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.”