Nurses Should Address Financial Toxicity With Patients

We once lived in a world where we believed insurance would cover any and all out-of-pocket costs. Sadly, those days are gone—especially for those with cancer, given that the cost of cancer drugs has escalated in the past 10 years, as have patients’ expected out-of-pocket costs. The cost for insurance has also escalated, with more patients facing higher premiums, higher deductibles, and higher co-pays. In 2016, Scott Ramsey, MD, and colleagues found that patients with cancer who face bankruptcy are more likely to die than patients who don’t.¹ Interesting to note is that patients with prostate cancer facing bankruptcy were almost twice as likely to die as those not facing medical debt, and those with colorectal cancer facing bankruptcy were 2.5 times more likely to die.

Financial toxicity refers to the out-of-pocket expenses that patients incur during and after cancer treatment. It can affect quality of life and even prevent patients from receiving their cancer treatment.² We know that patients often do not willingly share their economic hardship. Many will suffer in silence as they try to decide whether to pay for their medication or use the money to put food on the table for their family. Today, research continues to support the need for all members of the healthcare team to initiate a conversation with their patients. Oncology nurses are in an excellent place to start this dialogue, and an understanding of who might be at risk is critical to facilitating this conversation. Patients at high risk for financial toxicity include those who:

• Self-pay, are uninsured, or have Medicaid or Medicare without secondary insurance

• Face a high deductible (>$2000)

• Have advanced and/or metastatic disease

• Received a diagnosis at an early age

• Are a member of a minority population

Equally important is helping patients understand the new terms associated with the financial cost of cancer care.³

Out-Of-Pocket All costs not covered by an individual’s health insurance

Co-payment Amount paid for each healthcare service, such as a doctor appointment or a prescription, after meeting the yearly deductible

Coinsurance Percentage of costs paid for a service that health insurance covers after the deductible is paid

Deductible Amount an individual pays for covered medical care before the health insurance plan begins to pay

Cost sharing The share of cost covered by insurance that patients pay out of pocket; generally includes deductibles, coinsurance, co-payments, or similar charges; does not include premiums, balance billing amounts for non-network providers, or the cost of noncovered services

The cost of cancer care is very personal and may explain why many patients do not initiate this discussion. Many patients are reluctant to start a conversation that includes finances or cost of care. Not only is it embarrassing, but patients may also be afraid that by sharing details about financial toxicity, they may not receive the best treatment. Helping patients overcome this fear and enabling them to engage in these conversations is just as important as shared decision making for treatment planning.

Nurses should acknowledge financial toxicity and address it during patient visits. Some have found it helpful to share that many people face challenges when paying for their cancer treatment. Remind patients that the cost of cancer treatment has escalated and that reimbursement is not what it once was. Be an advocate for your patient by asking, “Are you concerned about the cost of your care?” Even if the patient responds that they aren’t, you have will have opened the door to future discussions about financial options that may be available to them should the time come. As we come together, we can help to ensure our patients no longer suffer in silence.

References

• Ramsey SD, Bansal A, Fedorenko CR, et al. Financial insolvency as a risk factor for early mortality among patients with cancer. J Clin Oncol. 2016;34(9):980-986. doi: 10.1200/JCO.2015.64.6620.
• Zafar SY, Abernethy AP. Financial toxicity, part I: a new name for a growing problem. Oncology (Williston Park). 2013;27(2):80-149.
• Glossary. HealthCare.gov website. healthcare.gov/glossary/. Accessed May 2, 2019.