APRNs Can Help Address Global Financial Toxicity
Advancements in oncology, such as new diagnostic tools and novel therapies, have improved overall survival rates but have come at a high cost. In 2011, targeted therapies accounted for 63% of all chemotherapy expenditures (https://doi.org/10.1200/JCO.2014.58.2320). A novel cancer drug routinely costs each patient more than $100,000 per year; annual spending on cancer drugs is globally estimated around $100 billion U.S. dollars and is predicted to rise to $150 billion by 2020 (https://doi.org/10.1038/nrclinonc.2017.31).
Long-term solutions should focus on reducing unsustainable drug prices and promoting innovative insurance models (https://academic.oup.com/jnci/article/108/5/djv370/2412415) through the pharmaceutical industry and government agencies, but those are not quick fixes. Advanced practice RNs (APRNs) and clinicians play a pivotal role in presenting and discussing care options with patients and caregivers and must intervene now.
Oncology Care Model’s Financial Incentives
The goal of the Oncology Care Model, developed by the Centers for Medicare and Medicaid Services (https://innovation.cms.gov/initiatives/oncology-care), is to use financial incentives to improve care coordination, appropriateness, and access for beneficiaries undergoing chemotherapy. The financial incentives are intended to improve quality and reduce healthcare expenses while addressing the complex care needs of those receiving chemotherapy treatment, increase their use of high-value services, and decrease their use of unnecessary services.
Clinicians, including APRNs, must have healthcare cost discussions with patients early (i.e., before treatment begins) and often (i.e., periodically throughout treatment). Patients and families are most likely to worry about out-of-pocket expenses (https://doi.org/10.1634/theoncologist.2016-0207): not only the direct costs of medical care, but also nonmedical costs such as transportation, childcare expenses, housing costs (https://www.bankrate.com/mortgages/how-to-afford-home-expenses-during-cancer-treatment/), and time off work while receiving treatment.
APRNs and other clinicians can improve the value of cancer care while limiting financial toxicity through several strategies. First, before considering and discussing costs with patients, ensure that patients understand the goals of care. Second, understand and be aware of the prevalence of financial burden and help patients to feel comfortable with ongoing financial and affordability discussions. Finally, focus on eliminating (https://doi.org/10.1634/theoncologist.2016-0207) the use of low-value tests and interventions.
To help clinicians, including APRNs, proactively address financial issues so patients can access high-quality cancer care for a better quality of life, the Association of Community Cancer Centers (https://www.accc-cancer.org/home/learn/financial-advocacy/guidelines) developed its Financial Advocacy Service Guidelines. The work was done as part of a larger initiative with ACCC’s Financial Advocacy Network (www.accc-cancer.org/home/learn/financial-advocacy), which offers an online bootcamp learning course, Patient Assistance and Reimbursement Guide, and financial advocacy toolkit.
The American Society of Clinical Oncology (http://www.choosingwisely.org/wp-content/uploads/2015/02/ASCO-Choosing-Wisely-List.pdf) has a list of 10 tests, procedures, and treatments that physicians and patients should question based on available evidence. ASCO also has an updated version of its Value Framework to identify “a combination of clinical benefit, side effects, and improvement in patient symptoms or quality of life in the context of cost.”
Finally, the National Comprehensive Cancer Network (https://www.nccn.org/evidenceblocks/pdf/EvidenceBlocksFAQ.pdf) has its Evidence Blocks, five key components of value (efficacy, safety, quality and quantity of evidence, consistency of evidence, and affordability) that provide important information about specific recommendations from the NCCN Clinical Practice Guidelines in Oncology.
Financial toxicity is a real concern in patients receiving oncology care. In addition to using the ACCC, ASCO, and NCCN initiatives, APRNs and clinicians can impact the financial burden of their patients (https://academic.oup.com/jnci/article/108/5/djv370/2412415) by focusing on the value of care delivered, encouraging patient and caregiver engagement on costs of care, and becoming better educated on available financial resources for patients.