Practices Should Refocus Efforts on Helping Patients Address Financial Toxicities

Optimizing clinical pathways to address financial toxicities faced by patients with cancer requires a complex, multifaceted approach. However, even small in-practice changes may ease the financial burdens and improve outcomes.

Validated measures to describe, quantify, and qualify have proven difficult to establish across all levels of care.¹ At an institutional level, assessments from the National Cancer Institute’s Community Oncology Research Program (NCORP) and the National Comprehensive Cancer Network (NCCN) have demonstrated that despite nearly three-fourths of practices having financial screening methodologies in place, effective management protocols are not established.^2,3 Using a benchmark of 75% of NCCN centers (n = 17) having a financial screening process, reports in the community setting were comparable.^2,3 Among 221 practices, 72% had a financial screening process, with 50% reporting a cancer-specific financial navigator among their staff.³

Despite the high rates of screening, the most common method for financial screening was identified as in-take forms (68%), which investigators noted may only highlight insurance-related burdens.3 Financial burden of care can influence several aspects of patient quality of life, the most prevalent 3 being material consequences (ie, out-of-pocket expenses, debt, decreased income), psychological effects, and deleterious coping mechanisms (ie, delaying care, nonadherence).⁴

Results of a recent survey of individuals with cancer who received treatment at ambulatory infusion centers (Mayo Clinic in Phoenix, Arizona; and Mississippi Medical Center in Jackson) showed that financial hardship has been demonstrated most predominantly in patient-reported findings. Using several measures, the range of financial hardship was reported in 48% to 68% of participants.⁵ The authors found that financial literacy may be integral in reducing adverse outcomes and that interventional programs are needed to increase literacy and aid those without it.

“Patient-reported financial hardship from cancer treatment is a growing challenge,” Khera et al wrote in the study.⁵ “The field of financial hardship is now shifting toward interventions. Understanding the association between health insurance literacy and financial hardship and how financial literacy may change this association is important because these factors are potentially modifiable.”

One of the crucial tools used to determine f inancial literacy is the FACIT-COST assessment (Financial Toxicity—Functional Assessment of Chronic Illness Therapy Comprehensive Score). This uses a scored assessment (range, 0-44) with lower scores indicative of higher burden.⁶

Topics in the FACIT-COST include the following⁶:

• I know that I have enough money in savings, retirement, or assets to cover the costs of my treatment.
• My out-of-pocket medical expenses are more than I thought they would be.
• I worry about the financial problems I will have in the future as a result of my illness or treatment.
• I feel I have no choice about the amount of money I spend on care.
• My cancer or treatment has reduced my satisfaction with my present financial situation. My illness has been a f inancial hardship to my family and me.

Additional tools include the National Health Interview Survey and the Health Insurance Literacy Measure, which captured insights on an individual’s ability to evaluate health plan information and select the best plan to cover their health circumstances.⁵

Methods of Tackling Financial Toxicities

of NCCN centers reporting financial assessments, only 56% reported repeating that assessment. Results from an additional study of NCORP sites showed that patients with metastatic colorectal cancer experienced a “major financial hardship” defined as major debt, loans, refinancing, or a loss in income of at least 20% of cases within in 3 months of starting treatment.^2,3

The NCORP investigators proposed adapting the 5As approach, which has had success in smoking cessation, to tackling financial toxicity in the community setting: ask, advise, assess, assist, and arrange.³ Major components of effectiveness rest in the assess and assist steps. Financial navigators, nurses, and clinicians can assess whether altering treatments alleviates the financial burden and reduces nonadherence issues. They then can assist in updating and monitoring outcomes to ensure continued effective care.³

Takeaways from several studies presented during the 2022 American Society of Clinical Oncology (ASCO) Quality Care Symposium showed efforts are underway to assess integrative approaches to tackling financial hardships in practice.^7,8

Investigators at The Ohio State University in Columbus implemented a study to identify patients with breast, lung, or hematologic malignancies who stated they had financial hardships and to optimize pathways to connect them with appropriate services.⁷ At 3 clinics—surgical breast oncology, hematologic, and thoracic medical oncology—no f inancial screening systems were in place. The screening asked, “How hard is it for you to pay for the very basics such as food, housing, medical care, and heating?” Responses ranged from not hard at all to very hard, with the option to not respond. Among 4732 participants, 10% of respondents noted financial hardships by choosing “somewhat hard,” “hard,” or “very hard.”⁷

The investigators proposed a workflow that would cycle patients to the appropriate services; however, several hurdles were identified in the areas of accountability for components of the process. For example, if a patient was identified as having financial hardships, who should put the referral in (eg, nurse, advanced practice provider, physician), how should the referral be documented (eg, phone call, email, consult), and who was responsible for follow-up on the referral?⁷

A second workflow tackling these questions demonstrated a more complex, but staggered patient referral system that identified stakeholders. Following the intake nurse asking a screening question, patients were categorized as urgent or not if they identified as having f inancial hardships. From there, individuals categorized as in urgent need were assigned a social worker, whereas those who were not categorized as in urgent need were place on a weekly list and assigned to a patient navigator who would either address the need or refer the individual to a social worker or financial counselor.⁷

These workflows rely on practices having appropriate staff in place to accommodate the steps of this process. Other areas of need include optimizing electronic health records to record and provide these data to the appropriate parties.

