June 11, 2021 | Edward Townley CPC, CEMC, CUC, ROCC, Founder, Cogent9 Consulting
Challenges for patients in cancer care include many devastating factors, including loss of a job or changes in job status, such as switching to part-time work or taking extended leave. For those who have a job to return to, there are other obstacles, including difficulty returning to work, or taking a position earning less income. At best, there may be a general loss of productivity at work or at home.
Financial stresses, also known as financial toxicity, can and often do result in emotional, mental, and physical stress. Extreme financial distress, as manifested by personal bankruptcy, might be associated with worse mortality in cancer patients.
Medical bills are reported to be the number one cause of U.S. bankruptcies. One published study from 20071 has claimed that 62.1% of bankruptcies were caused by medical issues. We can only infer that this may be a larger number now.
Patients may be uninsured or underinsured (often without knowing or understanding the implications). Many patients have opted for the insurance plans that they could afford at the time but were not aware of the issues of increasing cost-sharing (high deductibles, high co-pays, and restrictive networks).
Patients may be the last to know that, even when they have made honest efforts to find a provider in their health plan’s network, facilities providing chemotherapy, radiation therapy, or surgical services are out-of-network.
What can we in the oncology providers’ offices do to help with these issues? One of the best practices is to employ knowledgeable and empathetic staff in the role of a Patient Financial Counselor (PFC) or financial navigator. This position is part coder, part A/R analyst, and part social worker.
Developing an ongoing relationship with the patient is key to success in this job. Many patients have a meeting at the initiation of therapy with a nurse or an advanced practice provider like a PA or NP for ‘chemo teaching’ to let them know what to expect from therapy. Introducing the PFC at this meeting and providing an overview of their role and setting appointments and providing contact information is a convenient way to start the connection.
In that first appointment, the PFC can meet with the patient and spouse or caregiver to provide an accurate cost estimate of the course of therapy. Review of the insurance benefits and expected co-pays and co-insurance may enable to set up a time payment plan to receive portions of the payment weekly so that when the course of therapy is completed the balance is satisfied or at least minimized.
A critical step is to provide a cost estimate for care that is as accurate as possible. Cost estimates can be very specific to the patient’s insurance contract and fee schedule. Some practices estimate everything according to Medicare rates. Unless the patient is covered by a traditional Medicare plan, those estimates may be quite far off from reality.
Education of the providers can be very helpful in many cases. Presenting relative differences between modalities in patient costs can be an eye-opener for many physicians. A comparison of a course of 3D conformal versus IMRT planned treatments of radiation therapy or a comparison of alternative chemotherapy drugs is something for which the clinical staff may assist.
Knowledge of the availability of clinical trials, if available, may also help with getting patients the treatments that they need while minimizing the catastrophic effects of cancer care.
To reduce financial toxicity, patients have a role to play as well. Patient-level interventions must focus on improving patients’ conceptual knowledge of health insurance and finance, also known as cost-related health literacy. Interventions should focus on educating patients on the basics of health insurance, potential costs they might face during treatment, and available resources like patient assistance programs.
As professionals, we are adept at reading technical documents like Explanations of Benefits [EOBs] / Remittance Advice [RA] documents. We must remember first that these are foreign language to the patients and in many cases, the patient receives a much different document with less detail and more ambiguity.
Educating the patients on what their insurance will pay, what contractual allowances are applied, and how to read their EOBs are functions of the PFC that are very helpful to the patients and their caregivers.
Monitoring the accounts for patients under therapy can let the PFC know when patients struggle to make agreed payments. This can be a point at which assistance programs (disease-specific, local cancer society programs, drug manufacturer subsidies) or even recommendations to apply for state-level benefits like Medicaid. If your practice has some type of indigency program this might be a help as well.
If under-insured patients have unpaid balances, we may have to wait until insurance benefits are exhausted to enable any discounts to any remaining balances (we have seen, for example, if the patient makes a $100 payment an added $100 discount to the account is written off). Check your managed care and other payor policies with your management to set standardized policies.
In summary, establishing a position of a financial navigator who can teach patients about the health insurance plans, benefits, and cost-saving methods for treatments for which the patients are eligible.
This helps the patient, helps the practice, and helps avoid medical bankruptcies and ameliorate financial toxicity of cancer care.