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Difficult Financial Conversations with Patients: Broaching the Subject and Finding Solutions

Grand Rapids, MI—Many individuals do not like to broach the topics of finances and healthcare, but financial toxicity caused by the high price of healthcare is nondiscriminatory, and therefore incredibly necessary to discuss with patients. Concerns about money affect the choices made by the insured and uninsured alike and, in turn, greatly influence their health outcomes.

At the 14th annual National Organization of Rheumatology Managers (NORM) conference, Clara Lambert, BBA, OPN-CG, Oncology Financial Navigator, Advocate Good Samaritan Hospital, Downers Grove, IL, discussed a proactive approach to mitigating the financial toxicity facing many rheumatology patients.

A Deeper Look at Financial Toxicity

Many people start treatment with preexisting debt and already limited assets. According to Ms Lambert,

at the time of diagnosis, certain factors in a household can determine how financially vulnerable a patient might be. These factors may include whether the patient is a wage-earner in the household, has had trouble paying bills prior to diagnosis, or is currently insured.

“When patients receive a diagnosis, they have many thoughts running through their minds…about their diagnosis, their treatment, and how much it’s going to cost,” Ms Lambert said. “And the fact that cost factors into their treatment is exactly why financial toxicity has become a common term.”

Worries about finances affect a patient’s treatment plan in many ways. To save money, patients may partially fill a prescription, take less than prescribed, or even avoid filling their prescription altogether. They may dig into their savings to pay for medications, reduce spending on food or clothing, or cut back on leisure activities.

Ms Lambert noted that some people might see leisure activities as frivolous, but she argues that they are indeed necessary. “When you’re going through something like this, you need that sense of normalcy,” she said. “You need to still do movie night or date night; you need to keep that up.”

She shared the story of her husband’s cancer diagnosis 14 years ago, and the ways in which financial toxicity affected her own family. Their income was significantly reduced, they had to meet a $1500 deductible and a $3000 out-of-pocket twice (because of the time of year for his diagnosis and the way his treatment timed into the benefit years), and they had to ask for help financially. But one silver lining, she noted, is that the financial navigation she did for her own family inspired her into a new career path.

Changing Our Viewpoint

“Because we work in healthcare, we understand the lingo and the complexities. We understand how billing works, how long it takes, and how different insurances work together,” Ms Lambert said. “But, most of the time this is all new and foreign to people who don’t work somewhere within the revenue cycle.” She noted that many clinicians do not understand it as well.

Ms Lambert told attendees to keep in mind that patients may not understand commonly used terminology. “We need to realize that when we’re talking quickly and saying something is ‘out of network,’ we might need to stop and explain what ‘out of network’ means, and how that’s going to affect the patient,” she said.

Many times, patients receive bills from multiple providers for 1 care episode, which can be incredibly confusing to them. According to Ms Lambert, patients may only be able to visualize a few steps—treatment, the bill being sent to insurance, and, finally, receiving the bill—they often do not understand the work taking place behind the scenes that allows them to receive their treatment.

“So, we need to change our viewpoint,” she said. “I encourage each and every one of you to think about the patient perspective when working within the revenue cycle. We need to make it easier to understand, and we need to help them get what they need to have peace of mind during treatment.”

Ms Lambert also advised attendees to find ways to help streamline the appointment scheduling process. Patients need to be educated on their potential out-of-pocket expenses and research assistance options, and, whenever possible, they should be referred to a financial navigator or advocate who is equipped to discuss their concerns and find solutions.

The Effects of Financial Burden

According to Ms Lambert, a financial navigator should meet every new patient at the time of initial diagnosis, regardless of whether they appear to have financial concerns. The navigator should review the patient’s insurance coverage in conjunction with the prescribed treatment and then work alongside the patient to determine a plan.

Many patients may not understand how their insurance benefits work. They may not know that they need financial help or may be unaware that resources are available to assist them with their prescriptions, medical expenses, or living expenses, she said.

Other times, patients are embarrassed to ask for help; they may perceive it as charity or worry that expressing financial need may equate to treatment being withheld or interrupted. Therefore, it is crucial for a financial navigator to remove these misconceptions.

“Assistance is available for people in times of need, and this is a time of need for them,” she said.

If a patient is unable to work—especially if he or she is the provider of family insurance—a financial navigator can compare plans and determine the best solution. This may also be the time for a patient to apply for Social Security Disability.

If a patient loses his or her insurance coverage, it is important to maintain continuity of care. At this point, a navigator can help the patient review and apply for Marketplace Insurance, premium assistance, Free Drug (if he or she qualifies during that gap in coverage), and perhaps Medicaid, depending on the financial situation.

Often it is more than a month before patients receive the first bill. In that time, they may receive a bill with insurance “pending” before they have an obligation to pay, and this bill can be shocking, as it does not show the insurance adjustment amounts. Ms Lambert says this is a good time to schedule another meeting with patients to help them understand how their insurance works.

Many people struggling to pay medical bills have employer-sponsored medical insurance and may initially decline help. Ms Lambert explained that she keeps an eye on these patients and reaches back out if they have not paid a bill within 30 days.

“At that point, I am likely still able to do something, and the patient is likely to be more receptive,” she said.

A Proactive Approach to Financial Toxicity

A proactive approach to managing financial toxicity involves upfront conversations with patients before they find themselves in a dire financial situation.

Identify patients in need of financial assistance and educate them on their insurance benefits and financial responsibility regarding treatment. Optimize insurance coverage whenever possible, and connect patients to financial assistance, including prescription drug assistance and copay assistance (either directly from pharmaceutical companies or from disease-specific foundations). Create realistic payment plans with patients and maintain open communication by keeping them aware of things, such as impending insurance changes or payments from copay assistance.

Ms Lambert warned of red flags that may signal a patient’s potential for financial toxicity, such as Medicare with no supplement, high out-of-pocket maximums, disease progression (to a point where the patient may need to stop working), previous bad debt, or nearing Medicare eligibility (a point at which patients may need counseling on the choices available to them).

She also stressed the importance of ongoing investigation. Rheumatology managers must stay informed on new and improved resources, to network with colleagues (even those across the country), to utilize the state and community resources available to patients, and to stay on top of healthcare law and policy, as this affects patients’ insurance, treatment, and finances.

“But there are also times that you come across a patient in a situation where you have little to no resources with which to help,” Ms Lambert said. “And this is where advocacy comes in. Keep current on political topics pertaining to healthcare, call and visit your representatives, and share your stories.”

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