Breakthrough treatments in hematology and oncology have the potential to cure, and to extend the lives of many patients with cancer—but only those who can afford them. As cancer care improves, the price tags associated with these treatments continue to rise. Today, prices higher than $10,000 per month for cancer treatments are common. Even with 25% coinsurance with a typical employer-sponsored insurance (ESI) plan, a patient would have monthly out-of-pocket (OOP) costs of at least $2,500.1 This represents nearly 70% of the monthly income of a full-time wage or salary worker in the United States.1,2 Surveys of patients with cancer have indicated that about 1 of 5 individuals spends $10,000 to $20,000 or more in annual OOP costs for their cancer treatments.1,3 As a result, many Americans with cancer struggle with the hardships imposed by high OOP costs. These hardships—collectively referred to as financial toxicity— include those that are financial, psychosocial, and medical.4,5
Although financial toxicity affects a wide range of patients with cancer, major disparities exist across our nation in the hardships inflicted by high OOP costs of cancer treatments. The hardships are particularly burdensome for Americans who are uninsured or underinsured and for cancer patients who may lose wages as a result of missed workdays or unemployment. Millions of Americans already struggle to pay rising health insurance premiums and co-pays or to reach high deductibles before insurance coverage begins.1 The COVID-19 pandemic has compounded the financial toxicity problem by severely disrupting the national economy and making a profound impact on health insurance coverage. Furthermore, as the country starts to “reopen” from various levels of lockdown, we have already begun to see bottlenecks at oncology practices, further limiting providers’ abilities to search for and find financial assistance for their patients.
The COVID-19 pandemic has exacerbated an already growing problem
Since outbreaks of the novel coronavirus that causes COVID-19 were reported in the United States, more than 30 million workers have filed for unemployment.6 As workers lose their jobs because of the slowdown in economic activity, millions of Americans under 65 years of age will lose their ESI and become underinsured or uninsured. Near-term forecasts suggest 25 million workers or more could lose ESI due to COVID-19–related unemployment. Among those workers losing ESI, it is estimated that 7 to 12 million will become uninsured, with states that have not expanded Medicaid under the Affordable Care Act having larger numbers of those losing ESI coverage and becoming uninsured.7 In these financially challenging times, Americans without ESI who seek out other insurance options may choose only catastrophic insurance, leaving them vastly underinsured. Even among the well insured, hundreds of thousands of Americans will face financial stress due to a reduction in overall disposable income, and retirement income will likely be threatened for many Medicare enrollees. With the well known prevalence of cancer in this country, it stands to reason a sizable portion of individuals who suffered unemployment and those otherwise experiencing financial hardships have cancer. This includes hundreds or even thousands who have not yet been diagnosed and equally staggering numbers of cancer patients whose treatment has ceased as a result of the pandemic’s effects on the economy and the healthcare system.
Impact on patients and families before COVID-19
Even before COVID-19, it was well recognized that patients with cancer and their families frequently suffer the hardships of maintaining employment, along with decreased income and loss of ESI, concurrent with the adversities of high OOP costs that are commonly incurred with cancer treatments.8 Prior to the pandemic, an estimated 1 in 5 cancer patients decided not to receive recommended oncology care, including treatment, because it was too expensive, and 25% of individuals experienced treatment delays or stopped treatment due to cost, according to the Cancer Support Community.9 In general, patients who forgo treatment prescribed by their oncologist or experience treatment delays have a higher likelihood of diminished outcomes, including a greater risk of death.5,10 The largest disparities in cancer death rates occur among the poorest US counties and the preventable cancers, such as lung, liver, cervical, and colorectal cancers.1 As a whole, the oncology community has struggled to effectively address the experience of financial toxicity for a significant portion of the cancer patient population.8 This problem is only getting worse during COVID-19.
As a consequence of the COVID-19 pandemic, patients have avoided in-person medical appointments due to fear of contracting the coronavirus, and medical offices have been closed due to shelter-in-place orders that swept the nation. Since oncology appointments have halted and cancer screenings, such as colonoscopies and mammograms, have waned during the COVID-19 outbreak, preventive care essential for detecting and treating cancer has fallen precipitously.11,12 Consequently, new diagnoses of cancer in the United States have declined and even more cancer patients than before COVID-19 are not getting treatment or are experiencing delays in receiving treatment.
