Higher insurance premiums, deductibles, and co-pays, along with the increased cost of cancer care, have made it more complicated to find aid.
Robin Zon, MD
Not too many years ago, it took only a rudimentary search for financial counselors at Michiana Hematology Oncology’s Advanced Centers for Cancer Care in Indiana to find financial aid for the few patients, primarily those without insurance, who needed it. Since then, higher insurance premiums, deductibles, and co-pays, along with the increased cost of cancer care, have made it more complicated to find aid. Approximately 40% of insured patients at the practice now need financial assistance. Moreover, sources of assistance, such as foundations, have not been able to keep up. Their funds become depleted rapidly, often requiring practices to widen their searches and work more hours.
“The foundations and drug manufacturers are doing their best to try to keep up, but the demand has gotten out of hand” said Robin Zon, MD, medical oncologist practicing at Michiana Hematology Oncology in Elkhart and Mishawaka, Indiana.
Because of the rising volume of patients who need financial help, many practices such as Zon’s are turning to software tools developed over the past decade. These include automated online applications, electronic health record (EHR) notifications about patient assistance programs, and cloud-based tools that can search for oncology assistance programs and enroll patients.
Automated Search and Application Increases Efficiency
Physicians and financial counselors interviewed for this story added that increasingly specific drug indications and eligibility rules for many assistance programs have made it more challenging to deliver affordable care to patients and maintain financially sustainable community practices.Cicely Wang, patient advocate at Broome Oncology in Binghamton, NY, a six-physician practice, stated that she spends approximately five hours per day searching for financial assistance for patients. “One of the first things I do in the morning is to go on the computer and see which funds I can access and whether I need to look further,” she said. Online applications now possible for most of the third-party foundations that provide patient assistance have helped cut the approval time from weeks to minutes; however, the fund depletion rate can be equally fast.
Wang has found this out the hard way when funding sources have been exhausted during the several minutes it took her to fill out the application. She attributed the rapid depletion in part to the fact that many foundations are not receiving as much money as before from major sources, such as pharmaceutical companies. “Foundation funds are drying up for big diagnoses,” said Wang. “We’re having to look further into smaller sources, and patients continue to come in needing assistance.”
Wang also said that patients often need additional expensive agents to counteract the side effects of chemotherapy, making it necessary to fill out multiple applications. “If I could do just one application and get all the funds at once, that would be huge,” she said.
With this increasing workload, many financial counselors are using new products designed to save time. These products have many advantages, but they do require a transition period for training and implementation that many busy practices are hesitant to initiate, and they have other limitations that are described below.
To aid in the search process, Shelly Rentsch, administrator of Gabrail Cancer Center in Canton, Ohio, uses Clinical Decisions Gateways (CDG), a program developed by Altos (currently Flatiron) that identifies drug-specific financial assistance and support programs and enables enrollment directly through the electronic medical record (EMR). “CDG identifies patients with a certain diagnosis and on a certain medication, and if there’s a [financial assistance] program that is associated with that drug, the system alerts us,” said Rentsch. However, she must still perform additional research for patients, such as those on Medicare, who do not qualify for patient assistance programs sponsored by pharmaceutical companies.
Last February, Zon’s institution began using assistPoint, a cloud-based platform developed by onPoint Oncology and Unlimited Systems that enables users to search for financial assistance from oncology foundations and pharmaceutical drug companies. Lori Fleischauer, financial counselor at Michiana Hematology Oncology, stated that the program has dramatically improved efficiency at their practice. “Before using the software, some patients got money that they didn’t use, while others needed money and were unable to get it. With this program, you can get [patients] registered for exactly what they need with far less administrative burden and research.” The software has helped Fleischauer discover new sources of funding, and a higher proportion of her patients are qualifying for assistance from foundations that she has previously used. Furthermore, assistPoint has improved communication among Michiana’s practice sites, which are spread out throughout the state of Indiana. A counselor based in one county can write a note in the system that will inform decisions by counselors based elsewhere, said Fleischauer.
