Sep 01, 2021
By Geraldine Carroll, ASCO Publishing
Rising health care costs across the globe have increasingly caused financial distress for patients and their families. Patients with cancer report financial toxicity as a major impediment to their quality of life, and its association with worse outcomes is well documented. A novel approach to address financial toxicity, published in JCO Oncology Practice, features the first Financial Toxicity Tumor Board (FTTB) developed by the Levine Cancer Institute (LCI) in North Carolina.1
“This is really becoming a huge problem nationally. We avoided analysis-paralysis by trying to do something, and hoped that this new approach might work… and it did,” said LCI president and study first author Derek Raghavan, MD, PhD, FACP, FRACP.
The FTTB is modeled on the concept of a conventional multidisciplinary tumor board, and functions as a multidisciplinary conference providing a wide range of problem-solving approaches to financial toxicity. Since the FTTB was established at LCI in 2019, more than $55 million was avoided in personal expenditure for 1,749 patients in the program’s first year, and more than $60 million for 1,819 patients in 2020. Additionally, the program provided more than $1.3 million of co-pay assistance to patients experiencing financial challenges.
LCI offers all oncologic services for Atrium Health, a system comprised of more than 40 hospitals and 900 offices that provides more than 12 million encounters per year in North Carolina, South Carolina, and Georgia. LCI sees more than 18,000 new patients each year and provides services for 200,000 visits annually.
A Multidisciplinary Approach to Reduce Patient Costs
The FTTB was established at LCI as a regular cancer management entity which brought together physicians, nurses, financial counselors, nurse navigators, social workers, and administrators on a monthly basis. The FTTB is linked to a Patient Assistance Program for oncologic pharmaceutical agents, a domain that constitutes a major cause of financial toxicity for patients. Due to the confidential nature of patients’ fiscal status, and on the counsel of the Patient Family Advisory Council, patient representatives were omitted from the initial FTTB, although this decision remains under review at LCI.
The director of nurse navigation was routinely present for FTTB, representing a team of more than 30 nurse navigators. The director of financial counseling, also a routine participant, represented eight financial counselors, ensuring that new standard operating procedures from FTTB were shared with relevant support staff. At least one representative from each department and discipline attended each meeting to address problems including payer impediments, under-insurance, complexities of certification, coding/billing issues, and inadequate internal standard operating procedures.
Representation of clinical staff at FTTB ensured that patients with potential concerns were aware of the support service. Patients, family members or caregivers, physicians, nurses, members of the administration, and all other stakeholders involved in FTTB were able to refer specific financial or insurance issues for FTTB discussion.
Cases were triaged based on acuity and severity. For example, cases involving failure to secure Medicaid or Medicare coverage, lack of documentation, or reluctance to disclose financial issues were managed operationally by financial counselors, members of the Finance Department, a clinician, nurse navigator, or a social worker. More complex issues were referred for assessment and management by the multidisciplinary FTTB.
Tools to Address Financial Toxicity
LCI expanded the Patient Assistance Program for injectable pharmaceutical agents and co-pay assistance as a conjoint initiative between LCI and the Atrium Health Department of Pharmacy. The initiative was designed to proactively manage the availability of free cytotoxic, symptom management, and targeted agents; proactively manage co-pay assistance for patients with financial challenges under defined criteria; and manage bad debts associated with lack of insurance to cover complex medications. A systematic approach was implemented, involving repeated review of need for each new patient, and all new infusions and regimen changes were evaluated for eligibility for free drug programs or co-pay assistance.
“It has been very pleasing to see how we have been able to help patients, their reduction of stress, and [their] very positive response to this new concept,” Dr. Raghavan said.
Pharmacy technicians were placed or embedded virtually in clinical practices to track and coordinate expensive oral medication needs for patients, and handled prior authorizations, co-pay assistance, free drug procurement, and directing to appropriate pharmacies based upon a patient’s insurance. Additionally, an algorithm was developed to facilitate an additional check by a pharmacy technician to ensure that prior authorizations were in place 72 hours in advance of scheduled infusions for all drugs, reducing unnecessary insurance challenges.
LCI adopted the use of biosimilars to reduce costs to payers and patients after a meticulous review by the Pharmaceutics and Experimental Therapy Committee of the efficacy and toxicity data of any proposed biosimilar prior to acceptance into the formulary.
Major Causes of Financial Distress
Although some financial toxicity continued to impact some patients after a year of operation, the FTTB addressed the majority of issues, and reduced patient debt, distress, and the frequency of the most commonly reported concerns.
Lack of adequate health insurance coverage (either complete or partial) was reported as one of the major concerns, along with impediments to reimbursement by insurers, and inadequate internal guidelines for communication between clinical and non-clinical teams. Common issues included challenges with health literacy, financial accessibility of novel therapeutics, and costs associated with complex surgical or radiation therapy. In some cases, lack of awareness by clinical staff of the fiscal consequences of selection of treatment, unplanned diagnostic test, or treatment without pre-authorization were identified and circulated to clinical staff to avoid repetition.
During the COVID-19 pandemic, the FTTB transitioned to virtual platforms to continue its operations and will maintain a virtual format in the future.
FTTB Approach Enhances Health Equity
LCI noted that the substantial savings were not surprising considering the high cost of treatment programs, including CAR-T therapy and newer immunotherapy and targeted agents which can exceed $300,000 to $500,000. They also noted that prolonged in-patient care after complicated surgery can accrue similar patient costs for uninsured and under-insured patients.
Dr. Raghavan hopes that LCI’s experience with FTTB will prompt other health care providers to consider the FTTB approach as a more cost-effective way to proactively manage financial toxicity and enhance health equity. “This is a proof-of-principle study that actually could be applied to any complex and expensive disease management situation, not just oncology,” he said.
- Raghavan D, Keith NA, Warden HR, et al. Levine Cancer Institute Financial Toxicity Tumor Board: A Potential Solution to an Emerging Problem. JCO Oncol Pract. Epub Jun 8, 2021. doi: 10.1200/OP.21.00124.