https://www.ajmc.com/journals/evidence-based-oncology/2017/patient-centered-oncology-care-2016/panel-presents-unique-cost-sharing-viewpoints-in-oncology-care
Panel Presents Unique Cost-Sharing Viewpoints in Oncology Care

Christina Mattina

DURING THE 5TH ANNUAL PATIENT-CENTERED ONCOLOGY CARE® MEETING, stakeholders with diverse experiences in the cancer care landscape discussed the effects of cost sharing during the panel, “Does Cost Sharing Influence Patient Adherence and Outcomes in Oncology?”

Moderator Joseph Alvarnas, MD, associate professor, Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, kicked off the discussion by referencing a “poignant and powerful” speech made the night before in which Allison Morse, a cancer survivor, discussed her experiences negotiating drug prices at the pharmacy and having to choose between paying rent or for her cancer medications. To begin the panel discussion, he turned to another patient advocate, Samantha Watson, MBA, founder and CEO of the Samfund, who explained the impacts of cost sharing from the perspective of the patient.

Watson explained that “when the burden of cost sharing falls too heavily on the patient,” it forces them to make “impossible decisions” between their financial health and their physical health. In her experience, most patients confronted with this choice will “incur the cost no matter what” by using a credit card, but some will decide to skip treatment altogether.

From a payer perspective, William H. Shrank, MD, MSHS, chief medical officer of the University of Pittsburgh Medical Center Health Plan, said that the harm and suffering experienced by patients in these instances result from “a blunt formulary without really thoughtful consideration about the clinical nuance.”

Jonas A. de Souza, MD, MBA, assistant professor of medicine at the University of Chicago, concurred that benefits must be redesigned to alleviate the out-of-pocket cost burden on patients. He compared cancer care to an iceberg, with financial issues like cost sharing being at the tip. “This tip is what will sink the ship,” he warned, by bankrupting patients and actually worsening their chances of survival.

As president of the Patient Access Network (PAN) Foundation, Daniel J. Klein, MHS, has seen the consequences of this “broken system” first hand. His organization helps patients navigate their high out-of-pocket (OOP) costs and provides financial assistance that allows 90% of recipients to initiate or stay on their cancer treatments. Without this safety net, however, there are many cracks that patients can fall through, even in programs like Medicare, Klein said.

Shrank added that although patient assistance programs sponsored by pharmaceutical companies are far from ideal, “there are a lot of stopgaps to help patients meet their needs if they know how to access them.” Watson agreed, but expressed concern that patients often do not access the significant amount of resources that are available to them. She argued that the disconnect between patients and resources indicates a much larger problem— that the OOP costs affecting patients’ treatment decisions are not acknowledged by the current system.

Acknowledging that charitable assistance can be difficult for patients to navigate, Klein said that a bigger issue is actually the ineffectiveness of cost sharing. Patients with cancer are not more likely to become better healthcare consumers when they are asked to pay a copay or deductible, he said. Alvarnas suggested that cost sharing could be used to improve the system by directing patients toward preferred pathways and prioritizing efficient drugs. Shrank agreed that cost sharing at its core is meant to work as a barrier, but that an alternative approach to value could instead reward patients for adhering to their treatment regimens, so “all of those pieces can fit into a rich, value-based contracting design.”

The idea that cost sharing could be used as both a tool and a barrier was reinforced by de Souza, who suggested providing incentives to patients for preventive services or palliative care while also discouraging low-value care. He also discussed the possibility of implementing dynamic benefit design, such as different OOP costs for the same drug based on its benefit for the patient’s specific condition.

Watson routed the discussion back to the patient’s point of view, saying that patients newly diagnosed with cancer may not be ready to discuss cost and value—rather, they may be more concerned with their chances of survival. “In that case, a lot of the legwork and decisions about value-based care need to be made behind the scenes,” she said, so that when patients are presented with their options, they are not making decisions based on cost.

Instead, providers should ensure patients are aware of options like social workers and financial assistance programs, which, she believes, can reduce the patient’s stress earlier and improve their ability to manage costs down the line. Both Shrank and Klein agreed with the importance of having a robust case management system to help patients navigate the day-to-day challenges of oncology care. According to Klein, however, the lack of reimbursement for case management remains a challenge.

Shifting the conversation back to cost sharing, Klein talked about the need to educate policy makers that patients with serious illness should not be treated the same as a “regular patient,” where cost sharing is used as a tool to keep premiums low or to get patients to choose less expensive treatment options. Patients with cancer will not want to be asked questions about treatment choices, as they instead look to their healthcare provider to direct them to the best treatment.

Shrank agreed that current formularies are not constructed with the unique needs of cancer patients in mind. It may also be more difficult to quantitatively demonstrate to payers the effectiveness of eliminating cost sharing because the oncology medications are expensive and will not be able to prevent subsequent hospitalizations. Instead, payers are more likely to respond to the argument that eliminating cost sharing will result in better quality of care and improved patient experience.

To wrap up the panel discussion, Klein looked to the future, saying that those looking to overhaul the healthcare system need to “understand that not being thoughtful in the near term could leave a lot of people with challenges in terms of getting access to their treatment.” He encouraged providers, payers, and patients to work together to increase education and transparency, encourage a rational benefit system, and maintain critical safety nets.
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