Financial Support Models: A Case for Use of Financial Navigators in the Oncology Setting

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“Financial Support Models: A Case for Use of Financial Navigators in the Oncology Setting”

by Daniel E. Sherman and Kristen L. Fessel

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Background: Financial toxicity causes significant psychological and practical distress for patients and can affect their ability and willingness to undertake optimal treatment. Although different models of financial support are typically available to patients undergoing cancer treatments, not all models can offer equal amounts of support and effective solutions, particularly to those patients at the highest levels of risk for this toxicity.

Objectives: This article discusses the two most prevalent models available to healthcare institutions to provide financial support (financial counseling and financial advocacy) and makes recommendations for implementation of a more comprehensive, proactive financial navigation model.

Methods: This article reviews current and emerging financial support models.

Findings: Financial toxicity is on the rise, and the financial navigation model shows promise in decreasing the number of patients experiencing financial hardship.

Impact of trained oncology financial navigators on patient out-of-pocket spending

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Abstract:

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.

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Financial Navigation for People Undergoing Cancer Treatment

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View online PDF here: Financial Navigation for People Undergoing Cancer Treatment

INTRODUCTION

The impact of cancer goes far beyond its physical effects. Many cancer patients endure significant financial and personal hardships because of the high costs associated with cancer treatment. High cost- sharing requirements, especially for those who are uninsured or underinsured, as well as reduced income during and after treatment, can lead many to experience financial distress or toxicity—defined as the adverse impact on a patient’s well-being due to out-of-pocket healthcare costs related to cancer treatment.

In November 2016, the Michigan Cancer Consortium (MCC) held its annual meeting, during which the topics of financial toxicity and financial navigation were discussed. The discussion piqued the interest of health system representatives who asked for more information about the need for financial navigation programs and how to develop and implement such programs. The Michigan Department of Health and Human Services, with members of the MCC Survivorship Workgroup, formed the Financial Navigation Subcommittee to address these questions. The subcommittee comprises hospital administrators, financial navigators, and members of the MCC Survivorship Workgroup. A list of the members is available in Attachment A.

The following white paper, which describes the purpose and benefits of comprehensive financial navigation programs, is the result of the subcommittee’s work. This paper offers information on cancer prevalence and treatment costs, the effects of financial toxicity, current approaches to financial counseling, and comprehensive financial navigation as a promising practice that can provide benefits to patients and health systems. It also provides examples of successful financial navigation programs in cancer centers, hospitals, and health systems in and outside of Michigan to give those interested in implementing such programs a sense of the potential benefits for patients and health systems alike.

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Transforming Practices Through the Oncology Care Model: Financial Toxicity and Counseling

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American Society of Clinical Oncology

“Transforming Practices Through the Oncology Care Model: Financial Toxicity and Counseling”
by Dan Sherman

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In the last 5 to 7 years, a significant amount of research has been performed on the experience of financial toxicity in the oncology setting. Studies by such researchers as Yousuf Zafar,1 Scott Ramsey,2 and Jonas A. de Souza,3 to mention a few, have successfully shed light on the this growing problem; however, to date, little work has been done to find effective solutions for this financially vulnerable patient population.4 We could argue that the problem at hand is multidimensional. Responsibility should fall on providers, patients, pharmaceutical companies, politicians, and payors alike. This article will focus on the provider responsibilities that seem to play a part in the growth of financial toxicity for the oncology patient.

Financial toxicity often results in decreased treatment adherence5 as well as a decrease in overall sense of wellbeing.6 This should not be surprising, as we understand that a person’s financial stability or instability has significant ramifications on their physiologic and emotional wellbeing. From a psychosocial standpoint, Maslow’s theory of the hierarchy of needs plainly established that if a person’s basic needs and his or her sense of security is threatened, the person will likely be unable to experience wellness. When a person is diagnosed with cancer, the provider focus is on the medical needs of the patient and less expert attention is provided to the basic and security needs of the patient. Yet consideration should be given to provide expert guidance on both the medical and financial concerns of the patient on the basis of a survey conducted by the Community Oncology Alliance that found that Americans fear the costs of cancer care as much as they fear dying from the disease.7 Patients often experience difficulty in maintaining employment; decreased income; loss of employer-based health insurance; increased expenses, such as transportation and caregiver assistance; and the increasing out-of-pocket responsibilities that are likely to be incurred with pending treatments. Financial toxicity often takes hold as a result of a lack of expert guidance on these issues. In addition, many Americans do not have a cushion of savings to cover unexpected expenses. A study by Bankrate.com8 found that 57% of Americans would not be able cover an unexpected bill of $500. When considering these factors, it is easy to understand why so many oncology patients experience some level of financial toxicity.

