Have you ever talked to your patients about financial toxicity? It's likely you wouldn't have used that exact term — it sounds quite harsh — but you've probably discussed the negative effects of the cost of cancer treatment and other high-priced medical care on your patients' quality of life and health. After all, costs greatly affect their ability to adhere to treatment plans. The specific term was coined in a 2013 Oncology article and has been gaining momentum as a major element of providing optimum care.
It's certainly a hot topic, both in the industry and for patients who are directly affected, because cancer costs in particular have continued to rise. As a physician, you want to provide your patients with the best treatment options regardless of cost, but the unfortunate fact is the actual value of chemotherapy drugs or other treatments aren't always in line with their price tags.
Top Drivers of Cost
Everyone is feeling the sting of rising medical costs. Reimbursement formulas lag behind the true cost of cancer treatment, and financial incentives often don't support the most cost-effective solution. Plus, physicians face shortages of older, cheaper chemotherapy drugs.
For patients, especially those under 65, premiums are skyrocketing and deductibles are high. Almost all oral chemotherapeutics fall into the top tiers of prescription drug plans, creating large copays. Patients are also living longer and are therefore charged with receiving more treatment.
The overuse of tests and procedures that offer no benefit, as profiled by JAMA Internal Medicine, is another growing concern throughout the industry. When it comes to cancer treatment, expensive drugs greatly contribute to high costs, underscoring the importance of choosing the most effective and beneficial surveillance, diagnostic, and treatment options. Government and advocacy groups are working to address more factors regarding costs on the payer and pharmaceutical side.
Financial Toxicity Forces Impossible Decisions
The cost of cancer treatment hurts patients physically, mentally, and emotionally. Some people have to pay a large percentage of their income for out-of-pocket expenses related to cancer care — and all the numbers are going up. An Institute of Medicine workshop on the costs of cancer drugs estimated that monthly expenses have risen from $100 in 1965 to $10,000 in 2013. From 2007 to 2014, the per-pill cost of Tarceva doubled, Sprycel went up by 130 percent, and Gleevec increased by 158 percent. Granted, these drugs' quality and effectiveness have advanced, but that's little comfort to the people who have to pay for them.
These rising costs mean patients are forced to make difficult, and sometimes nearly impossible, decisions. They not only have to cut their vacation or leisure spending, but they also have to ration funds for basic items such as food and clothing. Some end up using their savings to pay for these expenses.
Some patients choose not to pay for these drugs, preferring to accept the health consequences instead. One study in The Oncologist found that patients were not taking medications as prescribed, partially filling prescriptions, or not filling them at all. One physician shared his experience in a piece for The New York Times about a patient who refused to take a drug that cost $5,000 per month. The pill was his last treatment option, but the patient felt it was more important to leave his family financially sound than to extend his life for a few months.
Helping Your Patients Consider Value in Treatment Decisions
You can make a difference for your patients by proactively choosing drugs that have lower costs with similar side effects and outcomes as their more expensive counterparts. At a session during the 2015 American Society of Clinical Oncology's annual meeting, presenters discussed how physicians can make those decisions, underlining that cost does not always reflect drug value.
Deborah Schrag, MD, discussed a study that evaluated the effectiveness of one drug versus another combined with a common chemotherapy regimen. From the beginning, the study included an economic analysis. She found that the two drugs had similar survival outcomes and quality-adjusted life years, as well as similar costs for hospitalizations and acute care. However, one drug was vastly more expensive than the other, creating a cost difference of more than $39,000 between the two groups.
Physicians face many of these treatment decisions, for medications and also for ordering tests, surgery, and certain procedures. In cases like the example above, Dr. Schrag said that the cheaper drug should be the first choice but explained not to take the more-expensive drug off the table for patients who were willing to pay.
Lower Costs Through Clear Discussion
Sometimes the best choice is the most expensive, and you can still help your patients deal with the burden simply by talking about it and helping them find resources to cover out-of-pocket costs.
Emerging research is showing that patients have limited understanding of insurance terms and their financial responsibility. Guide them to financial counselors or staff members who can explain deductibles, copays, and prescription benefits, and point them to prescription-assistance programs or foundations that help cover copays. Physicians and care teams can also advocate on behalf of patients to insurance companies to help find relief, as well.
Although your information in the office is limited — you're not likely to have knowledge of the person's insurance benefits during a visit — you can talk in general about treatment options known to have vastly different prices. Setting reasonable expectations for treatment and outcomes also helps lower patient's expenses.
Working together with patients, pharmacists, financial counselors, and social workers is the best way to lessen the burden on patients and let them focus on getting well faster. These are challenging times, but with continued advocacy efforts and value-based care decisions, you can make headway in spreading awareness of available choices while still providing patients with the best outcomes.