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Impact of Trained Oncology Financial Navigators on Patient Out-of-Pocket Spending
Todd Yezefski, MD; Jordan Steelquist, BA; Kate Watabayashi, BA; Dan Sherman, MA; and Veena Shankaran, MD

Impact of Trained Oncology Financial Navigators on Patient Out-of-Pocket Spending

Todd Yezefski, MD; Jordan Steelquist, BA; Kate Watabayashi, BA; Dan Sherman, MA; and Veena Shankaran, MD
Hospitals that used trained financial navigators were able to provide financial assistance for their patients with cancer, providing access to care that would otherwise be unaffordable.

Objectives: Patients with cancer often face financial hardships, including loss of productivity, high out-of-pocket (OOP) costs, depletion of savings, and bankruptcy. By providing financial guidance and assistance through specially trained navigators, hospitals and cancer care clinics may be able mitigate the financial burdens to patients and also minimize financial losses for the treating institutions.

Study Design: Financial navigators at 4 hospitals were trained through The NaVectis Group, an organization that provides training to healthcare staff to increase patient access to care and assist with OOP expenses. Data regarding financial assistance and hospital revenue were collected after instituting these programs.

Methods: Amount and type of assistance (free medication, new insurance enrollment, premium/co-pay assistance) were determined annually for all qualifying patients at the participating hospitals.

Results: Of 11,186 new patients with cancer seen across the 4 participating hospitals between 2012 and 2016, 3572 (32%) qualified for financial assistance. They obtained $39 million in total financial assistance, averaging $3.5 million per year in the 11 years under observation. Patients saved an average of $33,265 annually on medication, $12,256 through enrollment in insurance plans, $35,294 with premium assistance, and $3076 with co-pay assistance. The 4 hospitals were able to avoid write-offs and save on charity care by an average of $2.1 million per year.

Conclusions: Providing financial navigation training to staff at hospitals and cancer centers can significantly benefit patients through decreased OOP expenditures and also mitigate financial losses for healthcare institutions.

Am J Manag Care. 2018;24(5 Suppl):S74-S79
Takeaway Points

The use of trained oncology financial navigators can increase access to care and save money for both patients and hospitals.
  • In the 4 hospitals studied, patients saved a total of $39 million over 11 years.
  • Patients, on average, received $33,265 in free medications per year and saved $12,256 through enrollment in insurance plans, $35,294 with premium assistance, and $3076 with co-pay assistance each year.
  • Hospitals saved $2.1 million annually on care that would have previously been provided as charity care or gone to bad debt.
After a cancer diagnosis, patients and families face many stressors, including the possibility of significant short-term and long-term financial consequences. Rising premiums, deductibles, coinsurance, and co-payments for oral oncology drugs, many of which cost over $10,000 per month, expose patients and families to significant out-of-pocket (OOP) healthcare spending. These direct medical costs, in combination with the indirect costs related to patients’ and families’ decreased work hours or loss of employment, create a perfect storm for financial devastation. Indeed, up to 75% of patients with cancer report experiencing high levels of anxiety or distress related to the financial aspects of treatment. Many patients, particularly younger, nonwhite, and lower-income individuals, experience significant financial setbacks, including accrual of debt and loans, loss of savings and assets, and personal bankruptcy, as a result of healthcare costs.1-5 Recent studies have shown that patients with cancer who experience financial hardship have a higher risk of treatment nonadherence, poorer quality of life, and higher mortality than those who do not experience such hardship.6-8 Efforts to mitigate the financial burden of cancer treatment are therefore desperately needed.

Many have argued that a critical step in addressing the financial side effects of cancer care is improving communication about costs between patients and oncologists.9 However, most oncologists fall short in providing adequate guidance to patients and families about financial issues. In fact, although a majority of oncologists feel that it is important to discuss how treatment may affect financial well-being, nearly one-third feel uncomfortable doing so and one-fifth do not think that cost should ever be considered when making treatment decisions.10 Improving cost communication between patients and oncologists is therefore not sufficient in order to truly address patients’ and families’ financial issues; clinics must either collaborate with outside organizations that have expertise in financial counseling and medical costs or invest in internal financial navigation resources to provide consistent and proactive financial support to all patients beginning at diagnosis.11 The latter model is appealing in that in-house navigators can work with other members of the team and access clinical information easily and quickly. Few such models for providing financial navigation within the clinical setting have been described. In practice, the work of financial navigation frequently falls on poorly trained staff who do not have the required education or credentials to be able to offer true expertise in dealing with the complexities of the insurance marketplace and treatment-related costs.11 Therefore, a high need exists to establish and evaluate the benefits associated with different types of oncology financial navigation models.

The NaVectis Group is a company that provides education and training to healthcare staff on how to improve patient access to financial assistance. Key components of the program include training staff who have higher levels of education, implementing systematic processes for identifying patients in need, obtaining or improving insurance coverage for patients, and using tracking software to quantify benefits. Here, we show that by instituting a financial navigation program using trained counselors, hospitals can save money that would typically have gone to bad debt, and patients can gain access to care that would otherwise have been unaffordable.


Patient Population

Four hospitals in the United States participated in this study and received training by The NaVectis Group to implement a financial navigation program. Three hospitals trained current employees, and the fourth hospital hired a new employee for the position. All patients with cancer seen at the hospitals were eligible to be seen by these NaVectis-trained financial navigators.

