Patient Financial Assistance for Immunotherapy

Financial toxicity affects many patients with cancer and has increasingly become an additional unwanted side effect of the disease. The economic burden accompanying a cancer diagnosis is likely to intensify as the costs of cancer continue to grow in the United States—faster than other non-cancer healthcare costs¹—and as checkpoint inhibitors enter a new era of combination regimens.

As part of its focus on empowering providers to support patient access to immunotherapies, ICLIO recently spoke to Clara Lambert, Oncology Financial Navigator at the Cowell Family Cancer Center in Michigan, about the range of financial assistance options for patients with cancer.

Identifying Red Flags

What is involved in being an oncology financial navigator?

Clara Lambert: Oncology financial navigators are different at each facility. Here [at the Cowell Family Cancer Center], we concentrate on navigating the patient. We’re looking at potential financial barriers for access to care and we try to find patients that we think will benefit from our services. First, our insurance verification team tries to identify patients that they think would benefit from financial assistance, such as new patients who either are uninsured, under-insured, or who have some red flags.

One big red flag to me is Medicare with no secondary insurance or no supplemental insurance. We know that these patients are going to have a 20 percent out-of-pocket without a cap on it, and we try to meet with them up front. When we’re verifying benefits to start treatment, other patients with financial barriers for access to care would be people that have out-of-pocket expenses or a high percentage for an oral treatment.

Quick Fact

According to Kaiser Family Foundation estimates, 14% of Medicare beneficiaries do not carry supplemental insurance.²

Then we meet with the patient to review their insurance with them, and have a discussion about their potential out-of-pocket costs. That discussion leads us into the different types of assistance that we can find to help with those costs. We do everything we can to help the patient obtain whatever financial assistance that we’ve chosen as the best plan for them, and walk them through the whole process of applying and gathering the information and getting the approval. Then we pass it off to our billing team at the hospital, and [we] also assist with access to oral medications through the specialty pharmacies.

We would love to have identified every patient that we should be working with and initiate that relationship at the start, but that doesn’t always happen. Here at the Cowell Family Cancer Center, if anybody expresses some financial distress, staff contact me or my coworker to let us know what’s going on, and see what we can do to help that patient.

Learning the Language of Insurance

What kinds of support or financial education do patients typically need in relation to immuno-oncology therapies?

Lambert: There have been a lot of changes in the insurance industry over the last 20 years, especially for Baby Boomer patients. When this generation entered the workforce, they had medical insurance that covered everything, but in the past 5 to 15 years we’ve seen the patient responsibility portion grow drastically. Monthly premiums, the amounts that are being taken out of paychecks or out of their retirement funds, and out-of-pocket expenses like deductibles and coinsurances, have all been growing.

This is new and a change for people, especially if they’ve been fairly healthy over their lives, and then they suddenly get a cancer diagnosis. A common statement or sentiment for people when they have to pay something out-of-pocket is, “Well, that’s not covered by my insurance,” when in reality it is covered by their insurance but it’s going towards their deductible. There’s some benefit since they’re getting the pricing from the insurance company and they are meeting their deductible.

Quick Fact

Average worker contributions to premiums have doubled since 1999, and the average annual deductible has more than doubled, from $584 in 2006 to $1217 in 2014.³

I have found that it’s helpful to review definitions of those different terms (e.g., premium, deductible, out-of-pocket) and also to review when the patient’s benefit year starts, so that we can identify different times that they might need to talk to me again. People get a calendar for their treatments, but there’s also a calendar for their finances in cancer treatment. Knowledge is power, and so patients are empowered when they understand how their benefits are working.

If somebody is diagnosed toward the end of the calendar year and their insurance is a calendar-year program, they might not have had anything going on with their health; then in September or October they’re diagnosed and they start treatment. They’re going to be meeting their deductible at the end of 2017 and paying for their treatment. Then, January 1, while they’re still in treatment, they have to start all over again to meet their deductible. So, they have a double hit. But for some patients, the benefit year starts on another date, so anybody that’s not on a calendar-year plan is going to have to meet a second deductible when their plan starts over. It’s important to know those benefit dates when you’re talking to a patient because it’s not just January to December for everyone.

Educating Patients about Insurance Optimization

What kind of assistance would you be able to point patients with a ‘double hit’ toward?

