Abstract
Patients with cancer are often burdened by financial stresses during treatment. The presence of a financial counselor can help alleviate these concerns for both patients and providers.
Facing financial burdens at a time when they are dealing with cancer is detrimental to patients' well-being. When patients are inadequately insured or cannot afford treatment, their anxiety rises, they may deplete their savings, and they sometimes abandon treatment or skip doses.
For privately insured patients, employers are shifting more insurance costs to the patient side. Many face paying thousands or tens of thousands of dollars for their care. Medicare beneficiaries also face rising costs of monthly premiums and supplemental insurance and increased cost-sharing requirements. Worse, 11% of Medicare beneficiaries do not carry any supplemental insurance, according to a 2009 Kaiser Family Foundation analysis.1
Health care reform is addressing some aspects of insurance coverage that apply particularly to cancer treatment, such as barring a lifetime cap, but the law's provision to prohibit annual benefit caps does not go into effect until 2014. In addition, the costs of some health care reform changes, such as covering dependents until age 26, are already being passed on to insurance plan members through higher premiums, deductibles, and coinsurance levels.
“The uninsured population is not our biggest growth area, the underinsured are,” says Sharon M. Roeder, director of McKesson Specialty Care Solutions/US Oncology's oncology reimbursement services and patient assistance program. “Foundations are reporting that the number of underinsured patients is growing 30% each year—that's our pattern also.”
On the practice side, as the patient proportion of total expenses increases, collections from patients become a larger portion of total revenues. More patients can't pay for their treatment. Oncology practices have larger write-offs to bad debt. It's a lose-lose situation.
Designation of Financial Counselor to Addresses Patients' Needs
Some oncology practices have turned this scenario into a win-win by creating a staff position of financial advocate or financial counselor. Thomas L. Whittaker, MD, an Indianapolis oncologist who is also president of the Association of Community Cancer Centers (ACCC), says his practice has had financial counselors for 5 years. The large practice, with 16 medical and radiation oncologists at five sites, started with two financial counselors. “We quickly saw that having a financial counselor was a tremendous benefit for the practice and for patients, and we now have five.”
Small practices can also gain from having a financial counselor. Lynn Kay Winters, the practice administrator for an oncology practice with two doctors and four nurse practitioners in Riverhead, NY, on Long Island, says that until a year ago her practice didn't provide proactive financial counseling. “We always tried to help patients who cried out for help, but we didn't have a systematic way to approach them.” Now, the intake coordinator identifies patients who might need assistance—those on Medicare without supplemental insurance, or those with a 20% coinsurance responsibility, for example. Winters herself has taken on the financial counseling responsibilities, including identifying patient assistance programs for eligible patients. As these responsibilities have increased, she is now planning to add a part-time position to fill that role. She says the practice has already increased the reimbursement per patient and she feels that she is really helping patients in need.
What Does a Financial Counselor Do?
The first responsibility of a financial counselor is to educate patients about their insurance benefits, including how much of the annual deductible has been paid, the difference between copayments and coinsurance, and any benefit caps in place. The financial counselor explains the total cost of the planned treatment, the patient's out-of-pocket expense, and the practice's payment policies.
“Often they have no idea they will have such a large out-of-pocket expense,” says Amy J. Davidson, RN, BSN, OCN, administrator for a practice with four oncologists in Youngstown, OH. Carolyn Spranza, the business office manager for an oncology practice in Hinsdale, IL, puts it this way: “Ninety percent of people know diddly squat about their insurance.”
Determining the patient's financial needs is not a one-time exercise. The financial counselor should meet regularly with the patient and family to stay abreast of any changes in job status or insurance coverage, answer questions about bills or explanations of benefits, and reevaluate financial resources.
Patients may also have concerns that their treatment will be based on their financial status. They may have the misconception that the price of a treatment is related to outcome or to quality of care, or that no costs are involved with enrolling in a clinical trial. They also may be reluctant to reveal their financial status and resources.
The financial counselor must establish rapport with the patient to candidly and compassionately communicate about treatment costs and the practice's payment policies. Initiating a discussion with them requires sensitivity and skill. “I seek to forge a partnership with the patient,” Winters says. “When I introduce myself I say, ‘I want you to know I am poised and ready to help you negotiate the financial process.'”
