Practice Management Curriculum

Communicating with Your Patients about Cancer Care Costs

After this session, you will be able to:• Describe why the costs of cancer care are

problematic• Discuss stakeholder perspectives on the cost

of cancer care • Describe the importance of patient-physician

discussions and challenges surrounding those discussions

• Understand the characteristics, skills and duties of an effective financial counselor

• Identify tools and resources to assist in communicating the costs of cancer care

Cost of Cancer Care

• The cost of treating cancer is a burden for most families who are affected by the disease– 25% of families affected by cancer report

that cost of treatment are a “major burden”– 25% report having used up all or most of

their savings– 11% report being unable to pay for basic

necessities

Source: USA Today/Kaiser Family Foundation/Harvard School of Public Health National Survey of Households Affected by Cancer (conducted Aug 1-Sept 14, 2006)

Cost of Cancer Care• Cancer spending growth will accelerate

– Costly new treatments and new medical technology

– Increase in number of cancer cases as population ages

• Drugs used to treat cancer represent a large expense for patients, hospitals, and oncology practices– High co-pays/coinsurance amounts– Drug cost sometimes exceeds reimbursement

from payers

Stakeholder Perspectives on Costs: Physicians

• Focus on quality care and “healing”• Desire to provide evidence-based care with

the greatest benefit or outcome• Face rising costs/expenses within the practice• Have increasing need to integrate cost

implications treatment considerations and the evaluation of therapeutic alternatives

• Struggle between social responsibility and overall patient constraints

Stakeholder Perspectives on Costs: Patients

• Cost of treatment and out-of-pocket expenses may be an obstacle in obtaining care (delays in treatment or even noncompliance)

• Ability to make optimal treatment decisions • Impression that price of treatment may be

related to outcome or quality care• Depletion of savings and personal bankruptcy• Employment status concerns during treatment• Concern about burdens placed on family

members

Stakeholder Perspectives on Costs: Payers• Control costs

– Increase in patient financial responsibilities and possibly limit coverage

– Increase in prior authorizations, developing formularies, scrutiny of off-label coverage

– Updating policies and contractual agreements (changing reimbursement)

• Measure quality and outcomes• Support evidence-based medicine

Stakeholder Perspectives on Costs: Industry• Goal is to develop new devices, drugs

and biologicals aimed at improving diagnosis and treatment

• Rising developmental/production costs– Leads to increased prices for new products

• Patient assistance programs for those who cannot afford to pay– Scaling back some programs and/or

limiting eligibility

A Survey of Oncologists on Communication

• Perceptions

Schrag, D and Hanger, M: Medical Oncologists’ Views on Communicating With Patients About Chemotherapy Costs: A Pilot Survey. Journal of Clinical Oncology 2:233-237, 2007

Always/Mostly

Sometimes

Rarely/

Never

I have a sense of my patients financial well-being

54 33 13

Paying for cancer treatment is difficult for my patients

37 52 11

Costs influence my patients’ decisions about treatment

23 46 31

A Survey of Oncologists on Communication

• Attitudes and Philosophy

Schrag, D and Hanger, M: Medical Oncologists’ Views on Communicating With Patients About Chemotherapy Costs: A Pilot Survey. Journal of Clinical Oncology 2:233-237, 2007

Strongly

Agree/ Agree

Neither Agree

nor Disagree

Strongly

Disagree/Disag

ree

It is important to be explicit with patients about the financial consequences of treatment options

80 10 10

It is important for patients to understand the cost of their treatments even if they do not bear it directly themselves

72 17 11

A Survey of Oncologists on Communication

• Behaviors

Schrag, D and Hanger, M: Medical Oncologists’ Views on Communicating With Patients About Chemotherapy Costs: A Pilot Survey. Journal of Clinical Oncology 2:233-237, 2007

Always/Mostly

Sometimes

Rarely/

Never

I am comfortable discussing costs of cancer treatment with patients

37 32 31

I discuss the costs of cancer treatment with my patients

42 32 26

A Survey of Oncologists on Communication

• Behaviors

Schrag, D and Hanger, M: Medical Oncologists’ Views on Communicating With Patients About Chemotherapy Costs: A Pilot Survey. Journal of Clinical Oncology 2:233-237, 2007