The following are four opportunities that will help alleviate financial toxicity in the oncology setting:

  1. Increase the commitment to the role of financial advocacy. Although oncology programs across the United States have demonstrated the financial and practical value of having a financial advocate in place,9 providers continue to be slow in investing in the role10 (Fig 1). The responsibilities of the job often fall to low-paid staff members who do not see the role as a favorable career path, or it falls in the laps of social workers or front office staff who have had no specific training to provide such a service to patients. Furthermore, the role will often focus on benefit and prior authorization processes that result in the neglect of the patient who needs help navigating our complex health insurance systems.
  2. Establish certification and education requirements for the financial advocate role. All disciplines within the medical field—physicians, nurses, dietitians, social workers, physical therapists, etc—have standard education and certification processes in place before they are allowed to practice their skill on patients. In fact, the provider can incur huge liabilities if these requirements have not been fulfilled; however, to date, there are no standards or certification requirements in place for financial advocates that are employed within the health care system. Research completed by the Oncology Roundtable11 has found that 45% of financial advocates in the oncology setting have only a high school diploma, 37% have an associate’s degree, 26% a bachelor’s degree, and only 14% a master’s degree (Fig 2). We ask undereducated staff to deal with the number one concern of oncology patients. We ask them to solve multifaceted problems within a health insurance system that is the most complex system on the planet. The United States health care system has changed dramatically in the last 10 years, with the creation of Medicare Part C and D and the Affordable Care Act. These massive systems have complex enrollment and entitlement guidelines that few financial advocates understand on an expert level.
  3. Increase physician engagement in understanding the dynamics of financial toxicity. Oncologists have proven themselves effective in dealing with the many adverse effects of chemotoxicity; however, research12 suggests that few oncologists feel comfortable broaching the topic of financial distress with their patients. Financial toxicity is a true adverse effect of treatment; therefore, oncologists should be prepared to have discussions with patients and the financial navigation team to identify the best treatment options in the context of the pending financial toxicity the patient will experience.
  4. Improve processes to identify patients in need. In most hospital oncology programs across the United States, financial advocacy services are located outside of the oncology department. Patients are referred to these services rather than the services coming to the patient. As a result of this, little to no communication occurs between providers regarding the details of the patient’s diagnosis, prognosis, and treatment plan. The financial advocate is then treating the patient blindly and offers the same conveyer belt solutions to all patients who are referred. Our current process of intervention also tends to follow a reactive approach. We treat, bill, and then deal with the financial toxicity experienced by the patient (Fig 3). This should be reversed. We should anticipate and prevent financial toxicity, then treat the patient. In other words, we should provide competent financial navigation services before incurring medical debt for the patient.

It is important for providers to understand that financial navigation is complex and that it impacts the patient from both a practical and psychological standpoint. As a result of the complexity of financial toxicity, there is increased potential for providers to underestimate the psychological damage that occurs once financial toxicity takes hold. When we read the work of Zafar, Ramsey, and de Souza, as well as reports provided by national organizations, such as Kaiser Family Foundation,13The Community Oncology Alliance,7 Association of Community Cancer Centers,14and Cancer Care,15 we can acknowledge that, as a whole, the oncology community has failed to effectively deal with the experience of financial toxicity for a significant portion of the oncology patient population. A pertinent question, therefore, is what level of responsibility should the provider have in addressing these issues, and at what level of expertise should they be intervening?

The following is a case scenario that illustrates the point:

D.T., a 71-year-old married male is diagnosed with stage IV colon cancer. His monthly household gross income is $1,590 and he has $10,000 in assets. He has Medicare Parts A, B, and D only. His treatment regimen includes surgery followed by bevacizumab, oxaliplatin, and oral capecitabine for 12 months, along with antinausea and pain medications. He will also need palliative radiation treatments. His total treatment cost for 1 year is estimated to be approximately $350,000, and the patient responsibility is estimated to be approximately $40,000.

In most hospital settings across the United States, financial advocates would assist this patient in applying for both Medicaid and charity; however, in most states, these interventions would do more harm to the patient than help. He would likely qualify for Medicaid, but not without some spend-down responsibilities. He would be required to spend down his $10,000 in assets to below $3,000. This intervention, which occurs daily across the United States, harms the patient’s financial security needs as the $10,000 in assets provides a significant security blanket. This patient will be a classic statistic of financial toxicity; however, a financial navigator with an expert knowledge of Medicare would lead this patient down a completely different pathway. He qualifies for several entitlement programs that would not only optimize his health insurance but increase his monthly income. By navigating the Medicare Savings Program as well as the Low-Income Subsidy program, this patient can be moved from a $40,000 responsibility down to as little as $0 out-of-pocket responsibility, and his income would increase by more than $200 a month. This becomes a win for the patient and the provider.

The Oncology Care Model is putting in place the 13 components of the Institute of Medicine’s Care Management Plan requirements, most of which will influence the patient’s sense of financial wellbeing. Informing the patient of his or her diagnosis, prognosis, length of treatment, and treatment benefits and harms, as well as providing an estimate of the total and out-of-pocket costs of treatment all heavily impact the patient’s financial sense of security or wellbeing. Asking an untrained and noncertified financial advocate to address these complex circumstances is unfair to both the financial advocate and the patient. With the implementation of the Oncology Care Model, physicians and financial advocates need to be better prepared to deal with the many ramifications of financial toxicity. Unfortunately, personnel in most health care systems do not have the skill level to do this, and as long as that continues, financial toxicity will continue to plague the oncology patient population. Oncology providers across the United States should invest in improving the skill level of their financial advocates and navigators, which would result in improved patient experience, revenue capture, and reduced financial toxicity.