Having discussions with patients about their entire financial picture can be uncomfortable. Spranza says, “You have to be rather personal with people. But people really need the help and they can't get it unless we broach these sensitive financial topics with them.”
An excellent aid for both patients and financial counselors is ASCO's booklet Managing the Cost of Cancer Care, which can be ordered in quantities or accessed at cancer.net/managingcostofcare and is available in both English and Spanish.
For underinsured patients or those in need, the financial counselor helps find assistance. Most pharmaceutical firms have patient assistance programs, and local, state, and national assistance programs and charities offer grants for eligible patients. Local organizations may provide practical assistance with transportation and household needs. Very few patients are even aware that such assistance is available.
Reimbursement and Patient Assistance Programs, a booklet available to members of the ACCC, offers details of more than two dozen patient assistance programs of both pharmaceutical and nonpharmaceutical companies. In addition, ASCO's booklet, mentioned above, lists a number of national nonprofits that help people with cancer.
An advantage of having a staff member dedicated to financial advocacy is the experience gained by familiarity with the eligibility rules and application process for the dozens of assistance programs available. “Patients on multiple drug regimens may have two or three applications to complete,” says McKesson Specialty Care Solutions/US Oncology's Roeder. “Some foundations offer assistance for patients whose income is less than 400% of the poverty level. Others have different thresholds. We explain to the patient what documentation is required.”
The financial counselor obtains the applications for patients and helps them file them. Applications can be two to 10 pages long, says Roeder, whose department supports practices in the McKesson Specialty Care Solutions/US Oncology network by identifying sources of aid and facilitating the application process.
Going the Extra Mile
It is not unusual for financial counselors to become personally vested in finding help for patients. “These are the most compassionate people I know,” comments Davidson, the administrator from Youngstown. She offers an example: “One winter a patient had no money to fix a broken furnace. The financial counselor got her dad, a handyman kind of guy, to go out and fix it. She also got help to buy groceries for the patient.”
Whittaker, the Indianapolis oncologist, echoes this report. “Our financial counselors have made it their own personal goal to find something for every patient. They find help under a rock. They might find help to clean someone's home.” He reports that one financial counselor who “will not take no for an answer” worked with a young patient with breast cancer who had lost her job. “The financial counselor couldn't find help, so she set up a ‘bowlathon’ that people from the patient's office came to.”
Practice Reimbursement Also Benefits
Practices with a financial counselor in place report increased revenues. The return on investment is almost guaranteed, according to ACCC executive director Christian Downs, MD, MHA. In the introduction to the ACCC booklet mentioned above, he says that ACCC member programs report that the money the financial counselor has obtained has more than covered the cost of adding a full-time staff person.
Billing office manager Spranza, who began providing financial counseling part-time in 2009, says that pharmaceutical programs for patient assistance have grown in the last year. She reports that in all of 2010 she recouped $21,000 of charity money, whereas in the first 3 months of 2011 the practice has already obtained about $40,000.
McKesson Specialty Care Solutions/US Oncology helps all practices in its network set up a financial counseling program. Roeder says that in the first quarter of 2011, the total brought in from foundation grants was $6.6 million, in addition to $4.4 million in the value of free drugs for patients. Whittaker says that his practice has improved its net revenue by 1.5% per year by adding financial counselors to the staff.
“Angst and Frustration” Removed From the Examination Room, Front Desk, Billing Office
In addition to finding financial assistance, an important benefit of having financial counselors is relieving physicians and other staff members of the uncomfortable and time-consuming task of discussing finances with patients. Whittaker says, “It has made my job so much easier. It has now been four or five years since a patient has brought a bill to me in an exam room. Someone would start off saying ‘Why did I get this?' It added angst and frustration to the visit. Now they know there is this expert in the office who is dedicated to solving those problems.”