Always/Mostly

Sometimes

Rarely/

Never

I refer my patients to a third party such as a practice administrator or billing representative

46 30 24

I refer my patients to a third party when recommending high-cost treatments

63 19 18

Survey Summary• 80% of oncologists agree or strongly

agree that it is important to be explicit with patients about the financial consequences of treatment options

• BUT only 37% are always/mostly comfortable discussing costs of cancer treatment with patients

• What does this all mean? Discussions on cost of treatment do not always occur

Why is communicating with patients about cost

important?• Key component of providing high-

quality care• Treatment discussions and decisions

can be optimized• Contributes to overall well-being of the

patient• Minimizes financial risk for patient and

practice

• An estimated cost of treatment (by cycle, regimen, or overall treatment)– Acknowledgement that treatments/options may be

costly

• An explanation of the “value” of the proposed treatments– Benefits/outcomes

• Financial and supportive services– What the physician/ practice can do and what the

patient/family can do

• Periodic review of financial responsibility

What Patients Need

Goals of Communicating with Patients about Cancer Care

Costs• Help patients understand treatment options and cost

implications • Identify patients at financial risk

– Communicate with the patient care team to develop appropriate treatment options

– Investigate patient financial assistance programs

• Improve practice-patient relationships• Contain or minimize expenses/costs to both the patient

and the practice

• How do you lay the ground work for communication?

Cost is Important for All Patients

• Uninsured• Underinsured• Even patients with “good” health

insurance have increasingly substantial copayments

Challenges in Communicating about Cost of Cancer Care

• Physician and practice challenges– Treatment data (benefits/outcomes) is not

always readily available or publicly accessible– Cost-effectiveness data on most cancer

therapies are “scarce” – Utilization data on effective treatments is not

available– Physician time constraints– Reimbursement/economic challenges – Difficult conversations to have

Challenges in Communicating about Cost of Cancer Care

• Patient and family challenges – Uncomfortable discussing financial situations or

concerns with physicians– Believe the physician does not have time for this

type of discussion– Concern that treatment recommendations

and/or decisions will be based on financial status – Concern that practices don’t offer assistance or

payment options• Assistance finding outside resources, offering

payment plans

Cost of Care Discussions in the Practice

• Cost of care discussions require a team approach– The oncologist

• May or may not be comfortable with cost discussions

• Time is at a premium

– The financial counselor– Others?

• Nursing• Business office

The Financial Counselor

• Identify the staff responsible or dedicated to this task – May be a new position – Duties may be divided amongst several staff

• Practice size, patient demographics, payer mix will help define the type of position

• Experienced in accounts receivable, patient accounts, social work, or patient advocacy

Characteristics and Skills• Excellent communication skills• A good listener• Friendly, outgoing, non-threatening• Analytical• Experienced and knowledgeable about

oncology care• A willing patient advocate

– Patient focused and unafraid to inquire about patient’s finances

Key Duties• Establish a communication line

– With patient and family/caregivers and physician

• Develop a counseling process within the practice– Remember this should be a team effort – the

physician and his/her staff

• Educate patients and family/caregiver about insurance benefits, co-pays, co-insurance amounts, and any insurance limitations

Key Duties• Determine costs associated with treatment

plans and identify areas of financial risk• Educate patients and their

family/caregivers about practice policies, their insurance benefits and their financial obligations – Establish expectations for co-pay, co-insurance

collections

• Monitor patients’ insurance for changes in coverage and benefits

Key Duties• Help patients obtain outside financial

assistance when needed – Includes governmental resources and drug

assistance programs

• Match the patient’s financial situation to an appropriate care setting – Some services may be outside of the

practice

Key Duties

• Meet regularly with the patient and the family/caregiver – Re-evaluate patient’s situation as

necessary

• Communicate, communicate, communicate– With the patient and the patient care team

Best Practices

• Meeting with the financial counselor must become an integral part of the patient care process

• New patients meet the financial counselor as part of the intake process– Include patient’s family or other caregivers– All chemotherapy patients should meet with

the counselor before starting a regimen

Best Practices

• Regular meetings should occur – Watch for changes in job status or insurance

coverage– Re-evaluate eligibility for government or state

programs and drug assistance programs

• The financial counselor should be a resource for patients, their family or caregivers, clinical staff, and the physician

