Providing Comprehensive Financial Advocacy Services in Rural America

Montana has approximately 1.1 million people across 147,040 square miles—making it the fourth largest state in the United States. In comparison, Brooklyn—a borough of New York City—has more than twice the number of people, yet it is only 69.4 square miles. Montana’s peculiar population density makes it one of the most rural states in the U.S., a significant hurdle for patients with cancer.

Financial toxicity in recent years has had a disproportionate impact on survivors of cancer who live in rural America. One study found that 50.5 percent of rural survivors report financial difficulties due to their anti-cancer treatment, while survivors living in urban areas experience financial difficulties at a rate of 38.8 percent (that is a 11.7 percent difference). The cost of traveling to medical appointments coupled with higher rates of uninsured and underinsured patients in rural America are contributing factors, as financial advocates grapple with helping these patients manage the financial burden of their cancer care. Becky Franks, MA, is at the forefront of this mission.

From Minnesota to Montana
Franks began her career in health education and primary prevention, working with children and families who were struggling with substance abuse in rural Minnesota. Franks moved to Montana to continue her work, where her mother’s breast cancer diagnosis prompted a pivot to oncology. “I started in an organization that was very small and run solely by volunteers,” Franks said. “They hired me as their executive director, and I was the only person there.” Her public health background influenced Franks to prioritize delivering evidenced-based cancer care to patients. In pursuit of this objective, her organization joined Cancer Support Community—a research-based and advocacy institution—in 2007.
Franks is now the chief executive officer at Cancer Support Community Montana, where she is working to support and empower patients with cancer. With in-person services available in Bozeman and Missoula, Mont., or virtually, the organization’s mission is centered around empowering patients to increase knowledge, find strength, and thrive in community as they move through treatment into survivorship. Through its patient active initiative, Cancer Support Community Montana educates and screens patients for anxiety and distress, while identifying the financial concerns and barriers to care they are facing. Using Open to Options—an interview technique that accounts for patients’ understanding of the cancer care continuum—the organization understands all the issues patients may have, while helping them develop individualized questions for their care team. “Most people call for very task-specific issues, but during an interview, we may find out that they need so much more,” Franks said. “That is why the interview process is so critical. So that we can help people figure out the best path forward for themselves.”
Studies suggest that the unmet psychosocial needs of patients with cancer are a source of severe distress. Research has also shown that addressing that distress has a positive effect for patients, their families, and the healthcare system. In recognition of this, Cancer Support Community Montana employs mental health providers, who have been trained in oncology navigation. They meet with new patients, providing the Cancer Support Source distress screening to identify and assist with patients’ needs.
Challenges Rural Patients Face
According to a report from the American Society of Clinical Oncology, only 7 percent of oncologists practice in rural areas. However, 20 percent of the oncology population resides in such communities. Approximately 1.6 million rural households do not own a vehicle; this, coupled with the lack of effective public transportation in rural communities, makes travel to medical appointments difficult for patients with cancer. “We are having a big conversation about travel in rural communities, and the financial impact when you have to travel 300 miles just to get care,” Franks explained. “That means you have to stay overnight, but you have nowhere to stay and no gas.” Franks and her team help patients by providing gas cards and hotel vouchers. Additionally, they are working with healthcare professionals to improve access to infusion centers and psychosocial care in critical access hospitals—thus reducing the distance patients must travel. “You can be near your home, heal better, get the care that you need, and not have to go broke,” Franks said.
In the past, patients in rural Montana with certain types of cancer would have to fly to Denver, Colo., or Seattle, Wash., for treatment. According to Franks, one mother and her son flew to Denver for his leukemia treatment. Before they returned home to Montana, there was a $100 thousand bill for the airflight in her mailbox—one that insurance would not cover. “I cannot help her feel better, until I make that bill go away,” Franks said. Fueled by the drive to advocate for the mother and patients like her, who are encumbered by suffocating costs as they embark on a battle for their lives or that of their loved ones—Franks and her team sought a legislative solution. “We helped implement a solution that placed that burden of cost on the airflight company and the insurance company, not the mother of a sick child,” Franks shared. “When a system of care is making it harder to receive medical and psychosocial care, then we have a problem. Many people with cancer do not know how to fix that, but I have the ability and energy to do so. And so do a lot of other people.”
Franks asserts that dealing with the financial aspect of cancer care may be too much for patients to handle, thus an avenue to help them address the burden of these costs should always be available. “Cancer is so complex, and people are not ready for it. All they are thinking about is surviving,” she said. “It really takes health advocates and the ability to push forward.”