Guiding Patients Through Cost-Based Treatment Choices

Having a conversation with patients about the cost benefit of their cancer treatments is difficult, and many clinicians are unprepared for this discussion. Fortunately, however, resources are becoming available to help clinicians aid patients in determining how much they are willing and able to pay for treatments that may cure them—or only buy a few extra weeks of life.

PAF Brochures for Providers and Patients
At the annual meeting of the Ameri can Society of Clinical Oncology, representatives from the Patient Advocate Foundation (PAF) unveiled a primer for providers on discussing healthcare treatment costs with patients (www.patientadvocate.org/pdf/pubs/gu_provider_cost.pdf) and a companion brochure for patients.

Beth Patterson, President of Mission Delivery at the PAF, said the material is being well-received, as is the foundation’s advice to clinicians dispensed over the phone on how to help patients make what can be extremely tough decisions.

“Providers realize the financial implications of medical care are a major issue for their patients, but it falls outside the scope of their healthcare training,” Ms Patterson explained. “It’s not an area that they’re confident and comfortable in talking about yet. So they’re very appreciative of having at least a starting point.”

She said the 4 recommendations that providers have found most useful are:

• Gain the patients’ trust and encourage them to see their relationship with you as a partnership. This will help ensure open and honest communication
• Ensure that your staff creates a chart of insurance plans with which your office is contracted, and list each one’s referral requirements. Also create a list of approved facilities for such services as laboratory tests, blood work, imaging, and hospital admittance
• Have your office verify what type of coverage each patient has, and arrange a meeting with the patient to discuss the treatment protocol and out-of-pocket requirements
• Have a list available in your office of practical and financial resources for patients, including the Patient Advocate Foundation, CancerCare, the American Cancer Society, and the National Coalition for Cancer Survivorship. The list should also include resources such as national copay programs, discounted drug programs offered by pharmaceutical companies and pharmacies, and pharmaceutical companies’ indigent-drug programs. Charity-care programs that are available through the physician’s local office/institution/community should also be listed. “Unless patients are in a financial crisis, and unless they locate one of these charity-care programs on their own, they might not be aware that these are options,” said Ms Patterson.

Guiding Points of Discussion
A recent study corroborates that patients may be less willing to commit to high copayments for treatments with modest benefit (Wong YN, et al. Understanding how out-of-pocket expenses, treatment value, and patient characteristics influence treatment choices. Oncologist. 2010;15:566-576). It also showed patients who had made sacrifices to be able to afford treatment in the past were far less willing to accept higher copayments than were those who had not made such sacrifices. This can be critical information for clinicians, says lead author Yu-Ning Wong, MD, MSCE, Attending Physician and Assistant Professor, Medical Oncology, Fox Chase Cancer Center, Philadel phia, PA.

“If a patient wants to go for broke for their treatment, that’s a personal decision, but we need to help them put it in context of their other financial responsibilities,” she told Value-Based Cancer Care. “It was only after one of my patients died that I found out his wife had spent all their money providing for his care...Should families spend a significant portion of their savings on noncurative treatments that may only extend life for a short period of time? Those are uncomfortable conversations, but we need to get better at having them.”

The authors of a 6-step protocol for discussions about the cost of medical care proposed using the simple question, “Are you having financial worries about your treatment?” to broach the topic (McFarlane J, et al. SPIKE$: a sixstep protocol for delivering bad news about the cost of medical care. J Clin Oncology. 2008;26:4200-4204). They also recommend modifying the standard patient–physician discussion form to include financial issues such as levels of copayments, out-of-pocket payments, and any insurance denials. They suggest a discussion that follows the acronym SPIKES—Setting and listening skills, Patient perception, Information, Knowl edge in giving facts, Explore emotions and options, and Strategy and summary—to ensure financial issues are covered.

“If we want patients and families to make the most informed decisions, the oncologist must give an honest and realistic estimate of the benefit of a treatment and put that in terms relative to its cost,” urge the authors. “Almost all data suggest that patients want us to give them the most complete information available, even if they choose to ignore it or misinterpret it.”