Practices Ill-Equipped for Patient Financial Needs

Gina Villani, MD

The swift increase of cancer care costs has created difficulties for independent oncology practices, but the largest of the challenges may be finding a financially sustainable way to provide good care to patients who cannot pay all of their own bills.

The Affordable Care Act (ACA) was designed to get more Americans the insurance they need to cover major medical expenses in full, and the percentage of American adults without insurance has fallen from 20.3% to 13.2% since passage of the healthcare act, according to statistics released earlier this year by the Department of Health and Human Services.

However, many patients who obtained policies through ACA exchanges have limited coverage for cancer care. Others are overwhelmed by the growing copays demanded by the traditional plans they receive through their employer. Still others lose their insurance when they go out on disability, only to find themselves unable to afford continuing insurance.

The Commonwealth Fund Biennial Health Insurance Survey of 2014 found declines in the number of people reporting cost-related access problems and medical— related financial difficulties.1 The number of adults who did not get needed health care because of cost declined from 80 million people, or 43%, in 2012 to 66 million, or 36%, in 2014, the study said. Still, the study found that even among patients with insurance, cost barriers were an issue in obtaining adequate medical care.

All providers thus need strategies for providing good care to underinsured patients without bankrupting themselves. Ample resources are available for bridging the gap between the costs of care and what patients can afford, says Gina Villani, MD, the CEO and medical director of the Ralph Lauren Center for Cancer Care and Prevention in Harlem, which specializes in charity care. “There is always money available somewhere for patients who cannot afford the best treatment for themselves. It’s not always easy to find, but with all the programs both public and private, there is money there for everyone. What’s more, it’s the practice’s responsibility to find it. Sick patients cannot deal with the complexities of medical finance on their own,” Villani says (Figure).

Debra Patt, MD

Oncology practices are generally in a better position than their patients to understand who qualifies for what programs—and to fill out the applications for those programs—but practices that rarely need to find such help for their patients may struggle to do it efficiently. Villani, therefore, offers an unexpected piece of advice to practices that genuinely feel ill-equipped to serve needy patients: direct as many of them as possible to practices, like hers, that specialize in serving the underinsured and disadvantaged.

The result may be that patients end up getting better care than by sticking with the original practice, she says.

“Many facilities clearly have no desire to care for patients who can’t pay. I did a ‘secret shopper’ experiment and tried to set up initial appointments at a variety of different institutions including public, private, and safety net hospitals. Wait times for appointments were significantly longer for uninsured and underinsured patients than well-insured patients. Practices that don’t want particular patients would serve those patients better by sending them to places that do want them, rather than giving them second-rate care,” Villani says.

“Even places that are seriously committed to providing top-quality care to patients with financial issues should think about encouraging those patients to go to places that specialize in underserved patients. Practices that rarely care for underserved patients do not have the sort of expertise that specialty practices have in getting them medical coverage,” Villani says. “They do not have the expertise that specialty practices have in getting truly poor patients support services like nutrition assistance. They do not have the expertise that specialty practices have in getting vulnerable patients to comply with treatment protocols. I know it can seem callous to send a patient elsewhere, but it can be the best thing for the patient because if there’s one thing that’s true of cancer care, it’s that specialization breeds success.”

Villani’s advice may be a workable option for independent practices that rarely encounter patients who cannot pay for care, at least those in parts of the country that are heavily populated enough to have practices that cater to needy patients. Many practices, however, need an economically feasible way to provide good care for such patients in-house, either because there are no specialty practices in their service areas or because so many of their patients struggle financially that it simply makes sense for them to develop expertise.

Figure. Both Uninsured and Insured Adults Report Having Medical Bill Problems

^aHad problems paying medical bills, contacted by a collection agency for unpaid bills, had to change way of life in order to pay medical bills, or has outstanding medical debt.

^bFPL refers to federal poverty level. Income levels are for a family of four in 2013.

^cIncome level.

Source: The Commonwealth Fund Biennial Health Insurance Survery (2014).

Different practices have taken different approaches to this. They are moving away from making physicians, nurses or administrators help patients find money and toward hiring people who specialize in payment assistance. Different practices have different titles for these workers, titles that range from “financial consultants” to “patient navigators.”

Texas Oncology, a large practice with offices across the Lone Star State, has social workers at some locations to find help for patients who need it.

“There are so many different programs from federal and state governments and—here in Texas, at least—county governments as well, along with those offered by pharmaceutical companies and cancer organizations. It is a very complex landscape, but we are fortunate to have a social worker in our office who does an incredible job figuring out which patient qualifies for what assistance and getting them enrolled in programs they need to obtain treatment,” says Debra Patt, MD, who treats patients at Texas Oncology’s Austin Central office and directs health economics and outcomes research for the US Oncology Network.

Practices that cannot afford to devote a single full-time staff member to helping their patients secure coverage for cancer treatment may have to make financial assistance duties a small part of an existing employee’s job. This could mean forgoing the effectiveness that comes with specialization. However, there may be another option that delivers expertise at a reasonable expense. “Practices that cannot hire people who specialize in helping patients who need extra help should set up a meeting with the people who run their local hospitals and see if they can tap some of the experts those hospitals keep on staff,” says Lovell Jones, PhD, a professor emeritus at MD Anderson Cancer Center and associate dean for research at Prairie View A&M University College of Nursing.

Jones has spent much of his career researching best practices for providing better medical care to underserved patients. His research has suggested patient navigators (both medical and financial) improve patient outcomes while reducing total costs. “Underserved populations who receive patient navigation services report fewer disruptions in care and are more likely to complete required treatment,” one of his studies concluded.2

Lovell Jones, PhD

Jones says that the idea of teaming up with hospitals for patient navigation may seem risky from a competitive standpoint, “but it makes sense for everyone. If the hospital declines to provide assistance—or at least rent its experts out for a reasonable cost—the patients that don’t manage to find coverage through whatever assistance their oncologists can offer will tend to skip appointments, take half as much medication as they should, get very sick, or go to the hospital emergency room and stay there for a long time before failing to pay the bill,” Jones says.

“No organization has a greater incentive to keep poor patients out of the emergency room than the local hospital, so if you can convince them that lending their expertise is a good way to reduce uncovered emergency department bills—and the research I’ve worked on concerning navigators for lung cancer patients suggests that they do save large amounts of money—then everyone wins,” Jones says. “It may not work every time, but it should probably be Plan A for a lot of practices.”

References

1. Collins S, Rasmussen P, Doty M, Beutel S. The rise in health care coverage and affordability since health reform took effect. The Commonwealth Fund. 2014. http://www.commonwealthfund. org/~/media/files/publications/issue-brief/2015/jan/1800_collins_biennial_survey_brief. pdf?la=en. Accessed September 23, 2015.
2. Pereira AN, Enard K, Nevarez L, Jones LA. The role of patient navigators in eliminating health disparities. Cancer. 2011;117(15):3543-3552. http://www.commonwealthfund.org/~/media/ files/publications/issue-brief/2015/jan/1800_collins_biennial_survey_brief.pdf?la=en. Accessed September 23, 2015.