Expanding Financial Advocacy Under the Value-Based System

Groundbreaking developments in cancer therapies can change lives, extending survival and sending patients who previously thought their chances were slim into remission. But these therapies come at a cost, and many patients reel at the prospect of heavy financial burdens. To help patients and programs meet the challenges of affording cancer treatments, community cancer centers are expanding the role of financial advocates in their organizations.

According to the Association of Community Cancer Centers (ACCC), financial advocates may be financial counselors, navigators, and advocates; social workers; nurses; patient advocates and navigators; pharmacy technicians; practice managers; billers and coders; patient benefit representatives; and others.¹ What they all share is the goal of minimizing the economic impact of cancer therapy on patients and the institutions that treat them.

During a preconference presentation at the Association of Community Cancer Centers 35th National Oncology Conference in Phoenix, Arizona, 2 experts shared how the role of the financial advocate is evolving within a value-based system where patient access and patient-centered care are key. Nikki L. Barkett, RN, BSN, OCN, Oral Antineoplastics Nurse Navigator, University of Arizona Cancer Center, and Eric Dallara, RPh, Head Pharmacist, New England Cancer Specialists offered insights from the clinician and oncology pharmacy perspectives.

Barkett and Dallara presented a case study in which a 53-year-old woman with rectal cancer was prescribed adjuvant capecitabine (Xeloda). They described how a pharmacy patient advocate and oral antineoplastics nurse navigator (AONN) worked together to manage the patient's care, ensuring that they kept a close eye on adverse events.

The pharmacy patient advocate obtained insurance authorization and managed drug dispensing. The OANN met with the patient to assess existing barriers of care and provide drug-specific education. Because the AONN called the patient weekly to assess adherence and adverse events (AEs), dose reduction and eventually discontinuation of capecitabine resulted.

“The patient might tell us [advocates] things they might not tell a doctor,” Dallara said.

The patient was a violinist and she could not feel her fingers when taking the medication, said Barkett. Treatment was delayed and ultimately stopped based on AEs. An oral antineoplastics pharmacist reviewed test results and worked with the provider team for any required dose adjustments. Close communication between the multidisciplinary team provided patient-centered care, considering the effect that treatment would have on the patient’s livelihood and adjusting the medication appropriately.

Advocacy and Compliance

To provide the best care, clinicians need to ensure that patients are complying with doctors’ orders, and taking their medication as directed. When patients try to cut costs by cutting their dosages, it has a negative effect on their treatment. Compliance issues with expensive oral oncolytics are common. In a value-based care model, oral compliance is required for QOPI certification and a part of the Oncology Care Model. Dallara and Barkett recommend:

• integrating compliance measures into the electronic medical record system
• requiring staff to conduct “compliance calls” and
• using smartphone apps that integrate with EMR and pharmacy software

Making process improvements in nurse workflow can also improve compliance. The University of Arizona Cancer Center implemented an oral antineoplastics program to improve patient outcomes and comply with the Oncology Care Model. The system incorporates documentation of all calls by the AONN in their systems, with a rigorous algorithm supporting follow-up calls at intervals depending on compliance and AEs.

Fight for a Better System

Financial advocates can take part in improving the current system by noticing issues as they advocate for their patients, telling their stories, and contributing to the conversation around reducing financial burdens on a larger scale. Two examples where financial advocates have noticed opportunities for improvement are in the areas of compassionate care and drug waste.

Dallara shared a story about a 69-year-old retired schoolteacher with multiple myeloma on her husband’s Medicare companion plan who had had 7 prior therapies and who was denied a new oral oncolytic that is currently in phase 3 clinical trials with good outcomes and slated to be approved in 2019. The woman’s financial advocate appealed to the drug company for free drugs, but her retirement income was deemed too high.

“There should be the same accessibility to compassionate care for oral medications [as with their IV counterparts], especially if there are data supporting this regardless of the patient’s income,” Dallara said.

Though 43 states have enacted “Oral Anti-Cancer Therapy Access” laws, according to Dallara, the states differ and the laws apply only to commercial insurance. The challenge is to apply it to Medicare as well.

Barkett described frequent situations in which there is an appalling waste of expensive oral oncolytic medications.

“When a patient qualifies for a free drug, the drug companies sometimes send them up to a year’s supply at a time,” said Barkett. “If they have to stop taking after 3 months, what happens to the rest of the drugs?”

Dallara tells of an 83-year-old snowbird who was placed on cabozantinib (Cabometyx). His dose was held due to toxicities, but the drug company kept sending him the medication so that he would have a supply when the treatment started up again. When he came to Dallara’s office in the summer to continue his treatment and was changed to immune-oncology therapy, the patient brought in a bag with $175,000 of unopened cabozantinib. “He had no idea how expensive it was,” Dallara said.

Finding a way to reduce drug waste and reuse unopened medication should be a priority among healthcare professionals. Dallara and Barkett acknowledged that verifying the quality of returned medications is a barrier to reusing them. As one member of the audience at the presentation pointed out: “What if a person left the drug in their car for 3 days in 130° heat?”

Dallara and Barkett recommend not sending refills on prescriptions of oral oncolytics to mail order pharmacies. They emphasize that there is not a more efficient way to get a patient their oral oncolytic medications than at the point of care, and they recommend advocating for oncology practices to dispense medications to patients.²

ACCC Financial Advocacy Boot Camp

The ACCC offers a training program to help healthcare professionals hone skills needed to advocate for patients. For more information, visit Financial Advocacy Boot Camp.

References

• Financial Advocacy Network. ACCC website. www.accc-cancer.org/home/learn/financial-advocacy. Accessed October 17, 2018.
• Barkett NL, Dallara E. Financial advocacy in a value-based world. Presented at: Association of Community Cancer Center 35th National Oncology Conference; October 17-19; Phoenix, AZ. files.eventsential.org/bc5400c1-3613-4d6d-8f86-1c1e8cefd794/event-12103/182728878-OPEN_Financial-Advocacy-Value-Based-World-Barkett_Dallara.pdf. Accessed October 17, 2018.

A version of this article was originally published by Targeted Oncology® as “Financial Advocacy Grows Under the Value-Based System”