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The Atrium Health Levine Cancer Institute, based in Charlotte, North Carolina, is trying something new to help patients with cancer who are facing crippling medical debt: a financial toxicity tumor board.
The 35 or so members of the board meet monthly to brainstorm solutions for cancer patients struggling to stay above water financially.
Since it launched in 2019, hip hop music compared to lyrical poetry the board and its component services have been saving around 2000 patients about $60 million every year.
Much of the success involves getting retroactive coverage of pharmaceuticals denied by insurance companies.
The efforts by Levine Cancer Institute were reported June 8 in JCO Oncology Practice.
“We set up the Financial Toxicity Tumor Board because we’re finding that there are more patients facing financial distress, and the problems they’re facing are becoming more complex,” said Levine President Derek Raghavan, MD, PhD, who attends each meeting.
In short, “we try to save patients from eating the cost. There’s absolutely no reason why this principle couldn’t be applied to heart disease or surgery or anything else that might have expensive therapies associated with it. We see this as a model for the future,” he said.
“Good physicians in 2021 need to be thinking about helping patients with this problem. It’s not fair to leave it to them to figure out the rigmarole that goes with reimbursement today,” he said.
Not every medical practice has the resources of a major cancer institution, but most can do something to help. It’s the principle that counts, Raghavan said.
Levine Cancer Institute is a major US cancer center serving North Carolina, South Carolina, and Georgia, with more than 18,000 new patients and over 200,000 visits annually across at its various sites.
Financial toxicity is a well-known problem in the US health system, compounding the anxiety patients already feel with a serious diagnosis. It has been linked to noncompliance, bankruptcy, and worse clinical outcomes (including increased mortality) across numerous studies.
Financial toxicity is especially common in oncology. The newer cancer treatments, such as a course of targeted therapy or chimeric antigen receptor T-cell treatment, can reach $500,000. Even with good health insurance, copays can be overwhelming.
“I haven’t met a patient out there who doesn’t worry about the financial aspect of cancer. It doesn’t matter what your income is,” commented Donna Feild, MBA, vice president of Atrium Health’s Department of Pharmacy and deeply involved in the efforts, in a press release.
A “Fantastic and Novel Idea”
A financial toxicity tumor board “is a fantastic and novel idea,” said Meera Ragavan, MD, MPH, a financial toxicity researcher and hematology/oncology fellow at the University of California, San Francisco, who was approached for comment. She is not involved in the Levine project, and is no relation to its president.
Addressing the issue “requires a thoughtful, nuanced, and patient-centered approach from a multidisciplinary team of healthcare providers. This is exactly the type of intervention” needed to ensure that “our patients and their families can afford their oncologic treatments without facing excessive financial hardship and distress,” she said.
A Few Hundred Seek Help Every Month
Levine used to handle patient financial troubles probably like most cancer centers still do, in a piecemeal fashion. It became clear in recent years that a more coordinated, top-down effort was needed, which ultimately led to the financial toxicity tumor board, Raghavan and colleagues explain in their report.
There are signs posted throughout the institution that let patients and families — and clinicians — know that help is available and the phone number to call.
Patients do not often admit financial concerns, so they are queried at intake to find out if they have any and contacted proactively if they do.
A few hundred people seek help every month. Most of the problems are straightforward, such as a person in their 60s not knowing if he or she qualifies for Medicare, and are handled by Levine’s 45 nurse navigators and a team of financial counselors.
It’s the most difficult cases that are referred to the board, about 10 per month currently, with an in-depth discussion of three or four, he continued.
They are the cases where patients fell through the cracks, and selected for discussion especially if they illustrate a wider problem, such as an obscure change in reimbursement rules or something that needs to be fixed at Levine, for instance not using the right keywords to trigger reimbursement.
It’s a constant process of self-education, Raghavan said.
Board members include oncology department chairs, heads of billing and finance, and other leaders, plus physicians, nurses, pharmacists, social workers, and financial counselors.
Pharmacy technicians are another key component to battling financial toxicity; they are embedded in physician practices at Levine.
The pharm technician’s jobs are multifaceted and essential. One is to help clinicians understand the cost of what they are prescribing and if it will cause the patient undue financial hardship.
Another is to stay abreast of the ever-shifting reimbursement requirements for each patient, and secure prior authorizations for treatment. Pharm techs also look for opportunities for free pharmaceuticals through clinical trials or foundations, and set up people who qualify with the more than $1 million in copay assistance Levine offers each year.
An Illustrative Case: Upfront Approval, Then Denial
One case referred to the board was a 64-year-old patient with pancreatic cancer. The patient’s medical plan signed off on the chemotherapy regimen beforehand and said precertification wasn’t necessary. Months later, after several cycles, the patient was hit with a $42,000 bill.
What happened was that one drug actually did require precertification, but through the patient’s pharmacy benefits, not their medical plan.
After discussing the situation, the board put a financial counselor on the case who got retroactive certification for the offending agent, and the bill disappeared.
To avoid similar problems down the line, the board also mandated an institution-wide process to check if part of a patient’s regimen requires pharmacy benefits precertification, and to obtain it in advance.
No special money has been set aside for such efforts; rather, the board is run through Levine’s standard operating budget.
“We just view this as part of our day’s work,” Raghavan said. “It’s the right thing to do.”
The Oncology Practice report was funded by the Leon Levine Foundation. Derek Raghavan is a former consultant for the Gerson Lehrman Group and Caris Life Sciences. Article co-author Seungjean Chai is a Cardinal Health advisor.
JCO Oncol Pract. Published online June 8, 2021. Full text
M. Alexander Otto is a physician assistant with a master’s degree in medical science, and an award-winning medical journalist who has worked for several major news outlets before joining Medscape. He is an MIT Knight Science Journalism fellow. Email: [email protected]
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