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Town Hall: Care Coordination and Financial Advocacy

This article was developed from the Evolving Role of the Oncology Pharmacy: Multidisciplinary Perspectives Pre-Conference at the ACCC 35th National Oncology Conference, October 17, 2018, in Phoenix, AZ.

A Team-Based Approach to Managing Oral Oncolytics

In October 2018, the Association of Community Cancer Centers (ACCC) hosted a pre-conference workshop at its 35th National Oncology Conference to review how oncology pharmacists can best respond to rapid changes in the oncology environment, including the increasing need for a coordinated approach to financial advocacy and navigation. A Town Hall discussion featured a panel of financial assistance experts who addressed audience-generated questions on care coordination and financial advocacy.


Angie Santiago, Lead Financial Counselor, Thomas Jefferson Hospital, Sidney Kimmel Cancer Center, Philadelphia, PA
Una Hopkins, RN, FNP-BC, DNP, Administrative Director, Cancer Program, White Plains Hospital, Center for Cancer Care, White Plains, NY
Sarah Hudson-DiSalle, PharmD, RPh, Oncology Pharmacy Manager, Medication Assistance Program and Reimbursement Services, Department of Pharmacy, Arthur G. James Cancer Hospital and Wexner Medical Center, Ohio State University, Columbus, OH
Lori Schneider, Business Office Manager, Green Bay Oncology, Green Bay, WI

How Is the Reimbursement Landscape Changing?

The scope of documentation and information that payers request to review therapy authorization is increasing in lockstep with the ever-expanding number of approvals for both old and newer classes of oncology agents. Despite payer requests for more documentation, denials occur more frequently across cancer care settings, and financial assistance and reimbursement specialists expend considerable time and energy on appeals. There is also considerable variation among payers over which therapies they will authorize, as well as variation over time within each payer. These variations likely reflect the rapidly evolving approval landscape such that, as Dr. Hopkins noted, payers are not able to stay current with approvals. These reimbursement changes reinforce the importance of using appropriate codes in authorization claims, as well as in tracking and assiduously monitoring claims, denials, and appeals.

What Methods Can Financial Advocates Use to Ensure Patient Literacy About Insurance Coverage?

Panelists shared a similar approach to assessing and supporting financial literacy among patents. At Thomas Jefferson Hospital Sidney Kimmel Cancer Center (SKCC), financial counselors meet with all new patients to discuss their insurance coverage, out-of-pocket expenses, and the availability of assistance resources to bridge any potential gaps in coverage. Counselors also use open enrollment as an opportunity to ensure that patients are aware of the coverage they need and to discuss opportunities to improve their coverage. Should patients lose insurance during treatment, financial advocates (also referred to as counselors or coordinators) at the cancer center explore free drug options to cover treatment until their new coverage begins. Similarly, the James Cancer Hospital offers an insurance check to patients at open enrollment, especially for patients eligible for Medicare Part D, to ensure their benefits for the next year, clarify their out-of-pocket expenses, and identify potential bridging resources, including manufacturer free-drug programs. Financial counselors do a benefits reassessment in the beginning of the year to assess patients’ outof- pocket expenses and identify assistance resources, if necessary.

Panelists also emphasized the importance of raising awareness among oncology staff about the value of financial assistance programs, including their impact on the revenue cycle and how they can potentially increase reimbursement within an organization. To ensure this awareness, onboarding for new physicians at Green Bay Oncology includes information from the program’s financial counselors. Understanding the financial counselor’s role can help to change organizational culture so that providers are aware of the potential costs of treatment and that patients are more widely informed about their treatment options. Furthermore, providers then know to whom patients should be referred if there is a financial concern.

How Does Your Organization Identify Patients Who Are Potentially at Risk for Financial Toxicity?

Panelists agreed on the importance of being proactive and speaking with patients about financial concerns as soon as possible prior to treatment initiation. Dr. Hudson-DiSalle commented that although it remains challenging to proactively identify patients who might be underinsured, reimbursement specialists at the James Cancer Hospital try to identify the co-pay expenses that patients are likelyto incur before the start of infusion therapy and to proactively work with on-site specialty pharmacy staff to identify assistance needs. In addition, the electronic medical record (EMR) populates a work queue for authorization when a treatment plan is added so that patients without insurance are referred to the reimbursement team. Resources that the team can call on to address financial need include low-income subsidy programs, patient assistance programs, foundation assistance, or switching to a different insurance plan during open enrollment.

Financial advocates at SKCC use the National Comprehensive Cancer Network Distress Thermometer as a screening tool to identify patients who may have distress related to financial concerns. Santiago emphasized that not all patients admit they need financial help; nevertheless, it is important to encourage patients to speak with financial counselors before starting any treatment to review the potential for financial assistance that could help to offset medical or eligible non-medical expenses. SKCC financial assistance staff track self-pay balances in the EMR and proactively use these metrics to spot when patients might need financial resources at critical points in the payment cycle. Financial advocacy teams at Green Bay Oncology and White Plains Hospital also include a daily “huddle” in their workflow to identify patients who lack insurance or are underinsured, for example. The huddle is a short, stand-up patient safety and quality improvement meeting that staff can use at the start of each shift (or workday) to review and prioritize clinical, financial, and operational issues.

What Financial Assistance and Benefit Tracking Methods are Available for Financial Advocates?

Excel remains a useful, accessible tool to track benefits, grant applications, renewal deadlines, and funding expiration dates, panelists agreed. For instance, Green Bay Oncology has developed a spreadsheet to track benefits for each patient that starts the day of chemotherapy initiation. This document ensures that patients have a record of their benefits and anticipated spend. It also provides a resource to help patients systematically approach open enrollment and identify the financial resources they are likely to need to remain on treatment. Foundation application portals also provide a monitoring function that can help the financial team stay current with application due dates. Panelists emphasized the importance of taking treatment timing into consideration when applying for foundation funding to ensure that patients are enrolled in assistance closer to the time of treatment. The ACCC Financial Advocacy Network has also developed a toolkit that includes a form to track denied claims.

What Training Resources Are Available for Financial Advocates Who Do Not Have a Medical Background?

Panelists highlighted the ACCC Financial Advocacy Boot Camp as an essential resource to support training. The ACCC Financial Advocacy Network offers resources for developing, implementing, and delivering effective financial advocacy services. Other training strategies include recruiting mentors to guide new employees through the process of reviewing financial and other documents required as the foundation for financial advocacy and identifying the information that payers and pharmaceutical manufacturers are looking for to support claims and requests for support. This mentoring process allows navigators to ask specific questions and see immediately the importance of being detail oriented. At White Plains Hospital, Dr. Hopkins and colleagues developed a Lunch and Learn program in partnership with in-house clinicians and pharmaceutical manufacturers. The program provides education on what financial advocates need to know to effectively interact with patient and co-pay assistance programs. Similarly, at Green Bay Oncology, new financial advocates are trained and supported by staff who are deeply familiar with oncology treatment modalities and processes. Moving forward, a new health navigator associates program at Northwest Technical College in Wisconsin will provide an additional source of education for care professionals.

To Whom Do Financial Counselors Report?

Reporting for financial advocates can vary across cancer settings. Whatever the reporting structure (e.g., the business or support office), Lambert noted that in a hospital system, it is often preferable for the financial advocate to be embedded within the cancer service line rather than the business office. This organizational location ensures that advocacy is patient-centered versus focused on optimizing on financial returns for the organization.

Final Words

Panelists agreed that healthcare law and insurance coverage is complex. It is important for financial advocates to stay current with coverage news and resources to proactively support patients and prevent financial hardship.