatment or test, as this will vary from each physician/facility. Although she has identified a surgeon for her treatment, she may not see the surgeon if her referring primary care physician does not have a contract with them—this may potentially delay her ability to obtain imaging and diagnostic tests and treatments.
Although Tammy is not interested in seeking new health insurance, the ACS offered to guide her through new coverage options if/when ready. In this case, HIAS staff focused on financial aid programs to help her with the costs of her treatment and care, as well as discussing changing her primary doctor if her ability to see her surgeon is limited.
Changes in health insurance have resulted in greater cost sharing through higher deductibles, co-payments, and coinsurance; we also know that cost sharing can affect a patient’s treatment decisions. For callers who were already covered, adequacy problems most often had to do with high cost sharing for covered benefits (24% of coded adequacy problems). Unaffordable co-pays and coinsurance were generally problematic, as well; for patients with cancer undergoing chemotherapy and radiation therapy, the per-visit cost sharing can quickly accumulate to unaffordable levels. According to a recent Commonwealth Fund report, 2 of 5 adults who had high deductibles indicated they had either delayed or avoided needed care because of the deductible.1
By evaluating several case studies that illustrate common issues faced by underinsured individuals, we identified solutions ranging from exploring financial assistance programs, such as co-pay relief and providing appeal information, to searching for more adequate or affordable insurance options. Additionally, the ACS has worked to find strong partnerships with other nonprofit organizations to aid in cost relief, but these are not ideal solutions and much is needed to better manage rising healthcare costs.
For patients with cancer and their families, there are significant implications connected to the level of health plan they choose. Choosing a health plan comes with some risk: those who are healthy may choose plans that aren’t adequate if they get sick. Higher-level plans (ie, Gold and Platinum) impose lower deductibles, co-payments, and coinsurance on individuals who use healthcare services, but also have higher monthly premiums. Conversely, Bronze and Silver plans are cheaper to buy, but as illustrated in our case studies, can expose patients to significant cost sharing over time. Individuals need comprehensive, easy-to-understand information about their options and the estimated cost sharing they will face.
Through reforms aimed at improving the comprehensiveness of coverage, we can ultimately reduce the number of Americans who are underinsured and the burden of being uninsured, as experienced by patients with cancer and their families. We should also be mindful of the rapidly increasing growth of healthcare costs and the impact of these high costs of care on patients and their families. Coordinated efforts to reduce healthcare cost growth are needed to ensure the affordability of both insurance and healthcare for working Americans.1
Although the ACA has made plans available to many patients and their families, the maximum for an individual’s in-network out-of-pocket costs is still too high for many individuals. This should not only be a concern for the patient and their caregivers, but also for the medical community and policy makers; new approaches are needed to improve the cost protection of health plans. By documenting access problems faced by patients with cancer, the ACS is better positioned to tell policy makers about the concerns of real patients with cancer and to work toward policy solutions.Author Affiliations: American Cancer Society, Atlanta, GA (KS), and Austin, TX (BS, MBS).
Source of Funding: None.
Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (KS, BS); acquisition of data (KS, BS, MBS); analysis and interpretation of data (KS, BS, MBS); drafting of the manuscript (KS); critical revision of the manuscript for important intellectual content (KS); statistical analysis (MBS); provision of study materials or patients (MBS); administrative, technical, or logistic support (MBS).
Address correspondence to: Katherine Sharpe, MTS, American Cancer Society, 250 Williams St NW, Atlanta, GA, 30030. E-mail: Katherine.firstname.lastname@example.org.