Recently conducted research on colorectal cancer confirmed that new diagnoses of the disease declined more than 30%, while the number of biopsies and colonoscopies performed fell by nearly 90% between March and April of this year, compared with the same period last year. Surgeries for colorectal cancer also were down by more than 50% during the same time period. These findings are particularly distressing because colorectal cancer is the nation’s second-leading cause of cancer deaths and screenings have proven to be critical in curbing the disease, saving lives by reducing death rates by greater than 50%. The precipitous drop in surgeries for colorectal cancer suggests that many patients who were newly diagnosed with the disease postponed procedures, heightening their risk that the cancer could progress.11
Even when they are not exposed to the coronavirus, cancer patients face daunting challenges around delays in care and interruptions in treatment due to the pandemic. While medical offices are slowly reopening, prolonged wait times to reschedule patient appointments are expected. It may be months before patients are able get the oncology care and cancer treatments they sorely need.11 For patients with a family history of aggressive cancer, delayed or canceled appointments are especially worrisome. Further delays in accessing potentially lifesaving treatments, due to high OOP costs coupled with lost ESIs and reductions in disposable incomes during the pandemic, will inevitably worsen the problem. The human toll is considerable, and patients and their families will feel the impact of COVID-19 for a long time.12
Impact on practices and providers before COVID-19
Prior to the COVID-19 pandemic, oncology practices and providers also experienced hardships from financial toxicity. The highly manual and typically reactive approach to financial assistance cycle management (FACM) that many practices utilize is both resource intensive and expensive. Although practices employ financial counselors, the process of navigating patient support programs (PSPs) offered by life science organizations and others is extremely time consuming and costly, due to the fact that there is a multitude of programs available (eg, co-pay assistance, free drug, hub services) and each program has its own nuances and requirements.4,5 Additionally, waiting on approvals from PSPs and prior authorizations from insurers not only frustrates oncology providers and increases practice expenses but also causes treatment delays for cancer patients, thereby adding to provider frustrations.5,13 Amid the COVID-19 pandemic, the hardships experienced by oncology practices and providers—stemming from financial toxicity—will inevitably worsen.
Physician visits, diagnostic tests, and surgeries are key sources of revenue for oncology practices and providers. Nonetheless, they postponed nonessential patient appointments, deferred cancer screening tests and consultations for second opinions, curbed surgical procedures, delayed diagnoses, and interrupted treatments in order to mitigate coronavirus infection in cancer patients and oncology staff.14 While the economic toll for oncology practices and providers has not been fully elucidated, lost revenue during COVID-19 is expected to be in the millions of dollars. Although many oncology practices received funds through the CARES Act, like thousands of other businesses in the United States, practices were forced to lay off staff and adapt in new ways. Oncology providers have been able to prioritize the most urgent surgeries for their patients with cancer and switch to virtual visits to replace in-person appointments, but not without setbacks. Practices have incurred challenges with organizing, implementing, and conducting telehealth, especially with significant staffing limitations due to layoffs and school closings and particularly in cases where patients have limited access to laptops, smartphones, and Internet service. Although there has been an unprecedented response by the oncology community as a whole during COVID-19, there is national concern as to how providers can deliver cancer care if the financial and operational tolls imposed by the pandemic cause their practices to close.12
In a post-pandemic era, oncology practices will continue to be challenged to catch up with the backlog of patients once shelter-in-place orders have been lifted and practices begin to schedule more normally. Providers will soon be overwhelmed with an influx of patients who missed appointments in the first half of 2020. Moreover, as a substantial portion of these patients will be unemployed or present to appointments with insurance changes, FACM will be even more burdensome to practices than before COVID-19. As nonclinical staff, particularly financial counselors, will likely continue to work in a remote or virtual environment for the foreseeable future, the ability to stay connected to the oncology practice and patients who need financial assistance will be critical for success. However, the reality of diminishing healthcare resources and increasing patient demands in the face of this public health crisis will inevitably create a paradigm shift in how oncology practices provide cancer treatments to patients, especially the burgeoning number who suffer from financial toxicity. As strategies for post-pandemic care continuity are developed and refined, oncology practices and providers must recognize that traditional FACM processes are not sustainable, and life science organizations need to understand the impact that COVID-19 is already having, or is expected to have, on their PSPs.
COVID-19 impact on patient support programs
The economic downturn is expected to result in greater demand for PSPs. In general, a spike in bridge supply of treatment and temporary financial assistance for many cancer patients should be anticipated. The industry also should expect a higher need for financial assistance via co-pay support for patients with commercial insurance and an increase in demand for targeted free and replacement drug for those who lost insurance coverage. Among workers losing ESI, it is estimated that 12 million to upwards of 21 million will gain Medicaid coverage. Given that unemployment rates have reached unprecedented heights during the COVID-19 pandemic, exorbitant increases in Medicaid coverage will strain state budgets, restricting already limited resources in the very communities hardest hit by the crisis.7 Additionally, in the mid to long term, life science field reimbursement managers who work with healthcare providers on access and reimbursement information will continue to have difficulty getting face-to-face time with oncology physicians, who are already overwhelmed with a backlog of cancer patients. Consequently, it will be challenging for physicians to keep PSPs at the forefront of their workflow, further compounding the imbalance of resources and demands. To blunt this impact, life science organizations should focus on digital integrations with providers and, more specifically, work with oncology practices to employ novel solutions that seamlessly connect their PSPs with provider workflows.
