As groundbreaking yet high-cost cancer treatments make their way into clinical practice, the effects of financial toxicity can put a damper on the profound results that new, lifesaving medications can have on patients with cancer. It’s a problem that even Washington, DC, hasn’t been able to address—so what can oncology nurses do about it?
It starts with every nurse, right at the practice level: assessing, referring, and supporting patients as they navigate all aspects of their cancer diagnosis and treatment, from physical to emotional to financial. In October 2019, the Clinical Journal of Oncology Nursing issued a supplement dedicated to nursing’s approach to the burden of cancer-related financial toxicity.
Although conducting formal financial toxicity assessments is not a feasible or necessary part of every clinical nurse’s role, all nurses should be alert for patient or caregiver worries about costs of care. Following up with questions such as, “Do you have any concerns about paying for your treatment?” or “Tell me what you understand about the out-of-pocket costs for your treatment” gives nurses the opportunity to refer patients to a financial navigator or patient assistance program.
More formal clinical financial assessments have been proposed as part of the American Society of Clinical Oncology’s (ASCO’s) Financial Toxicity Grading Criteria and discussed in ASCO’s booklet Managing the Costs of Cancer Care: Practical Guidance for Patients and Families. The booklet guides patients in discussions with financial counselors and navigators and connects them to resources to assist with the cost of cancer care.
A tool that clinical nurses can use to assess financial toxicity is the Comprehensive Score for Financial Toxicity (COST), a patient-reported outcomes instrument. A sample of the tool is reprinted in Carr and Rosato, but the authors reiterated that “its use in clinical settings is subject to the role of the clinical nurse, the nurse’s workflow, practice setting, and the contributions that COST data provide to the plan of care.”
Navigation as a Financial Support Model
Traditional financial counseling support models are reactive, not proactive, Sherman and Fessele said. In contrast, proposed financial navigation models address toxicity by guiding patients through health insurance options they may not have been aware of, reducing their out-of-pocket costs before they become a burden. Discussions with a financial navigator help patients and providers make advance decisions about treatment options and timing to maximize healthcare coverage benefits and reduce patients’ financial responsibility. Financial navigators can proactively intervene as early as the first treatment consultation and no later than at treatment initiation.
Who can benefit: Sherman and Fessele explained that financial navigation is a more complex model that not every patient would need. However, it could benefit populations at high risk for financial toxicity, such as the uninsured, the underinsured, those on high-cost oral medications, Consolidated Omnibus Budget Reconciliation Act (COBRA) recipients, Affordable Care Act enrollees, patients with Medicare Parts A or B only, patients with advanced stage disease, and those new to Medicare.
Navigation success: Financial navigators must possess a high degree of expertise for understanding complicated healthcare coverage and a solid understanding of the disease and treatment process. They must be able to proactively engage with patients and help influence the treatment plan to a certain extent. Their singular focus is to proactively support patients, and organizations should provide comprehensive training and a system to stay updated about insurance coverage, regulations, and assistance programs to enable their work.
Patient Assistance Programs
Outside of financial counseling or navigation, most clinical nurses have the opportunity to refer patients and caregivers to patient assistance programs sponsored by charities, advocacy organizations, or pharmaceutical companies. Programs from charities and other organizations usually provide grants to offset the costs of prescription copays or other expenses, whereas those from drug companies provide brand-name medications for free or reduced costs. However, patients with government insurance are not eligible for manufacturer-based discount programs because of the Anti-Kickback Statute.
Most charity programs require patients to meet minimum income guidelines; drug company programs may not require income qualification but do necessitate patients having commercial healthcare coverage with a prescription benefit so they can work with the insurance company to discount their copay amount.
Resources for identifying patient assistance programs are listed in the sidebar.
For more information about financial toxicity and how oncology nurses can help their patients, refer to the full CJON supplement. Each article offers 0.5–0.6 contact hours of CNE, free for ONS members.
Questions regarding the information presented in this article should be directed to the Clinical Journal of Oncology Nursing editor at CJONEditor@ons.org.