The Weight of Finances on Cancer Care: An Oncologist’s Perspective

Cancer is not a cheap disease to be diagnosed with. According to Loretta Nastoupil, MD, as treatments for various cancers have improved and survival rates have increased, the costs of these drugs have only gotten higher.

Nastoupil, an oncologist at Southwest Oncology in Durango, Colorado, spoke with CancerNetwork® about the intricacies surrounding the financial aspect of cancer and how she navigates it as a care provider. Furthermore, she discussed the state of economics in oncology overall.

Oncology practice consolidation, the transition away from traditional chemotherapy, and the rising efficacy of novel cancer drugs were among the contributors to changes in the economics of oncology that she highlighted. She noted that various other factors weigh into the financial side of care, such as the length and type of treatment, especially with CAR T-cell therapies.

What specific events have had a consequential effect on the economics of oncology?

I spent over a decade as an academic practicing oncologist at MD Anderson Cancer Center in Houston, Texas. I'm now a community oncologist in a rural community that's a hospital-based practice. There are unique challenges in both settings. But what has really impacted the practice of oncology over the last few years is the consolidation of oncologists. The cost of drugs and the delivery of therapy in terms of supporting office staff have become insurmountable for most private practices. To address this, most have consolidated. You have these large academic groups that are buying up community or private practices. They have a better outreach into the community because we know that most patients in the US receive their care in community practice. [Additionally], you have these large hospital groups that are coming in and buying up smaller practices, and that's currently where I practice.

Transitioning away from traditional chemotherapy to immune therapy, bispecific antibodies, and CAR T-cell therapies are major transition points. Married to that, because the cost of delivery of that care is so high, we're seeing changes in the payer mix as well. This is going to get even more challenging over the next few years. For instance, where I practice, we do provide care for patients who have Medicaid, Medicare, and even patients in the VA system, as there's no VA hospital near us. We probably provide care for fewer privately insured patients, given that we have a large mix of retirees in this community. That's also going to pose even greater challenges as we move forward.

Are there any specific policies that you monitor or stay up to date on that may have a large impact on the state of finances in oncology?

What I've learned in the recent past is that oncologists need to pay attention to both state and national policies, particularly for practices that provide care for patients who receive Medicaid. As we see national funding change, you'll need to pay close attention to your state laws and policies to see how much of that is going to be absorbed or changed by the state. There are also national organizations, such as the American Society of Clinical Oncology and the American Society of Hematology, that are paying attention to some of these changes and lobbying for patients, making sure that practices stay sustainable. Those are things that, 5 years ago, I paid very little attention to, and maybe that was because I worked for a state institution. Now, I'm much more inclined to pay attention to them.

How do the varying lengths of treatments affect patients’ finances differently, specifically considering CAR-T?

CAR-T is a good example to dig into. It is a one-time infusion, but it has to be delivered, generally, at a tertiary center that's FACT [Foundation for the Accreditation of Cellular Therapy]–accredited. That's going to isolate where those centers are, in a sense. A perfect example is where I am now; I have to send patients either to Denver, Salt Lake City, maybe Albuquerque—although they're a much smaller program that's up and running—or Phoenix. Generally, patients are going to have multiple trips. They're going for their initial consultation to see if they're an appropriate candidate. Then, they're going to be set up for a second visit to undergo the leukapheresis, and then they're going to come back for the third and longest visit, when they receive the lymphocyte-depleting chemotherapy followed by the cell infusion.

Generally, people have to travel. Even if you live within a large metroplex, there are often restrictions regarding the toxicity management that do require patients to be within a 30-minute radius [of the center]. Most patients will have some financial costs involved with this treatment, given the request for close monitoring. There have been attempts to reduce some of these barriers because we know that, particularly in lymphoma, only about 20% of eligible patients actually receive this therapy, which can be potentially curative or definitely alter the natural history of the disease. It can otherwise be highly fatal.

Why are there so few patients? Well, it is [due to] these financial burdens and this need for travel. They need to have a caregiver with them for 24 hours a day for the first 2 to maybe 4 weeks, so it is a huge financial burden. Now, there are patient assistance programs oftentimes provided by the manufacturer, or even some of these tertiary centers will provide some additional help in terms of housing and support. But I do think the challenge still remains in terms of the need to travel long distances; have a caregiver be off work, oftentimes for about 2 months; and then, if they have toxicity, that's even more significant, and may even lead to a longer time to recovery. Those are the challenges.

