By Anya Martin, A DOW JONES COLUMN
Survival is the first order of business when you face a diagnosis of cancer but failure to talk business upfront with your doctor could end up being your biggest setback down the road.
Don’t wait for your oncologist to bring up the topic of money, a new study suggests. Discussing treatment costs with health providers and budgeting for payment as soon as possible is the best way to soften a secondary blow for survivors who often still suffer the financial consequences years later.
In 2007, doctors discovered breast cancer in then-47-year-old Roseanne Nabhan. The Portage, Ind., woman underwent 28 weeks of radiation therapy and a lumpectomy to remove the malignant tumor and today she is free of her cancer– but not her medical bills.
Of about $60,000 in total costs, her insurance, a catastrophic-coverage individual plan, only paid $3,500. “I spoke to everyone at the radiation center and was really upset,” Nabhan said. “I told them I’m a waitress/bartender who earns $18,000 a year, what can I do? I can’t hand over my entire income.”
The radiation facility and the two hospitals where she had her surgery and other treatment were able to reduce her bill by just over half. However, she still owes more than $10,000, and the installments totaling $450 per month are a big challenge even when her paychecks are combined with those of her husband’s, who also earns only a modest income as a salesman.
Even patients with so-called “good” employer-provided insurance may face co- payments, co-insurance, deductibles over multiple years and coverage restrictions. The average medical debt for cancer patients with private insurance at the start of their illness was $35,878 in 2005, according to a 2005 Harvard University study of the causes of bankruptcy.
Cancer-care costs are rising at a rate of 15% per year, almost three times as fast as health-care costs overall, and the newest cancer medications cost thousands of dollars per month.
Better Communication Needed
Given the high costs, it’s not surprising that 84% of oncologists report considering their patients’ out-of-pocket expenses when making treatment recommendations, according to results of the largest survey to date on the topic released in the January 2010 issue of Health Affairs.
However, less than half of the surveyed physicians said they frequently discuss cost issues with patients, according to the Tufts Medical Center and University of Michigan researchers.
“It seems reasonable to suggest that there is a disconnect here,” said Peter Neumann, director of the Center for the Evaluation of Value and Risk in Health at Tufts’ Institute for Clinical Research and Health Policy Studies. “One could ask, how could it be that they are influenced by costs but not discussing it with patients?”
Still, one should be cautious about inferring that doctors are more focused on cash reimbursements than patient well-being, since this survey didn’t explore the reasons why doctor-patient cost discussions do not take place, he added.
Other studies have suggested that physicians prefer to focus on care over cost, feel they do not have a good solution when finances and the best treatment clash, are deterred by the complexity of insurance policies in today’s health system and think that financial discussions are better had with front-office or business-department staff who are more likely to be well-versed in the nuances of insurance guidelines, he added.
What’s needed is better communication on both sides–doctor and patient, Neumann said. “There’s a responsibility, even obligation on the part of the oncologists, but I do think there’s an important role for patients as well to understand the financial ramifications of decisions that they and their physicians are making.”
Care vs. Cash
Cancer patients often raise the topic of costs at the Hutchinson Clinic, said Dr. Mark R. Fesen, an oncologist for 16 years at the Hutchinson, Kan., multispecialty facility, and author of the book “Surviving the Cancer System.”
“Out here, we have a lot of patients who are less worried about themselves than the nest egg they built up and want to see it survive for a spouse or kids, ” he added.
In addition to business counselors who address insurance and payment issues, the Hutchinson Clinic employs a social worker, who can help patients access government assistance programs for which they may qualify, and another staff member, who matches cash-strapped individuals with nonprofit and other resources that can help with payment, including free-medication offers from pharmaceutical manufacturers.
Fesen doesn’t believe in limiting care based on a patient’s finances, but one situation where he and other oncologists may consider access to cash is when deciding between prescribing IV chemotherapy drugs or oral agents, he said. Both have similar survival rates but different side effects, and the latter can be more convenient for some patients since it doesn’t require visiting the center, he added.
Insurers generally cover IV treatments upfront, but oral agents, which cost $ 5,000-$6,000 per month, fall under prescription benefits which some policies dictate that the patient pay the pharmacy and wait for reimbursement.
Still, Fesen said he was troubled recently when an elderly woman on Medicare came to see him for a second opinion after a California oncologist expressed reluctance in treating her lung cancer. “She was going to pass away, but the tumor was treatable and her quality of life would be much better if it was treated than if it wasn’t,” he added.
Challenges in Medicare reimbursement may make some doctor less likely to encourage seniors with cancer to try expensive treatments, Fesen said.
Patients shouldn’t be uncomfortable bringing up payment concerns with their doctor and office staff, said Angelina Esparza, director of the American Cancer Society Cancer Action Network’s Patient Navigator Program.
The program has placed trained staff at 130 cancer-treatment facilities around the country to provide one-on-one support to patients and caregivers on issues such as finances, transportation to and from appointments, lodging, and understanding one’s diagnosis and treatment options.
However, the best prescription for preventing sticker shock is to make sure you fully understand your insurance coverage including deductibles, annual limits and other restrictions long before any diagnosis, cancer or otherwise, occurs, “When you do get sick you have so much on your plate, so at least having a general understanding of what insurance covers relieves some of that stress,” she added.
Next, start to estimate your total medical and nonmedical expenses; budget extra for unexpected costs, for example, if your treatment results in a complication; and consider consulting a financial planner, Esparaza said.
Help At Hand
Oncology practices and hospitals often employ specialized staff, such as a social worker or patient navigator, who can help identify other resources such as nonprofits and foundations specific to your type of cancer or geographic area, she added.
For example, the Boston-based SAMFund, founded by two-time cancer survivor Samantha Watson, provided $92,000 in grants to 58 young-adult cancer survivors in 2009.
Rachael Lozano, 26, received one which will pay off two and half months of $ 700 insurance premiums while she completes her last semester toward a bachelor’s degree delayed by three rounds of cancer treatment. Her high rate is due directly to her previous cancer diagnoses, she added.
“My husband calls it our mortgage payment,” Lozano said.
Other organizations facilitate fund-raising for a specific person with cancer, such as the Human Tribe Project, which allows users to create a Web-based social networking site to collect $20 donations in exchange for three steel charms, including one engraved with the beneficiary’s name. Since the Web site’s founding in July, 85 tribes have registered, raising $10,000.
“One woman said her tribe didn’t raise that much, but it was enough for a cleaning lady because she was too sick to do that,” said Human Tribe Project founder Jaclyn Foutz, who watched a now-deceased friend with cancer struggle with high medical bills.
Throughout her treatment, Nabhan says her radiation oncologist never asked about her ability to pay, although at one point front-office staff encouraged her to consider a credit card specifically for medical expenses.
However, she also never sensed that payment challenges affected her treatment, she added. “I have to give my oncologist credit that he did not make me feel like I was less than anyone else nor getting any less treatment.”
Recognizing a communication gap when it comes to cost, the American Society of Clinical Oncology formed a Cost of Care Task Force and last year issued a free booklet which includes tools to help patients talk with their doctor about managing the cost of cancer care, a summary of all the costs associated with treatment and suggestions for financial resources to assist with paying bills.
Another resource for help with budgeting for care is the American Cancer Society’s 24-hour hotline 1-800-ACS-2345 and Web site.
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