Bruce A. Feinberg, DO: I’ve heard from practicing physicians, and Ted, you can probably weigh in on frequency, that it is so common today to have a financial counselor in the practice; and that they were already doing that function, but it didn’t really advance the cause at all. If the doctor was already determining a net health benefit by some mechanism, and the financial counselor was then meeting with them to understand their personal financial situation, the framework—as applaudable as it is for what it tried to do—it doesn’t really advance our position.
Ted Okon, MBA: That’s right, and I think from a very practical level, that’s so true. Even in this day and age, small practices that are surviving basically have to have a financial counselor, or at least someone inherently that does that.
I was speaking with a practice administrator recently for a practice with 4 physicians, and it was really instructive. The practice administrator said, “Can you hold on for a second? I have to answer a question.” She took the phone, and she was, in essence, the financial counselor because they don’t have a dedicated person.
Obviously, in some big practices, they have teams of financial counselors. I think that’s an excellent point. Again, I look at it from a practical level. From a practical level, they’re already doing a lot of that. They have to because if not, the patient can’t get the medication or the patient is making the trade-off between groceries and medication.
Michael Kolodziej, MD: So let’s separate out the cost issues and the financial counselor role, and whether or not a physician is actually calculating a net health benefit. I think that’s a fallacy.
I talk to oncologists a lot, and sometimes they don’t like what I say. I would challenge them to tell me how they treated their last 10 metastatic lung cancer patients and what their partner did with the last 10. And the answer is, they don’t know. So tell me how they’re going to improve on that? They don’t even know what they’re doing at the beginning.
ASCO understands that what they have is an imperfect tool. But they are trying to develop a process by which they improve the inputs to get a better product. The separation of cost, because of the benefit design, looks at a Medicare patient differently than a commercially insured patient, and differently from a Medicaid patient. They put the cost in separate and they put the net health benefit in based on toxicity and efficacy. And they also realize that efficacy may be really important [to the patient], but maybe it’s not quite as important if they understand that they have a terminal illness.
Ted Okon, MBA: Quality of life, right.
Michael Kolodziej, MD: Maybe efficacy goes a little bit lower than progression-free survival.
Alan Balch, PhD: It still doesn’t address all the other costs—it’s only cost on the treatment side. From a patient perspective, if you want to have a cost conversation, if you’re not covering all those bases—from hospital costs, to transportation costs, to radiology (once you get past, sort of, the top 5 things in case management)—there’s a tie for first place among specialists and primary care visits to doctors, other medical providers, radiologists, anesthesiologists, etc; and then laboratory and prescriptions all sort of tie for fourth. Then, right below that is surgery and radiology.
So, if you’re not at least capturing the 5 or 6 things that patients identify as their primary sources of financial distress, especially for low-income patients, you’re not really having a comprehensive conversation about cost that’s going to mean something to the patient and help them with their financial situation.