Meeting with New Patients

• Before the first visit– Verify demographics and insurance benefits– Obtain applicable referrals, authorizations or

pre-certifications

• At the first visit– Review insurance benefits and financial

responsibility– Introduce patient and patient’s

family/caregivers to practice policies including co-pay, co-insurance collection policy

Meeting with Established Patients

• Financial Care Support– Routinely inquire about changes to

demographics and insurance information– Re-verify insurance benefits periodically or

when known insurance changes occur– Review insurance benefits and financial

responsibility if/when treatment plan changes– Answer questions about statements and other

financial issues

Clinical Trials Present Additional Challenges• Extra time will be needed to verify

insurance eligibility and coverage– Coverage for clinical trials varies

considerably from one plan to another– Important to take the time to understand

coverage before treatment starts

• Confirm that “standard of care” services are covered in the clinical trial setting

Indigent Patients

• Generally patients who are unemployed, uninsured, or underinsured– Assist patients in applying for local, state

or federal assistance– Indigent patients are often eligible for drug

assistance programs through pharmaceutical companies or nonprofit organizations

Indigent Patients

• Treatment for patients receiving drug assistance still represents a cost to practices – This is OK– Practice needs to budget and monitor

these costs (plan accordingly if possible on an annual basis)

– Taking care of patients means taking care of the practice, too

Help Patients and Keep Your Practice Viable

• High costs of cancer care and challenges of today’s economy create a difficult challenge for practices

• We must balance the financial needs of our patients with the financial viability of our practice

• An important time to review your practice’s revenue cycle processes

The Revenue Cycle

• Review the entire revenue cycle from front office operations through collections

• Ensure that your providers are documenting and charging for appropriate levels of care

• Review your charge capture processes• Make sure that billers are submitting clean

claims in a timely manner and appropriately managing accounts receivable

• Ensure that insurers are paying you according to contract and in a timely fashion

Understanding Bad Debt

• It is important to understand and monitor bad debt in your practice

– Don’t include bad debt and charity care in your contractual allowances

– Don’t use historical numbers for bad debt and charity

• You want to ask “Am I doing as well as I can?” and “Is bad debt or charity care increasing?” NOT “Am I doing as well as I did in the past?”

Understanding Bad Debt

• Do calculate an allowance for bad debt and charity care– First load your contractual allowances by payer

– You must know what you SHOULD collect and what you DID collect

• Your practice management system (PMS) should be able to do this– You don’t have to load every contract; focus on

your top 5 or 6 payers and report against them

Keys to Reducing Bad Debt• Assess the practice’s financial exposure to bad

debt posed by each patient• Help low-income and other patients with

financial hardships – Obtain outside assistance to pay their medical bills

• Arrange acceptable payment plans with underinsured and self-pay patients when needed

• Carefully monitor the financial status and treatment plan of all patients for any changes that might reduce or increase their ability to cover treatment costs

Identifying Resources

• An important part of the financial counselor’s responsibility

• Drug specific resources such as manufacturer programs; disease specific resources such as nonprofit foundations

Treatment Plan Tool• Some practices use these multi-purpose

tools available in the marketplace– Identifies the treatment options available to

the patient– Provides an estimation of cost for the patient

and a tool to develop payment plans– Important in both initial chemotherapy

regimens and changes in treatment– Detail or summarize known outcomes

Treatment Plan Tool• Tool may include the following information

– Regimen name – Drugs/doses– Regular procedures performed– Frequency/duration– Co-pay/co-insurance amounts (drugs and

procedures)– Calculation of total patient out-of-pocket

expense based on frequency and duration of regimen

Onmark’s Regimen Profilerwww.onmarkservices.com/onmarksite/content/rca

• Web-based tool – Practice-specific with daily updated drug pricing – Covers more than 500 referenced treatment

regimens – Customizable payer fee schedules – Customizable supportive care drug regimens – Body Surface Area (BSA) calculator – Patient–friendly financial responsibility reports