Copyright © 2017 by American Society of Clinical Oncology

REFERENCES

1. Zafar SY, Peppercorn JM, Schrag D, et al: The financial toxicity of cancer treatment: A pilot study assessing out-of-pocket expenses and the insured cancer patient’s experience. Oncologist 18:381-390, 2013 Crossref, Medline, Google Scholar
2. Ramsey S, Blough D, Kirchhoff A, et al: Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. Health Aff (Millwood) 32:1143-1152, 2013 Crossref, Medline, Google Scholar
3. De Souza J. A., Yap B. J., Wroblewski K, et al: Measuring financial toxicity as a clinically relevant patient-reported outcome: The validation of the COmprehensive Score for financial Toxicity (COST). Cancer 123:476-484, 2017 Crossref, Medline, Google Scholar
4. Zafar SY: Financial toxicity of cancer care: It’s time to intervene. J Natl Cancer Inst 108:djv370, 2015 Crossref, Medline, Google Scholar
5. Kaisaeng N, Harpe SE, Carroll NV: Out-of-pocket costs and oral cancer medication discontinuation in the elderly. J Manag Care Spec Pharm 20:669-675, 2014 Medline, Google Scholar
6. Fenn KM, Evans SB, McCorkle R, et al: Impact of financial burden of cancer on survivors’ quality of life. J Oncol Pract 10:332-338, 2014 Link, Google Scholar
7. Community Oncology Alliance: Americans fear paying for cancer treatments as much as dying of the disease. Oncol Times 31:16-17, 2009 Crossref, Google Scholar
8. Steiner S: Bankrate.com: Survey: How Americans contend with unexpected expenses. http://www.bankrate.com/finance/consumer-index/money-pulse-1215.aspx Google Scholar
9. The Advisory Board Company: Cancer patient financial navigation: Helping patients manage their costs while protecting program margins. https://www.advisory.com/research/oncology-roundtable/studies/2014/cancer-patient-financial-navigation Google Scholar
10. Association of Community Cancer Centers. 2016 Trends in Cancer Programs Survey. https://www.accc-cancer.org/surveys/CancerProgramTrends-2016-Overview.asp Google Scholar
11. The Advisory Board Company: The results are in: The 2014 cancer financial navigation survey. https://www.advisory.com/research/oncology-roundtable/resources/2014/the-results-are-in-the-2014-cancer-financial-navigation-survey Google Scholar
12. Schrag D, Hanger M: Medical oncologists’ views on communicating with patients about chemotherapy costs: A pilot survey. J Clin Oncol 25:233-237, 2007 Link, Google Scholar
13. Polltiz K, Cox C, Lucia K, et al: Medical debt among people with health insurance. http://kff.org/private-insurance/report/medical-debt-among-people-with-health-insurance Google Scholar
14. Association of Community Cancer Centers: Financial advocacy network (FAN). http://www.accc-cancer.org/resources/FinancialAdvocacy-Overview.asp Google Scholar
15. CancerCare: CancerCare patient access and engagement report. http://www.cancercare.org/accessengagementreport Google Scholar

Oncology Financial Navigators: Integral members of the multidisciplinary cancer care team

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As found in September-October 2014 issue of Oncology Issues. (view article online)

Oncology Financial Navigators

Integral members of the multidisciplinary cancer care team

By Dan Sherman, MA, LPC

The lights were dim when I entered the room of a newly- diagnosed cancer patient. As an oncology social worker, I had walked into rooms like this hundreds of times before. Little did I know that this encounter was going to change lives— not only the patient’s, but mine as well. In fact, this one visit with “Cathy” would affect thousands of other patients diagnosed with cancer in the future.

Having been a medical social worker for well over 10 years, I had all too often observed the financial devastation that a major medical issue could bring down on an individual and/or family. In fact, just six months before my meeting with Cathy, I’d had discussions with the leadership team at Lacks Cancer Center about the need to have a skilled individual on staff who could address the financial distress that our patients were experiencing, and to address it differently than we had in the past.

Far too many of my patients were anxious about their ability to pay for their cancer treatments. Too many were confused about options for reducing their out-of-pocket financial responsibilities; some were turning down care altogether. Not that charity care wasn’t available. In fact, our hospital wrote off millions of dollars in charity care every year. But when I spoke with the leadership team, I communicated that our current healthcare system was complicated, and our solutions to reduce the financial distress of our cancer patients were too simplistic.

But let’s return to the patient encounter that changed every- thing. Cathy had been admitted to our hospital with newly- diagnosed acute myeloid leukemia (AML). I recognized immediately that she would need extensive treatments for the next six months and close follow-up for several more years. Cathy had turned 65 a few months earlier; therefore, Medicare was her primary insurance. Although she did not have secondary insurance, Cathy did have a Medicaid spend-down (deductible) of about $800 a month.

When I entered the room to talk to her about coverage options, I found Cathy sitting alone in a corner of the room with various papers and forms in front of her. I introduced myself and asked if I could spend some time with her to talk about her health insurance status and her options for reducing her out-of-pocket responsibility.