The traditional approach to financial assistance cycle management is not sustainable
In a previous paper,4 we detailed the problems associated with the traditional approach to FACM. In brief, the processes utilized by many oncology practices are both manual and fragmented. The go-to tools used by administrative staff, typically financial counselors, are sticky notes and spreadsheets. Staff struggle to balance working with these manual tools while navigating hundreds of patient access portals. These endeavors are compounded with filling out enrollment forms with redundant data entry and taking copious notes to keep track of eligibility determinations and financial awards. Moreover, financial counselors work with hub services from life science organizations regarding their PSPs via telephone, email, and/or fax to triage questions and complete patient enrollments. This process can take weeks to complete. Meanwhile, patients in need of financial assistance experience delays in cancer treatment, and practices caring for these patients incur bad debt or payment delays.
In addition to the manual and fragmented processes commonly employed, most practices apply a reactive—rather than a proactive—approach to FACM. As a result, a significant number of patients who qualify for financial assistance are unaware of the existance of PSPs offered by life science organizations and others, and those who are aware typically self-select into these programs.15,16 Consequently, patients with the greatest financial need or at highest risk for bad debt may not receive available assistance and, therefore, struggle to afford their prescribed cancer treatments. In response to financial toxicity, patients may forgo or delay treatment. Some may resort to not getting prescriptions for treatment filled or not taking treatments as prescribed, including skipping doses and cutting oral medications in half, in efforts to make trade-offs with their financial spend (eg, pay for food vs pay for medication) and/or conserve treatment doses. Just as changes to usual oncology practice are necessary during the public health crisis inflicted by COVID-19, so too are changes needed to FACM.
Digitally connecting patient support programs with technologies focused on provider integration is imperative
The traditional, reactive approach to FACM entails treating, billing, and then dealing with the financial toxicity experienced by the patient and their family.8 For reasons described more fully above, oncology practices need to utilize a proactive approach to FACM, one that anticipates and prevents financial toxicity, then treats the patient. Considering the limited resources and time that providers and administrative staff have available for comprehensively vetting the myriad PSPs offered in the marketplace, it seems reasonable that technology-based solutions that streamline FACM processes are warranted. An exemplar case of this approach is AssistPoint®, an FACM software platform developed by Annexus Health.
AssistPoint® is a workflow platform that functions as a data aggregator and single-point destination for oncology practices to search, enroll, track, and analyze a patient’s third-party financial support options, including PSPs. The platform is designed to assist practices with identifying and applying for financial support after a patient has been diagnosed with cancer and the prescribing oncologist has established the applicable treatment plan. Due to the unique nature of cancer treatments and reimbursement options, financial counselors within these practices are most often responsible for assessing a patient’s ability to pay for treatment, helping patients understand billing and reimbursement information, navigating PSP options, and assisting patients with enrollment in PSPs offered by life science organizations and others.17 Among the many features, the platform includes workflow functionality, allowing practices the opportunity to integrate their electronic health record (EHR) and practice management (PM) system with AssistPoint® to connect front-end patient, treatment, and other relevant information with back-end billing, payment, and financial support within the software solution—as opposed to an otherwise manual and time-consuming process. This connectivity enables financial counselors to automate much of the PSP application process by allowing the digital exchange of information and prepopulating certain patient information from the EHR and/or PM system, accelerating the application and enrollment processes and continuously monitoring and measuring financial award balance activity for all patients in the practice.
For life science organizations, AssistPoint® includes functionality that allows PSPs to connect and automate their application and enrollment workflows within the platform, improving the ease of access for both providers and patients. Patient support programs that connect with AssistPoint® can essentially sync their portal and application process to the platform, giving providers and patients the convenience of applying for financial assistance within a single location. AssistPoint® provides secure data relay connections that allow providers and PSPs to exchange information, providing more of an end-to-end experience for financial counselors. Annexus Health also delivers a customized, on-demand analytics portal to its life science connectivity partners, which can aid them in allocating resources and improving market access strategies and services. Aside from the overall value of improving patient access to the prescribed treatment, the main value drivers for AssistPoint® to PSPs offered by life science organizations are efficiency and user experience.
Too often in oncology care, financial toxicity ultimately drives treatment decisions, influencing patient outcomes. The COVID-19 pandemic has presented unique challenges and learning opportunities for oncology practices.14 While the future trajectory of this pandemic is uncertain, rising unemployment rates are expected to significantly alter the health insurance coverage landscape for the foreseeable future,7 and the long-term financial impacts will be future challenges that both patients and practices must face.14 During these uncertain times, it is prudent that many more oncology practices adopt a proactive approach to FACM. Additionally, life science organizations have the opportunity to play an important role in FACM. AssistPoint® is a software platform that digitally connects providers and their patients with available PSP options in a more direct, time-efficient, and satisfying manner than the traditional, unstructured process of FACM. Life science organizations that utilize AssistPoint® can compress the workflow required to access their PSPs, thereby reducing the burdens confounding a proactive approach for providers and patients and improving the overall user experience.
About the contributor
Tim Koenig is the lead for Life Science Solutions and Marketing at Annexus Health. With over 20 years of commercial experience in life sciences, Tim embodies a patient-centric mindset to fuel his passion for developing innovative solutions that make a meaningful difference in patients’ lives. He is dedicated to working with life science organizations to seamlessly connect patient access programs with providers, ultimately enabling patients to access and better afford their prescribed treatments.
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