• Uses real-time cost data• Provides an estimate of financial

impact for various protocols• Eases burden of cost management for

practice

ION’s Protocol Analyzerwww.iononline.com/display.aspx?cid=ProtocolAnalyzerTutorial_596.cms

ASCO’s Cost of Care Brochure www.cancer.net/managingcostofcare

• Information, tools and resources to help patients manage the financial impact of a cancer diagnosis– Introduction on the Costs of Cancer Care– Understanding the Costs Related to Care– Questions to Ask about Cost– Financial Resources– Health Insurance– Getting Organized– Glossary of Cost-Related Terms

• Copies available at ASCO Bookstore or Cancer.net

Sources of Financial Assistance

• Local resources– City governments– State governments

• State Patient Assistance Programs• www.medicare.gov/contacts/static/allstateconta

cts.asp

– Internet search: “cancer advocacy groups” or “community-based support for cancer patients”

Sources of Financial Assistance

• National Resources– Chronic Disease Fund www.cdfund.org – Health Well Foundation

www.healthwellfoundation.org/index.aspx– National Organization for Rare Diseases

www.rarediseases.org/programs/medication– Patient Advocate Foundation www.copays.org

or www.pap.patientadvocate.org – Patient Services Inc. www.uneedpsi.org

Sources of Financial Assistance

• National Resources– Patient Access Network Foundation (PANF)

www.patientaccessnetwork.org– National Cancer Institute

www.cancer.gov/cancertopics/factsheet/support/financial-resources

– American Cancer Society www.cancer.org • Health Insurance and Financial Assistance for

the Cancer Patient

Sources of Financial Assistance

• Manufacturer-sponsored Patient Assistance Programs (PAPs)– Check with each manufacturer

• Manufacturer-sponsored Discount Cards– www.togetherrxaccess.com– www.pfizerhelpfulanswers.com– www.merck.com/merckhelps/uninsured

• Medicare Part D Low Income Subsidy

ASCOResources

ASCO In Action• Bi-weekly e-

newsletter via ASCO Express

• Updates on legislative and regulatory issues

• Updates on CMS initiatives

• Links to important resources, tools, and legislation

• Available online

Alerts & Breaking News

• Alerts and breaking news on issues affecting oncology

• Sent to ASCO members

• Available on ASCO website

• For Practice Managers and Executives• Highlights key issues • Resources for you, your practice, your staff, and your patients• To subscribe, email practice@asco.org

Journal of Oncology Practice http://jop.ascopubs.org

• Regular features include– Original Research– Practice of Research– Business of the Business– Ethics Vignettes– Practical Tips– Strategies for Career Success

• Manuscripts and letters to the editor may be sent to jopsubmissions@asco.org

Practical Tips for the Oncology Practice

• Detailed information about coding, billing, Medicare coverage guidelines

• Includes excerpts from Medicare coverage manuals

• Order at www.asco.org/

practicaltips

EElectronilectroni

cc HHealth ealth

RRecordsecords

• ASCO Electronic Health Record Initiatives at:– www.asco.org/ehr

• Social networking site– ASCOConnections.org

• EHR Lab at 2010 ASCO Annual Meeting

Why are we talking about Health Information

Technology?• Patients• Payers• Practice

Clinical Tools & Guidelines

• Executive summaries

• Flow sheets• Patient guides

www.asco.org/guidelines

Coding & Reimbursement Assistance

http://www.asco.org/billingcoding

• ASCO member benefit, provided free of charge to ASCO members and their staff

• Available to non-members for a nominal fee per inquiry

ASCO University• Three online modules

– Oncology Billing and Coding Primer

– Coding & Billing Case Applications

– Medicare Case Applications

• Excellent resource for your staff

• Includes Certificate of Completion

Practice Management Curriculum

– Communicating Cancer Care Costs– Adapting to Medicare Changes– Generating Practice Efficiencies– Health Information Technology: From

Policy to Practice– Effectively Integrating Non-physician

Practitioners in Oncology Practice– Practice Check-up: Assessing the

Financial Health of Your Practice

Contact Us

• ASCO’s Cancer Policy & Clinical Affairs Department– 571-483-1670– Practice@asco.org or – publicpolicy@asco.org