For the next 45 minutes we talked through Cathy’s options. One option was to enroll in a Medicare plan that would provide 100 percent coverage for radiation treatments, chemotherapy, and hospitalizations. This policy (at that time) would cost Cathy $25 a month. Obviously this was a much-improved scenario over the $800 a month Medicaid spend-down deductible. Cathy expressed her wish to enroll in this plan, and I walked her through the enrollment process.

Having completed the work of getting the appropriate coverage for her care, I was ready to leave for my next patient visit. As I started to leave the room, Cathy said, “Thank you.” I stopped and acknowledged her kindness and turned once again to leave. Again she called out, “Thank you,” so I turned and acknowledged her again. Finally, she said it again, “Thank you!” but this time with more force. I turned around and saw tears forming in her eyes, so I walked over to Cathy and gave her a hug. As I turned to leave for the fourth time, she grabbed my arm and said, “You just don’t get it! Before you walked into my room, I was planning my funeral. I knew I couldn’t afford the care I needed, so I was writing down what I wanted my funeral to look like. Now, I will plan to live.”

Cathy was right of course—I didn’t get it. At the time I didn’t fully understand the significance of the financial distress Cathy was experiencing. For this patient, the financial cost of her cancer care had implications far beyond something as basic as putting food on the table.

When I left her room that day, I had a new appreciation for the role of the financial navigator and a newfound passion that compelled me to step away from medical social work to become an expert in the field of financial navigation services.

I knew then that the status quo had to change. I thought to myself, “If we’re truly going to be a cancer center of excellence, we cannot allow our patients to go through what this patient just experienced.” Cathy needed help to understand all of her coverage options—not just the simplest and/or partial options that had been offered to her prior to my visit. Without my intervention that day, the “status quo” method of delivering financial navigation services would likely have put Cathy on a path to her premature death. Since that fateful visit, I have worked each day to make sure that all of my patients are given the best, most practical, and comprehensive options for paying for their cancer care.

Today’s cancer programs must accept that their old, band-aid approaches to discussing financial issues with patients are inadequate for solving a complex, systemic problem.

For social workers, financial advocates, patient navigators, and others who wish to offer a similar level of service at their own cancer programs, here is why we need to step up for change.

Challenging the Status Quo

Simply put, the standard of financial intervention in most cancer programs is inferior. When patients are underinsured with their Medicare plan, most cancer programs automatically try to get patients qualified for Medicaid benefits. Cathy qualified for that program—but with an $800-a-month cost-sharing responsibility. Obviously, the rote “business as usual” option did not solve Cathy’s problem. Today’s cancer programs must accept that their old, band-aid approaches to discussing financial issues with patients are inadequate for solving a complex, systemic problem.

Mercy Health Saint Mary’s health system has provided financial advocacy services at its hospital for many years. In fact, most U.S. hospitals have financial advocates to assist cancer patients. But as Cathy’s example illustrates—we need to ask ourselves if our current services are truly meeting the needs of our patients.

When we read the work of Zafar1and Ramsey2 and reports about financial distress among cancer patients provided by the Kaiser Family Foundation,3 the Oncology Roundtable,4 the Community Oncology Alliance,5 and the American Society of Clinical Oncology,6 we must acknowledge that, as a whole, the oncology community is not alleviating the financial distress of a significant portion of the oncology population. And we must be ready to ask some difficult questions. For example, if the financial counseling services we provide are effective:

  • Why do more cancer patients fear the financial obligation more than dying from the disease itself?5
  • Why are oncology patients twice as likely to file for bankruptcy compared to the general public?2
  • Why does 29 percent of this same population avoid or delay filling prescriptions due to the cost?1
  • Why do 24 percent of oncology patients suffer relationship problems due to the financial pressures of the cost of care?1
  • Finally, why are patients making treatment decisions basedon cost rather than factors such as survivorship or ability to tolerate treatments?

These grim statistics clearly show that the oncology community has done an inadequate job of addressing the financial burden of this country’s oncology patients.

When patients receive a cancer diagnosis, they trust that the care they will receive will be the best available. Most cancer programs promote their use of the latest available technology; I contend that financial navigation services need to match this same high level of care.

In 2009 the Advisory Board’s Oncology Roundtable released a statement that succinctly captured the issue:4

At present, few cancer programs have a systematic process in place to identify patients in need and to develop a plan to meet their cost of care. Rather, financial counseling services are typically fragmented, with responsibility for various aspects of the process divided among registration staff, social workers, business office staff and clinicians. As a result, many miss opportunities to assist patients and improve revenue capture.”

Unfortunately, this “siloed” approach to financial navigation services plays out daily in cancer programs across the country. But it’s time to get serious about change. Our patients desperately need the oncology community to provide these services at a level that truly meets their needs.

Understanding the Problem

Over the last few years, researchers have paid increased attention to this issue, resulting in a newly coined term—financial toxicity. “Financial toxicity” is defined as both an objective financial burden and subjective financial distress. Recent research by Yousuf Zafar, MD, MHS, found the following:1

  • 42 percent of individuals applying for co-pay assistancereported a significant or catastrophic subjective financialburden
  • 68 percent cut back on leisure activities
  • 46 percent reduced spending on food and clothing
  • 46 percent used savings to defray out-of-pocket expenses
  • 20 percent took less than the prescribed amount ofmedications
  • 19 partially filled prescriptions
  • 24 percent avoided filling prescriptions altogether.