Other staff also benefit from the work of a designated financial counselor. The receptionist receives information about what each arriving patient owes at that visit and can feel confident that the patient has already been informed about his or her financial obligations. If the patient disagrees with the amount requested, refuses to pay, or wants to discuss it, the receptionist can refer the patient to the counselor for a private talk. This process not only prevents an open controversy in the reception area, but also allows the counselor to explore problems the patient may be experiencing.
Take-Away Points.
Financial Counselor Skills and Qualities
Compassionate, sensitive
Communicates well
Listens
Enjoys interaction with patients
Familiar with diagnoses and treatments
Knowledgeable about billing and reimbursement processes
Aware of how different insurance plans work
Persevering
Analytical, with independent research ability
Organized
Patient
The proactive function of financial counseling also helps the billing personnel, who previously fielded calls from patients who were shocked by the balance due. Winters describes what used to happen: “The patient called the billing office, an argument ensued, and it became ‘shoot the messenger.' The billing staff had to make clear that the patient's costs were about their insurance company and not what their doctor had decided. Then the insurance company doesn't know what the patient is talking about, and they throw the doctor under the bus. They create a complete fabrication because they want to get the patient off the phone.” Since the practice implemented financial counseling, these scenarios no longer occur.
Processes Vary
Financial counseling processes will vary, but useful aspects are including the patient's family in the discussions and making the financial counselor an integral part of the patient care process, starting at the first visit and before treatment begins. Processes should be in place to keep the front desk personnel, the physician, and the billing office informed about each patient's financial picture. The financial counselor should calculate the value of drug assistance and grants received and report totals to the practice leaders.
Practices must establish a process for financial counseling that works with their patient flow and administrative procedures. In Whittaker's practice, the financial counselor first meets the patient in the examination room before the patient sees the doctor. After the physician puts the treatment regimen in the electronic medical record, the financial counselor uses it to determine the patient's out-of-pocket cost and meets with the patient again. A hospital-based practice reported using a team approach—scheduling a meeting involving a social worker, nurse, billing staff, and secretary.
Hospital-based oncology practices may have challenges because of having to coordinate activities with centralized hospital departments. One director of a hospital-based practice in the Midwest reports that she expects to have a financial counselor in place later this year, but has faced 2 years of resistance from the hospital's director of financial services, who has had to address major challenges in other hospital departments first. In the meantime, the oncology clinic's social worker has increasingly been taking responsibility for seeking patient financial assistance. The clinic director comments that when a financial counselor is finally on board, the financial counseling process should start with meeting the patients in the oncology clinic rather having patients go to the hospital finance office as other departments do.
A West Coast administrator of an oncology practice acquired by a hospital 18 months ago is also aiming to establish a financial counselor. “We realized early on that the hospital did not know how to counsel patients about the intricacies of oncology billing,” she says. Currently, the hospital provides a social worker to the oncology practice two half days a week, and through a cooperative effort among the billing department, the pharmacist, and the social worker, the practice has been able to help patients who have financial hardship. She comments that the practice has significant challenges in providing financial counseling because “we can't tell patients their total out-of-pocket expenses because we don't know the terms of the hospital contracts with insurance plans.”
Summary
The most compelling reason to use a financial counselor in practice is that it contributes to the overall well-being of patients. While facing the stress of a catastrophic disease, they have access to an expert who explains their insurance terms and will find payment assistance if needed. Practices benefit by having increased revenue and removing distressing financial discussions from patient interactions with the physician, the front desk, and the billing office. Davidson sums it up: “In years past it probably wasn't as important a role. Now it's one of the most important jobs in the practice.”
Authors' Disclosures of Potential Conflicts of Interest
The authors indicated no potential conflicts of interest.
Author Contributions
Conception and design: Dean H. Gesme, Marian Wiseman
Administrative support: Marian Wiseman
Collection and assembly of data: Marian Wiseman
Data analysis and interpretation: Marian Wiseman
Manuscript writing: Dean H. Gesme, Marian Wiseman
Final approval of manuscript: Dean H. Gesme, Marian Wiseman
References
- 1.Kaiser Family Foundation. Examining sources of supplemental insurance and prescription drug coverage among Medicare beneficiaries: Findings from the Medicare current beneficiary survey. 2007. http://www.kff.org/medicare/7801.cfm.