Data Collection

After training of staff by The NaVectis Group and implementation of the financial navigator program, de-identified information regarding the number of patients seen, number receiving assistance, types of assistance, and amounts of assistance were tracked annually. Each hospital instituted the program at different times, with Hospital #1 having 1 year of operation (2016), Hospital #2 having 3 years (2014-2016), Hospital #3 having 2 years (2015-2016), and Hospital #4 having 5 years (2012-2016). Only new patients seen in a given year were included in that year’s data.

Calculation of Cost Savings to Patients and/or Hospitals: Categories of Cost Savings and Assumptions

Free medication. In cases where free medication was provided directly to patients or to hospitals on patients’ behalf, we calculated patient cost savings as the amount that would have been charged to the patient by the hospital or pharmacy. Hospitals were either supplied with free medication on behalf of individual patients or were reimbursed for the cost of previously dispensed medication. In both cases, the benefit to the hospital was considered to be the acquisition cost of the medication.

Co-pay assistance. Cost savings from co-pay assistance were calculated as the total amount paid to hospitals to offset co-pays for medications and other services by patient assistance foundations or pharmaceutical industry programs.

Premium assistance. When hospitals paid insurance premiums for a patient, the benefit to the hospital was calculated as the amount of insurance reimbursement for the patient’s care minus the amount the hospital paid for the premium. As hospitals’ insurance payments for patient care are typically less than the initial charge, patient savings were calculated as the cost of the premium payments in addition to 150% of the insurance payments to the hospital, with a likely range between 100% and 200%.

Insurance enrollment. Financial navigators educated patients on insurance options and referred them to insurance brokers to help them enroll in insurance plans, including Medicaid, Medicare Part D, Medicare Supplement, Medicare Advantage, and Affordable Care Act (ACA) Marketplace plans. Based on prior data collected by The NaVectis Group, the patient benefit of enrollment in Medicare Supplement or Medicare Advantage was estimated to be $5000 annually, with hospitals receiving increased payments of $4000 and $2500, respectively. When hospitals helped a patient to enroll in a Medicaid or Marketplace plan, the benefit to the hospital was recorded as the value of the insurance payments to the hospital. The benefit to patients was estimated at 150% of the hospitals’ payments, assuming that direct-to-patient bills would be higher than the insurance negotiated rate, with a likely range between 100% and 200%. For Medicare Part D, the benefit to patients was recorded as the value of initial coverage under the Part D plan.

Marketplace maximization. Financial navigators helped patients in ACA Marketplace plans to obtain the highest level of coverage with the lowest OOP costs. Hospital #3 reported the actual cost savings to the patient and hospital, but for Hospitals #1 and #2, it was estimated that patients saved $2500 in OOP expenses from restructuring of their health plans and hospitals then received that same amount in insurance payments. Hospital #4 did not assist patients with Marketplace maximization. 

Community assistance. Patients frequently received assistance for other costs, such as transportation and medical equipment. This was reported as the actual amount that the patient received, with no benefit to the hospital.


A total of 11,186 new patients with cancer were seen across the 4 hospitals after financial navigation programs were instituted (Table 1). Hospital #1 was able to obtain financial assistance for 87% of new patients seen in the first year of the program, whereas other hospitals helped between 15% and 39% of new patients each year. There were differences in the number of patients helped in each assistance category (eg, free medication, premium assistance) among hospitals. For instance, Hospital #1 provided free medication to 15% of new patients in 2016, whereas fewer than 1% of patients at Hospital #4 received this benefit. All hospitals helped patients to enroll in insurance plans, with hospital #4 seeing a large increase, from 27 patients enrolled in 2013 to 174 in 2017, after they began helping patients to enroll in health insurance exchanges mandated by the ACA. Hospital #4 did not report data on community assistance or Marketplace maximization, in which financial navigators helped patients change to more appropriate coverage using healthcare exchanges.

Financial navigators saved patients a total of $39 million (range, $31-$47 million varying on the estimated cost savings) in the 11 total years of follow-up in the 4 hospitals. These savings consisted of help covering OOP costs, such as medications, co-pays, and insurance premiums, as well as helping patients obtain insurance and receive medical care that they otherwise would not have been able to afford (Table 2).

Medication costs were often covered by foundational support or drug companies, which allowed patients to save an average of $33,265 per year. Similarly, financial navigators helped patients access co-pay assistance programs, which primarily helped with co-pays for medications but also other types of care, totaling $2.5 million in assistance. All hospitals instituted programs in which they paid insurance premiums for patients who were unable to do so; this allowed patients to maintain insurance coverage that paid for their cancer care. This service provided $35,294 (estimated range, $23,529-$47,058) per year in care to patients. Financial navigators assisted patients in enrolling in insurance plans, such as Medicare Supplement, Medicare Advantage, Medicaid, and ACA Marketplace plans. As shown in Table 2, patients received medical care with an estimated total cost of $11,214,225 (range, $7,948,370-$14,480,079) or $12,256 (estimated range, $8687-$15,825) per patient annually as a result of gaining insurance coverage. Another service offered was helping patients to change medical plans and coverage through the ACA Marketplace plans in order to maximize coverage and minimize costs. Aside from direct costs of medical care, patients were frequently provided with community assistance to help with expenses like transportation, accounting for nearly $900 in aid per patient. As patient savings were only reported within the first calendar year after establishing care, it is probable that the total benefit to patients was much greater than these amounts, as many patients were likely seen for several years.

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