Financial toxicity following cancer treatment in the United States is a growing concern. Even small increases in out-of-pocket costs are associated with treatment nonadherence for some families, and may contribute to ever-widening social disparities in care and survival of patients with cancer. Patients from racial and ethnic minority groups are more likely to lack insurance and suffer from adverse financial consequences. In a recent Viewpoint article in JAMA Oncology, Dr Cathy J. Bradley et al advocated for a coordinated nationwide policy approach that supports clinicians and patients while reducing the financial burden associated with cancer treatment.
At the community level, it has been proposed that medical practices provide navigation to help patients and caregivers connect to resources. However, widespread adoption of patient navigators is limited by the lack of a sustained financial model for reimbursement. Another recommendation is for clinicians to integrate cost discussions into shared treatment decisions. Although many believe this to be an effective approach, few practices are doing it, for multiple reasons. Costs are rarely transparent, and benefits can be difficult to quantify. In addition, these conversations have limited benefit to patients who cannot afford even the lowest tier of care. Other barriers to practice-based approaches include staff shortages and the inherent conflict of interest driven by higher revenues from high-cost oncology drugs.
The authors suggest the path to alleviating the financial toxicity of cancer care is a coordinated national policy approach. Beyond drug price legislation, other critical policies are those related to insurance coverage options, flexible work schedules, paid sick leave, financial planning assistance, and limits on out-of-pocket spending relative to household income and assets. Many prescription drugs do not have an annual out-of-pocket cap, and some health plans have deductibles higher than some patients can afford. These patients need support not only for their care, but also to help provide for their daily needs beyond insurance for treatment. The Affordable Care Act has helped to expand coverage options, but implementation at the state level is inconsistent. The best way to ensure continued progress will be for multiple stakeholders to raise awareness of the devastation of financial toxicity and demand bold actions from policy makers.
High Level
Practice-based approaches, such as decision-support tools, may help close gaps in fiscal protection, but ultimately will require financial and technical support, as well as coordination to ensure success. If implemented, some level of funding and reimbursement would be required for these approaches to be both successful and sustainable. Policy makers need to establish strategies that close the disparities between financially secure and financially disadvantaged patients and help protect patients from high out-of-pocket costs. There is an immediate need for policies that address access to care, high healthcare costs, absence of paid medical leave, and other gaps. The resulting broader healthcare coverage could have important economic benefits, such as increased labor force participation and lower costs to small businesses.
Ground Level
Dr Bradley and colleagues suggested that despite potential barriers, practice-level financial screening and mitigation – with associated reimbursement – are still an appropriate part of routine care. Especially in the short term, practice-based approaches remain important because existing policies may fall short of sheltering patients and their families from the financial toxicities of cancer care.