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.
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.
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.
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.
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
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.
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.
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.
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.
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.