Another study from the O’Neal Comprehensive Cancer Center at University of Alabama at Birmingham came to the same conclusion when examining the referral process in place for patients treated at the gynecologic oncology clinic. In addition to intake questions about ability to afford medication and distress screening conducted by medical assistants and lay navigators, respectively, an additional financial hardship screening using the FACIT-COST was conducted during cycle ^1.8

Referrals to social workers, lay navigators, financial counselors, or other appropriate services were made if difficulties were identif ied. Overall, among 115 patients who had at least 1 financial need, 38 were assisted by a lay navigator and 98 had referrals placed, most of which were with social workers (86.7%). In addition to assistance, the investigators reported qualitative data from 43 patient interviews with most participants reporting that they “felt positively” about the financial questions and considered them relevant to their care.⁸

Universal financial screening is feasible and patients are open to participating, the authors noted; however, a dedicated financial hardship tool is needed. Fully integrating the assessment into workflow to ensure continuity of support for f inancial burdens remains an unmet need.⁸

Beyond the scope of major cancer centers, practice size, resources, and locations in the community setting have varying factors at play that may set them up at an increase for handling cases of greater financial hardships.³

For example, in a recent study, investigators sought to identify gaps in care pathways based on responses from stakeholders in 10 cancer care sites (5 rural and 5 nonrural practices).⁹

Across the sites, the investigators compiled 6 elements that were identified in the financial assistance processes: distress screening, referrals, resource connection points, pharmaceutical resources, insurance, and community. Identified opportunities included more systemic, proactive, and routine distress screening over time; dedicated staff in financial navigation; and the development of infrastructure to track external resource availability. These internal adjustments could take place across practices; however, investigators also noted that system-level reforms also are needed to influence change, including insurance expansion and pharmaceutical cost regulations.⁹

As with the other studies, facilitators were identified as the key stakeholders in implementing continued change. These must be staff members with institutional knowledge and relationships with external resources who are able to assess, process, and enact solutions for patients facing financial hardships, Biddell et al noted.⁹

“Financial hardship is most common among populations who have historically experienced challenges with accessing cancer care, including [individuals] who have low incomes, are uninsured/underinsured, or are racial/ethnic minorities, but financial hardship is becoming commonplace across the economic spectrum,” Yabroff et al wrote.¹ “Advances in expensive cancer treatments threaten to widen disparities in access to care based on the ability to pay. Thus, understanding how institutions and providers identify patients experiencing financial hardship and the strategies used to mitigate hardship and address patient needs is increasingly important.”

Referenecs

1. Yabroff KR, Bradley CJ, Shih YCT. Improving the process of screening for medical financial hardship in oncology practice. Cancer Epidemiol Biomarkers Prev. 2021;30(4):593-596. doi:10.1158/1055-9965. EPI-21-0111
2. Khera N, Sugalski J, Krause D, et al. Current practices for screening and management of financial distress at NCCN member institutions. J Natl Compr Canc Netw. 2020;18(7):825-831 doi:10.6004/ jnccn.2020.7538
3. McLouth LE, Nightingale CL, Dressler EV, et al. Current practices for screening and addressing financial hardship within the NCI Community Oncology Research Program. Cancer Epidemiol Biomarkers Prev. 2021;30(4):669-675. doi:10.1158/1055-9965.EPI-20-1157
4. Dee EC, Chino F. Financial hardship in cancer care-the need to define and intervene on actionable metrics. JAMA Netw Open. 2022;5(7):e2223149. doi:10.1001/jamanetworkopen.2022.23149
5. Khera N, Zhang N, Hilal T, et al. Association of health insurance literacy with financial hardship in patients with cancer. JAMA Netw Open. 2022;5(7):e2223141. doi:10.1001/jamanetworkopen.2022.23141
6. FACIT-COST. Facit.org. Accessed October 8, 2022. bit.ly/3ERxmMI
7. Obeng-Gyasi S. Implementing financial hardship screening in a comprehensive cancer center: what worked and what failed. Presented at: 2022 American Society of Clinical Oncology Quality Care Symposium; September 30-October 1, 2022; Washington DC.
8. Pisu M. The added value of a dedicated screening tool to identify patients with financial hardship. Presented at: 2022 American Society of Clinical Oncology Quality Care Symposium; September 30-October 1, 2022; Washington DC.
9. Biddell CB, Spees LP, Petermann V, et al. Financial assistance processes and mechanisms in rural and nonrural oncology care settings. JCO Oncol Pract. 2022;18(9):e1392-e1406. doi:10.1200/OP.21.00894