Zafar’s conclusion: having health insurance does not eliminate financial distress or health disparities among cancer patients.1

A recent ASCO report found similar results among insured cancer patients, with more than 47 percent of the patients in the study reporting concerns about healthcare costs.6

At the same time, financial navigation services face a number of hurdles, including lack of resources, a lack of motivation to change, internal system failures, and/or a shortage of informed, qualified personnel. And certainly the complexity of available coverage options and the time required to fully understand how to apply these options to meet the unique needs of each patient are also important factors.

It’s Complicated

The complexity of Medicare coverage choices, for example, understanding the coverage differences of Medicare Advantage plans vs. Medigap vs. employer-based plans vs. Medicaid, frequently results in patients making uninformed decisions, often at the advice of well-meaning family members or friends. The fact is that Medi- care beneficiaries who must choose from a list of 30 to 60 different coverage options—many of which have significant cost-sharing responsibilities—need advice from someone with more experience. More importantly, the uninformed consumer often is not aware of national open-enrollment and special-enrollment periods for Medicare plans. Patients who are unaware of the “fine print” details of their insurance plans often experience problems accessing care. At times, patients find themselves having to change doctors as a result of selecting a plan that puts their current providers out-of-network. Other patients choose plans that put them outside networks that are vital to their recovery needs.

This confusion harms not only the patient, but also the financial stability of the cancer program treating the patient.

While patients sometimes have questions about open enroll- ment and if, or when, they should apply, most often I see patients who are confused about the high out-of-pocket responsibilities that come with the Medicare plan they have enrolled in. The reasons for this confusion over cost-sharing responsibilities are multifaceted, but one major reason to consider is the host of Medicare options available to the general public. A recent pub- lication from the Kaiser Family Foundation reported that the leading contributor to medical debt for the individuals surveyed was cost-sharing responsibilities incurred for in-network services.3 Studies have also found that non-elderly Medicare beneficiaries experience more problems with cost-sharing responsibilities compared to elderly Medicare beneficiaries.1

In most states, access to supplemental policies for non-elderly Medicare beneficiaries is more restrictive, thus increasing the odds that these patients will enroll in a high cost-sharing Medicare plan. A well-trained financial navigator can help educate patients so that they enroll in the most advantageous plan for their specific medical needs.

The oncology community is seeing similar trends with the roll out of the health insurance exchanges under the Affordable Care Act (ACA). Again, patients are overwhelmed and confused about the enrollment process and the choices of coverage policies avail- able to them. As an example, I recently worked with a patient who was facing medical costs exceeding $150,000 after being diagnosed with ALL (acute lymphoblastic leukemia). He had not enrolled in a healthcare-reform-based insurance plan. Feeling overwhelmed and confused about that process, he was now outside the ACA’s open enrollment period. Just prior to being admitted to our cancer center, the patient had been seen at two other hospital systems—neither of which provided financial navigation services. On his admission to our program, I assessed his situation and was able to assist the patient with enrollment into an ACA health exchange plan under special enrollment guidelines. As a result this patient will now avoid medical bank- ruptcy and the hospital will be reimbursed for services provided.

When patients are left on their own to wade through the 50+ Medicare options; the extra help program for Part D; co-pay assistance programs; premium assistance programs; ACA enroll- ment guidelines; the choices of bronze, silver, gold, or platinum plans; and available out-of-pocket subsidies, they will likely experience financial toxicity as they journey through cancer treatment. The key to successful financial navigation is presenting patients with all the available choices in the context of their medical condition. Each patient is unique and, in most cases, the “status quo” approaches used by many hospitals and cancer programs of enrolling patients in Medicaid, charity, or patient assistance programs are simply inadequate in today’s market.

So How Can We Help?

I am proud to work for an organization that sees its mission as serving the poor and underserved. My hospital system often provides charity to those in financial distress. But charity programs can only manage a certain amount of debt load before program sustainability starts to be impacted. A better approach to financial navigation services is to educate patients on the programs that can help reduce their out-of-pocket responsibility. This education results in savings for the hospital’s charity program and reduces the number of patients who fall into collection services. Further- more, this process helps preserve the dignity of our patients, as most would prefer to avoid applying for charity altogether.

In 2009, following my experience with Cathy, I asked to head up a six-month pilot program (on a .5 FTE basis) where I would provide financial navigation services to the hospital’s oncology population. My responsibilities during the pilot period were to reduce financial barriers, improve access to care, and measure the financial benefit for patients and the cancer program. For the pilot, I targeted patients who were uninsured and underinsured and for whom Medicaid was not their best option. Specifically, I targeted patients who were:

  • In health insurance plans with out-of-pocket responsibilities of more than $5,000 a year
  • Medicare Part D patients in the coverage gap due to highcost oral oncology medications
  • Medicaid patients with a spend down
  • Patients with Medicare A/B only
  • Patients without health insurance coverage
  • COBRA recipients who could not afford the COBRA premiums
  • Patients receiving off-label treatments
  • Any patients expressing financial distress due to cost of care.

