The rise in popularity of oral cancer therapy has introduced issues of access and insurance coverage that oncology nurses did not have to deal with before, according to expert speakers at the 2022 Oncology Nurse Society Bridge. However, there are many resources available to nurses, and a key first step is to ask patients how they are doing financially.
“Even though you may not have all the answers right away when you talk to the patient, don’t hesitate to discuss it. [about] their finances,” said Mary Anderson, BSN, RN, OCN, oral oncolysis nurse navigator at the Norton Cancer Institute.
Anderson has presented alongside Christina Bach, MBE, MSW, LCSW, OSW-C, FAOSW; and Nora Hansen, CPhT, in a presentation entitled “Managing Oral Cancer Therapies: What Are Your Tools?” The team highlighted the extent of the financial toxicities problem, best practices for assessing financial toxicity, and resources to help nurses connect their patients to the care they need.
When assessing patients for the first time, oncology nurses are encouraged to ask the following questions:
- What is your support system?
- Where are they located?
- Can you go to the pharmacy to pick up your medication?
- Can you have medicines delivered to your home?
Other key questions include asking the patient to describe their insurance plan, highlight any other expenses that they fear may arise during their cancer care (i.e. transportation, parking, childcare children, loss of income), if he fears losing his job. , whether they have had difficulty obtaining a prescription in the past, whether their disbursements are in line with their expectations, and whether they are concerned about financial toxicity affecting their quality of life.
“I start by making sure people understand that I’m not trying to be intrusive or overstep my boundaries by asking really personal and private questions that we just aren’t trying to. [normally talk about]“, said Anderson. “I always say; ‘I know it’s personal. I know a lot of people don’t want to talk about it. But knowing this information will help me help you. And it’s all between the two of us.
“We validate that it’s uncomfortable,” she added. “We also validate that it’s hard to ask for help and also give them permission at all times to say, ‘You know what, I don’t want to answer that question. “”
Unfortunately, medical debt is the number one cause of personal bankruptcy in the United States.1 Since 2010, spending on cancer care has increased by approximately $175 billion. It is expected to continue growing and reach $246 billion by 2030.2 Additionally, the average outlay per patient has increased from $1,800 to $2,900 per month since 2010.
“We have a major crisis when it comes to medical debt in this country,” added Bach, an oncology social worker at OncoLink. “It has a lot to do with how cancer [treatment] has changed a lot in terms of oral oncolytics.
“What is available to patients and how they access it is very different from what it was when I started as an oncology social worker in 2000,” she added. “[In 2000,] almost [every patient] was admitted for all of his treatments for several days, he was covered by his [insurance]and there were very few oral medications available.
Presenters noted that solutions to help patients are also unfortunately limited: assistance from co-payment foundations is limited to certain conditions, procedures and availabilities. In private oncology practices, which are often the only geographic option available to patients, charity care is generally not offered.
Additionally, the United States has historically not regulated drug prices or had a drug price denial system and a diagnosis of cancer does not equate to automatic approval for disability. Paid family leave varies by state, but is generally limited, which means job loss (and the resulting loss of health insurance) is a reality that many Americans with cancer face.
“Our solutions are limited,” Bach said. “I often feel like my hands are tied. It is very frustrating and also very painful morally.
Due to these rising costs, it is not uncommon for patients to delay or forgo treatments due to their financial burden. However, it is documented in the literature that financial toxicity is often linked to poorer outcomes.3
Financial difficulties often extend to survival as well; 54% of survivors are between the ages of 18 and 64, with 42% reporting experiencing financial hardship after diagnosis. Debt is more prevalent among populations under the age of 64, as well as in black communities.
Previously, the problem in the United States was that most patients were uninsured. However, in 2022 the problem has become that patients are underinsured.
Speakers noted that it can be difficult for patients and nurses to understand the difference between Medicare A, B, and D. They highlighted the general difference between the plans as part of their presentation:
- Medicare Part A is hospital insurance and is often premium free;
- Medicare Part B is outpatient medicine and patients must enroll and pay a monthly premium;
- Medicare Part D is voluntary prescription drug coverage, patient pays premium and coinsurance (deductible and up to 25%);
- Medicare Part C is known as the “benefit plan”; it is offered by private insurance plans under contract with Medicare, it covers the same services as Medicare A, B and some drug coverage, and patients choose their provider and plan, such as HMO;
- Patients may also qualify for Medicare supplements, which provide optional additional coverage for coinsurance and deductibles.
Insured patients are responsible for paying a premium, deductible, copayment, coinsurance, but may overlook additional items that are not covered. These may include cancer-related needs or services, such as wigs, supplements, lymphedema clothing, certain durable medical equipment, private assistance, and indirect costs, including transportation, parking, healthcare. children/elderly, loss of income/salary and caregiving. This represents a heavy financial burden for many, the speakers agreed.
The recently passed Inflation Reduction Act, I expected to alleviate some of the financial toxicity patients face by capping the amount a patient is expected to pay per year and lowering premium prices .4 Additionally, the law introduced the concept of drug price denial, which could have monumental consequences for patients, according to Bach. However, despite the law’s approval, many of the benefits are many years away.
In the meantime, nurses need to know that while they play a crucial role in helping patients access the resources they need, they are part of a team of players who can help patients navigate the world of healthcare. ‘insurance. Other professionals who may be involved include private brokers, social workers, financial navigators/lawyers, state health insurance assistance program (SHIAPS) counselors, ACA navigation assistance, private brokers. Because there are so many people invested in helping patients help, nurses should not feel alone or intimidated to start the conversation: they are not expected to solve the problem, but they can help improve the situation.
Experts also recommend that oncology nurses take advantage of online resources, such as the ONS Oral Cancer Therapy Toolkit or OncoLink.org.
Some other resources to consider:
Cancer Insurance Checklist
ONS Financial Toxicity Contact Card
ONS Guidelines™ to support patient adherence to oral cancer medications
Cancer and careers
ACCC Financial Advocacy Tool
Cancer Support Community Financial Navigation
- Gordon D. 50% of Americans now have medical debt; a new chronic disease for millions of people. Forbes. October 13, 2021. Accessed September 26, 2022. https://bit.ly/3DU7fEg
- Abrams HR, Durbin S, Huang CX, et al. Financial toxicity in cancer care: origins, impact and solutions. Transl Behav Med. 2021;11(11):2043-2054. doi:10.1093/tbm/ibab091
- Yabroff KR, Han X, Song W, et al. Association of medical financial hardship and mortality among cancer survivors in the United States. J Natl Cancer Institute. 2022;114(6):863-870. doi:10.1093/jnci/djac044
- Fact Sheet: Cut Inflation Act Supports Workers and Families. Press release. The White House. August 19, 2022. Accessed September 26, 2022. https://bit.ly/3xUu2fi