Sarah Schlegel, financial counselor at Cancer and Blood Care in Ponca City, Oklahoma, acknowledged that programs like assistPoint can be useful for large practices, but stated that her independent practice with just two physicians is hesitant to implement assistPoint currently. “We don’t feel comfortable importing patient information into a software that we don’t know,” said Schlegel. “It sounds good for a hospital, where several people need to keep track of who is getting assistance, but in our practice, only I need to keep track.” She suggested that a simpler Web-based tool would be more useful, one that allows her to search for patient assistance by diagnosis, drug, or insurance type, and without requiring her to upload patient information.
Challenges Beyond Technology: The Highly Specific Financial Assistance Programs
Roberta Buell, content director for assistPoint, and Joe Gockerman, director of product development at Unlimited Systems, acknowledged that while the software can make it easier to navigate multiple websites and spreadsheets, implementing a new technology into a busy environment is challenging. “The result of that is a lot of potential for success, but it also forces them to adapt to a new system,” said Gockerman.Even the best technology cannot take care of everything related to financial assistance. There is still a need for human involvement. For example, some patients may not fully disclose their financial need until they have a large bill extending several months back. Wang checks in with patients who are not upto- date on their payments to help them obtain assistance if necessary.
In addition, changes in patient employment status or state Medicaid policies may fly below the radar of search tools, Schlegel said. She cited the case of a patient on disability leave with metastatic lung cancer who lost eligibility for Medicaid during his chemotherapy regimen due to policy changes in Oklahoma. He was told the expected waitlist time for early Medicare was two years—equivalent to his life expectancy—and only Medicare recipients could qualify for the only financial assistance programs for his cancer. The practice donated funds to finish the patient’s chemotherapy regimen and was eventually able to help him obtain a private insurance plan.
Navigating the strict requirements for financial assistance can be frustrating and may even dictate the type of chemotherapy a patient receives, Schlegel said. “The doctor will want to prescribe a treatment but if they have Medicare without secondary insurance, they could have an $800 deductible. So, we have to give them a different injection, even if is not preferred by the doctor for clinical reasons.”
Also, financial assistance for a chemotherapy drug through a pharmaceutical assistance program does not cover the multiple associated costs, such as port flushes, co-pays for doctor’s visits, additional blood work, or administration and transportation of the drug, which could strain the practice financially if it had to cover these costs, Schlegel said.
Physicians and financial counselors said they are frustrated by the number of Medicare patients who are turned down for assistance by pharmaceutical company programs. Nashat Gabrail, MD, a medical oncologist at Gabrail Cancer Center, said efforts should be made to improve the scanty financial assistance options for Medicare-insured patients versus what’s available for third party-insured patients. He described a recent conversation with a congressman who was unaware that it is “almost impossible” for a Medicare recipient to receive financial aid from pharmaceutical assistance programs. “This requires lobbying and diligent explanation to policy makers,” Gabrail said.
Growing Need for Financial Assistance Requires Automated Processes Extra staffing and software has become necessary to maintain the success of financial counseling efforts, and Zon said that for her practice the investment has been worth it. But the extra cost of a large financial counseling staff may not be feasible for some community practices. If the community practice cannot find financial assistance, the patient may be sent to the hospital, which, according to Zon, begins a “vicious cycle” in which treatment costs escalate and business declines for the community practice.
Zon also believes that with the effective—albeit expensive—treatments improving long-term survival of patients with cancer, reducing the number of patients who need financial counseling is unlikely in the near future and will require more tools to improve administrative efficiency. “There’s so much pressure on the patient to support the cost, and it’s not sustainable for them.” To help patients manage their treatment financially, Fleischauer and the other financial counselors at Zon’s practice receive additional in-house and external training and utilize resources from the Association of Community Cancer Centers financial advocacy network. They are also currently pursuing certification to become insurance navigators in Indiana.