Lambert: Sometimes we contact one of the foundations and ask for a second grant. Sometimes we might have to apply for two different grants from two different foundations. It really depends on the situation and the kind of insurance that patients have, and if that double whammy is going to take them over the assistance that we’ve been able to get for them in the first place.

We also have an opportunity here, because not only do we do financial assistance, but we help people with insurance optimization. If we’re getting toward a point where the patient has open enrollment and they have several choices, it’s definitely a good time to sit with that patient and compare their different choices side-by-side. Something that might cost less per month out of their paycheck might not help them as much overall, but if they were to pay $5 or $10 more a paycheck, they might get substantially better insurance coverage. The insurance education part is important, as well as looking at the calendar and using that timeline to help patients potentially have better coverage for their new year.

When you need to find grants and other resources to provide financial assistance for patients, where do you go?

Lambert: Typically, I would look at NeedyMeds, and type in the medication, and then that usually gives me a fairly accurate list of where I can go for the different types of help that I might need to get for that patient. Another place is the Association of Community Cancer Centers (ACCC) Patient Assistance and Reimbursement Guide. These are like my index and tell me where to start.

With a patient that has Medicare or any other government-funded insurance, we have to get assistance through a disease-specific foundation. With a patient who has commercial insurance, if the pharmaceutical company has a copay card, we can generally just get the medication straight from the pharmaceutical company. You have to know the guidelines. When we’re working with the pharmaceutical companies, most of the time there are very generous income guidelines, however some are more restrictive.

Quick Fact

A 2017 analysis of patient assistance programs found that the average maximum annual income for qualification for a free drug program was $86,279 and the average for copayment assistance was $104,790.⁴

So, it’s important to make sure that you find the best program for the type of patient you’re working with. If they have Medicare or a Medicaid spend-down, I automatically know I’m going to be looking at foundation assistance, and the income levels are 400-500% of the federal poverty level. When I’m working directly with the pharmaceutical company, it’s important to make sure that your patient is eligible by reviewing both income guidelines and the diagnosis code.

Each of the foundations are disease specific, so I find one of the foundations that has a fund open for the specific diagnosis that the patient has. If it’s a commercially-insured patient, then we have to make sure that the medication has an approved use for the patient’s condition. Pharmaceutical websites vary, but are usually pretty good at describing their program with most information readily available.

The other thing I’ve found is that it’s important to maintain a relationship with the pharmaceutical reps that come in. They know I’m a financial advocate and they make sure that they bring me copay cards and any new information on any new financial assistance programs. I usually meet with one or two a week and get as much information as I can about their product and what is available for that product.

We Need to be Detectives

Are you involved in finding supportive care assistance for things like transport?

Lambert: Yes, and there are some foundations that have some travel assistance, some pharmaceutical companies have some travel assistance. Our Medicaid programs in the state of Michigan have some travel assistance. The American Cancer Society has the Road to Recovery.

We’re financial advocates but we’re also detectives. We’re always trying to find solutions to help our patients with whatever we can, and there are lots of solutions out there. It’s a matter of putting them together and coordinating what is best for who we’re working with. I subscribe to a lot of lists so I know what new therapies there are and what drugs are being used for what diseases. When there’s something new, I’m always looking to find out what assistance is available so that I can help people as quickly as I can. I use a spreadsheet to track this information, and we have our electronic medical record that has nurse navigation software that we’re “hybrid-ing” for financial navigation. So, we’ve got a lot of different tools right now that we’re really trying to coordinate into one in the long run.

References

1. McDougall JA, Ramsey SD, Shih Y-CT. Financial toxicity: A growing concern among cancer patients in the United States. ISPOR Connections. 2014;20;2:10-11.
2. Cuabnski J, Swoope C, Boccuti C, et al. Report: A Primer on Medicare: Key Facts About the Medicare Program and the People It Covers. The Henry J. Kaiser Family Foundation, 2015. http://www.kff.org/report-section/a-primer-on-medicare-what-types-of-supplemental-insurance-do-beneficiaries-have/.
3. The Henry J. Kaiser Family Foundation and the Health Research and Educational Trust. 2016 Employer Health Benefits Survey. http://www.kff.org/health-costs/report/2016-employer-health-benefits-survey/
4. Zafar SY, Peppercorn J, Asabere A, Bastian A. Transparency of industry-sponsored oncology patient financial assistance programs using a patient-centered approach. J Oncol Pract. 2017;13(3):e240-e248.