The pilot had two governing goals: 1) to improve access to care by reducing the financial barriers experienced by oncology patients and 2) to reduce charity and bad debt by $70,000 within the pilot program’s six-month time period. Everyone agreed that the first goal would always take precedence over the second goal. The decision to prioritize these goals in this way was not only the right one to make, but it also created an atmosphere of trust that contributed to the success of the pilot program.

To put this in perspective, medical providers see patients at quite possibly the most vulnerable time in their lives, a time when they are being asked to make long-term, deeply life-impacting decisions. When a patient is considering their future financial security, they need to trust that the providers advising them truly have their best interests in mind. If patients do not have that level of trust, they will not be open to education about better solutions for their health coverage needs.

Our Approach

I would first interview patients to get to know them and understand their medical and financial situation. Next, I would introduce patients to coverage options that improved their out-of-pocket responsibilities.

In most cases, I sought out patients myself, but I also educated the social work, case management, and nursing departments to refer patients to the pilot program who met the specific patient types described above. I also worked closely with the billing department to identify patients with significant write-offs on their accounts. I made a concerted effort to communicate with each patient’s oncologist so that I would have a more informed understanding of his or her medical needs. This improved understanding allowed me to better educate patients about coverage options that would complement their upcoming treatment regimen. This communication also helped me to build trust with oncologists, who then referred more patients for consultation.

The pilot program had great success. I reached the $70,000 goal in savings to the hospital by the second month. By the end of month five, I had saved the hospital system $265,000 and decreased out-of-pocket expenses for the patient by more than $700,000. In all, 78 patients were navigated. Based on these results, the hospital hired one FTE for the financial navigator position. Since then, the program has achieved the following outcomes:

  • Year two of the program: 218 patients received navigation services, reducing out-of-pocket responsibility for patients by more than $2.6 million and saving the hospital system over $1 million in reduced charity and bad debt.
  • Year three of the program: 168 patients received navigation services, and The Lacks Cancer Center added a second .8 FTE. Out-of-pocket responsibility for patients was reduced by more than $4 million and saved the hospital system $2.5 million in reduced charity and bad debt.
  • Year four of the program: 211 patients received navigation services, reducing out-of-pocket responsibility for patients by more than $5 million and saving the hospital system $3.7 million in reduced bad debt and charity.

The decrease in the number of patients receiving financial navigation over the program’s four years is due to a large backlog of patients needing these services during the program’s first two years. However, the program’s benefits have increased significantly every year—even when fewer patients received services. This is attributable to the roll out of the federally funded Pre-Existing Condition Insurance Plan (PCIP) program during year two of our financial navigation program. PCIP utilization significantly increased savings to both our patients and our cancer program.

Today, we offer financial navigation services to the following patient types:

  • Uninsured
  • Underinsured (relative to the patient’s income status; we allow patients to self-describe as being underinsured)
  • Patients on high-dollar oral medications who need assistance with their co-pays
  • COBRA recipients
  • Medicaid patients with a spend-down
  • Patients with Medicare A/B only
  • Patients who are entering into the Medicare system
  • Every patient with advanced-stage disease.

Financial navigators may self-refer patients or receive referrals from the multidisciplinary cancer care team. Financial navigators then interview patients to see if they want to discuss their financial obligation for the medical care they are seeking, and if they’d like to discuss options for finding coverage systems that may reduce their out-of-pocket responsibilities.

For individuals with advanced-stage disease, we educate patients on the available options (STD, LTD, SSDI, SSI, COBRA, and Medicare) and answer any other questions they may have about how their disease may affect their long-term financial health. Anecdotally, our team has found that patients and families who address their initial fears of financial obligations early on tend to be more at peace with the disease and more compliant with care.

Financial Toxicity & Patient Satisfaction

A recent study by the Duke Cancer Institute found a correlation between high financial burden and patients’ dissatisfaction with their healthcare services, concluding that:10

Understanding the connection between financial burden and patient satisfaction may help identify the extent to which modification of burden can improve this important metric of quality patient-centered care and improve the downstream results of an enhanced patient experience.

Anecdotal evidence from our cancer program suggests that successful financial navigation programs can improve patient satisfaction scores. Successful financial navigation can also reduce distress among oncology patients. It is rare that a day goes by without a patient approaching me or my colleague with heartfelt gratitude for the services we’ve provided to them. Some of the comments we’ve received:

  • Because of you, we were able to keep our house.
  • Thank you for helping us access the medication we needed but could not afford.
  • I would never have understood my insurance options without your guidance.

I suspect that financial navigators from other cancer programs have heard similar sentiments from patients. At The Lacks Cancer Center, we have focused attention on the issue of financial toxicity, reducing the problem with solutions tailored to meet the needs of individual patients.

The Right Person for the Job

The financial navigation program has now been successfully replicated at 12 different cancer programs. I’ve learned that successful replication requires that financial navigators have a singular focus on the task, comprehensive training, one-on-one education, and peer support as solutions and programs constantly change and evolve. Successful financial navigation programs also require support from different departments, including billing, patient access, and pharmacy.

Successful financial navigators require multiple skill sets. The ideal candidate should possess clinical, financial, and mental health skills. It’s essential that financial navigators are able to build trust within the first few minutes of meeting with the patient—otherwise the ability to fully assist the patient becomes very difficult. Financial navigators must be prepared to have treatment-planning conversations with the ordering physician and understand how different coverage policies can complement the treatment regimen. Financial navigators need to have empathy and the skills to have difficult conversations with patients; this is why good mental health skills are critical to the role. Finally, the person you hire for this unique position must exhibit utmost professionalism, balanced with a clear passion for the role.

Financial navigators play a critical role on the multidisciplinary cancer care team. Unfortunately, in many cancer programs, financial navigation services are relegated to secondary status, resulting in less than optimal solutions being offered to patients. Focused, educated, and passionate financial navigators are motivated to improve their skills and continually identify better solutions for their patients.

In the end, financial navigators with a clear understanding of the patient’s medical diagnosis and treatment needs and who build trust with the patient can reduce or even alleviate patient financial toxicity. In some cases, a small delay in treatment may be an option as the financial navigator waits for new or added coverage to take effect. However, a comprehensive financial navigation program should never get in the way of providing optimal care for the patient. With the onset of the Affordable Care Act and considering some of the more complex solutions mentioned above, I believe that we are entering a new chapter of financial navigation services. This new era requires new wisdom and new processes so that our patients suffer less and our cancer programs remain financially stable.

Six Years Later. . .

I saw Cathy again this spring—six years after our first meeting. A little more frail and now in a wheelchair, her body is showing signs of aging. But one aspect of her personality has not changed—her smile. When I saw her in our cancer center, she yelled out “Hi Dan!” with a grin that defies description. Our first meeting changed the trajectory of my vocation and my life. I hope that Cathy realizes how her emphatic words of “You just don’t get it!” have gone on to impact the lives of thousands of other cancer patients being treated in our healthcare system.

Dan Sherman, MA, LPC, is a clinical financial consultant for Mercy Health Saint Mary’s, The Lacks Cancer Center, Grand Rapids, Mich. He is also founder and president of “The Navectis Group,” a consulting company that assists oncology providers in implementation of financial navigation programs. He can be reached for comment or questions at dsherman@navectis.com.

References

1. Zafar SY, Peppercorn JM, Schrag D, Taylor DH, et al. The financial toxicity of cancer treatment: a pilot study assessing out–of-pocket expenses and the insured cancer patient’s experience. Oncologist. 2013; 18(4):381-390.

2. Ramey S, Blough D, Kirchoff A, Kreizenbeck K, et al. Washington state cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. Health Affairs. 2013; 32(6):1143-1152.

3. Pollitz K, Cox C, Lucia K, Keith K. Medical Debt among People with Health Insurance: A Report from the Kaiser Family Foundation; January 2014. Available online at http://kff.org/private-insurance/report/ medical-debt-among-people-with-health-insurance. Last accessed July 9, 2014.

4. The Advisory Board Company. Addressing Patient’s Financial Obligations: Best Practices for Optimizing Collections and Supporting Patients with Need; 2009. Restricted content. Available online to Advisory Board Members at: www.advisory.com.

5. Community Oncology Alliance. Americans fear paying for cancer treatments as much as dying of the disease. Oncol Times; 2009;31(15):16-17.

6. Stump TK, Eghan N, Efleston BL, et al. Cost concerns of patients with cancer. J Oncol Practice. 2013; 9(5):251-257.

7. Mosely WG, Nystrom JS. Dispensing oral medications: why now and how? Community Oncol. 2009; 6(8):358-361.

8. Abboud C, Berman E, Cohen A, Cortes J, et al. The price of drugs for chronic myeloid leukemia (CML) is a reflection of the unsustainable prices of cancer drugs: from the perspective of a large group of CML experts. Blood. 2013; 121(22):4439-4442.

9. Avalere Health. Oral Oncolytics: Addressing the Barriers to Access and Identifying Areas of Engagement. Community Oncology Alliance Report, 2010. Available online at: www.communityoncology.org/pdfs/ avalere-coa-oral-oncolytics-study-summary-report.pdf. Last accessed July 9, 2014.

10. Chino F, Peppercorn J, Taylor DH, Lu Y, et al. Self-Reported Financial Burden and Satisfaction with Care Among Patients With Cancer. Oncologist. 2014; 19(4):414-420.

Oncology Financial Navigation – Best Practice Sharing

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from Mercy Cancer Network Newsletter, March 2012

One of the strengths of the Mercy Cancer Network is its ability to identify a best practice and coordinate a mechanism for sharing among member hospitals. The Oncology Financial Navigation program at Saint Mary’s Health Care in Grand Rapids is a perfect example.

Over the past decade there has been a shift in processes and responsibility for payment for health care services. This has resulted in the cost of care increasingly being transferred to patients. Unfortunately, few patients can realistically cover the financial responsibility of their cancer care. As a result, financial hardship has now become the number one stressor of cancer patients.

This hardship is then reflected in the financial performance for providers. The Financial Navigation Program at Saint Mary’s Health Care, under the leadership of Dan Sherman, Clinical Financial Consultant, addresses these issues.

Strategies have been developed that provide opportunities for financial access to patients, thus alleviating their stress level and enable them to focus on treatment and recovery. In addition, these strategies prevent financial losses and increase revenue.

This program has been a win-win for the patients and the hospital, leading to increased patient satisfaction and recovery.

Now the program is being shared across a number of MCN sites, through a structured training and implementation program led by Dan Sherman. This three-year program will be launching at St. Mary Mercy Livonia, St. Joseph Mercy Oakland, Mercy Health Muskegon, and St. Joseph Mercy Port Huron is also reviewing the program.

Each site will then be prepared to implement their own Oncology Financial Navigation program, realizing benefits for both the hospital and the patients. Best practice sharing in action!

For more information contact Dan Sherman at The NaVectis Group.

Oncology Financial Navigators

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“Oncology Financial Navigators”
by Dan Sherman

View online here

 

Could you save $3.5M with a patient financial navigation program?

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by Deirdre Fuller, found in The Advisory Board Company

St. Mary’s Health System in Michigan has saved $3.5 million and secured coverage for nearly 400 cancer patients over the past two years with its new financial navigation program. By understanding new provisions of the Affordable Care Act and educating staff about improving patient coverage, St. Mary’s is easing the financial burden on cancer patients and reducing its uncompensated care spending in the process.

Rising costs of cancer care hit patients and hospitals hard

In a 2010 survey commissioned by the American Cancer Society, 21% of people younger than 65 undergoing cancer treatment said they had used up all or most of their savings. Shockingly, another 19% reported that they or their family members had put off getting a recommended cancer test or treatment because of cost.

According to Bloomberg’s BGOV Barometer, hospitals’ uncompensated care in 2010 had risen to $39.3 billion, an 82 % increase since 2000. The American Hospital Association reports that uncompensated care, including charity and unpaid bills made up 5.8% of hospitals’ expenses last year.

With these statistics in mind, Dan Sherman from St. Mary’s Health Care in Michigan recently explained to us how St. Mary’s Financial Navigation Program helps cancer patients find optimal insurance coverage—and saved the hospital about $3.5 million over two years.

How does a financial navigation program help?

St. Mary’s Health Care in Grand Rapids is one hospital working to decrease the financial burden of cancer care for patients. The Financial Navigation Program, engineered by Dan Sherman, has secured coverage for almost 400 patients over the past two years.

In 2008, Mr. Sherman developed a pilot version of the program with the initial goal of saving $70,000 over six months. By the second month, he had met that goal and, by the fifth month, hospital leadership decided to make the program a permanent service offered to patients at The Lacks Cancer Center.

Traditionally, most financial counseling programs focus on charity care, patient assistance, drug replacement, and co-pay programs, which Mr. Sherman describes as “Band-Aids” that only temporarily stem health care costs for patients. In contrast, St. Mary’s Financial Navigation Program emphasizes obtaining or improving coverage for uninsured and underinsured patients. So, how was Mr. Sherman able to successfully design and implement this service both at St. Mary’s and at other sites nation-wide?

Understanding the provisions of the ACA

With the passage of the Affordable Care Act, patients with pre-existing conditions, such as cancer, became eligible for a number of new health plans. Mr. Sherman dedicated himself to understanding the coverage and supplemental plan options available for cancer patients.

Researching health plans in Michigan

Mr. Sherman spent an entire year researching health plans and supplemental coverage policies available to patients in Michigan. This included learning about Michigan’s health insurance regulations, how to improve coverage for Medicare beneficiaries, and when and how an individual can change health plans.

Educating hospital staff and physicians

Changing hospital culture was Mr. Sherman’s biggest challenge to successful implementation. Many staff and physicians find it easier to refer patients for charity care rather than referring them to the Financial Navigation Program. But with ongoing education, that is beginning to change.

Mr. Sherman found that it is critical to coordinate his team’s efforts with the patient’s care team to secure adequate health coverage. In some cases, there may be a delay before health coverage begins, followed by a request to delay treatment. However, Mr. Sherman stresses that the Financial Navigation Program never gets in the way of seeking optimal care for the patient.

Hiring the right person

The success of the Financial Navigation Program hinges on hiring an empathetic and trustworthy person who can identify suitable options for helping patients pay for their care, counsel patients and families, and work with them to secure financial support. Mr. Sherman describes the ideal candidate as someone with both a clinical and mental health background who also has an accountant’s understanding of health care finances.

Learn more

Interested in a consulting service designed to help other cancer centers implement the Financial Navigation Program? The navigation program requires one new hire and one participating institution has already seen savings of $1.2 million over the span of one year.

For more information, please contact:

Dan Sherman

The NaVectis Group

P.O. Box 185

Caledonia, MI 49316

More from the Oncology Roundtable

Oncology Roundtable members can join us at an upcoming session of the 2012-2013 national meeting to learn more about how the government, commercial payers, employers, and patients are managing the rising costs of cancer. Register now.

To learn more about how to support patients with need, Oncology Roundtable members can read our publication Addressing Patients’ Financial Obligations.