Now, if you look at the cost effectiveness of a therapy like CAR-T, it is oftentimes a curative option for about maybe 20% to 40% of patients, and then they're done once they get past that first 30 to 60 days of monitoring. Then, the visits become much less frequent, and they may not need additional therapy. I think we tend to spend a lot of time talking about the cost, but we sometimes minimize the effect in terms of this as a one-time treatment; they don't need subsequent therapy. As a society, if we can do a better job of identifying those patients who are going to have a one-and-done treatment, and try to prioritize those, then this becomes a much more financially feasible operation.

Have you noticed any differences in the experience of dealing with insurance companies over the years you’ve been practicing?

There appear to be more barriers instituted just to see if you have the staff or the determination to stick with it, or if you'll potentially just quickly move on to something that's potentially more financially feasible. Most oncologists will rely on NCCN guidelines to know what is essentially a standard-of-care option. Payers and insurers will also look at that as the standard of care. Most of your practicing oncologists in the community are going to fall within those guidelines, and they're generally not asking for things that are not FDA-approved or outside the window of being a standard-of-care option.

Even with those guardrails, we see that with some of our more modern therapy, particularly in the form of oral targeted agents—BTK inhibitors, for instance—you'll see that it often takes longer for insurers to even agree to it. That's even before we learn what the patient's copayment is or what their responsibility might be. If you don't have the patience, or you don't have the luxury of time with the patient in front of you, it's sometimes easier to just move on to that standard chemotherapy option that's been around for many years because you know you'll potentially get it approved faster. That's where the practice of oncology has probably changed the most over the last 10 years. You have to understand that we need to have patience on our side and we need to have patience with our staff who are negotiating on these payment plans, but you also need to manage the patient and their family's expectations. That's where people start to cave under the pressure in most situations because it's just so much communication and a lot of managing what a realistic wait time is vs what's unacceptable. But you're also doing that when you're busy seeing patients right in front of you. That's where payers and insurers know that they probably have an upper hand because they have the luxury of more time, they're not patient-facing, and they don't have to deal with the questions every day of why this is taking so long.

When did financial toxicity become a serious consideration for you?

When our therapies get better, meaning when we have more effective treatment where patients are going to be on therapy longer, they're going to have potentially longer drug exposure. That also raises concerns about chronic toxicity, but that's where the financial toxicity really came into the discussion. Rightly so, because if you have somebody who in the past may have expected to be on a drug 2 to maybe 6 months at most, maybe it's an intravenous therapy that they're getting intermittently. Now, we have combination strategies. We have targeted agents that are going to be potentially more effective and keep patients on the drug much longer. Some of these are oral therapies, and particularly for Medicare patients, how their supplemental will cover oral therapies can be vastly different. If you have a patient who is going to be on treatment for years, and every month they have a potential copayment that may cut into their living expenses, you have to be mindful of that. Oftentimes, even before we start the drug, some of those conversations are happening now; there are a number of patient assistance programs out there. That's where, if you have access to more ancillary staff in a larger Metroplex area that has the time to explore patient grants through pharmaceutical or manufacturers' disease organizations, those can be very helpful. [They] can open the door to patients where otherwise it may not have been financially feasible. But that's where the shift has happened. We got better drugs. People are on them longer. Now, we have to be mindful of what their cost is.

What tools are available to patients who may need help paying for their treatment?

For community oncologists, particularly, they're generally providing a service where the patient lives. In a rural setting, it's going to be a much smaller town, so it can be very rewarding in many ways. When you're working in a large Metroplex or a large academic center, you're often at a tertiary referral center, so you may be seeing patients that come in for a single opinion and then return home to their community oncologists, where they're going to be delivering that care. Those are vastly different approaches.

When you're delivering care that is going to be multiple courses of treatment and not just providing a one-time second opinion, that's when you're going to be more involved in the day-to-day [work] in terms of how much a given cycle is going to [cost]. The other thing we sometimes don't talk about is not just the cost of copayments, visits, and treatments, but the cost for the patient in terms of missed work opportunities. If you have patients who are generally living paycheck to paycheck, they now have a disease where they're going to be missing [work] multiple times a month. I've had several situations where patients are trying to decide whether they can keep their job so they can keep their insurance and continue treatment.

This is where oncologists need to become very familiar with state policies. In the state of Colorado, not everyone is eligible, but for most, [the state] can potentially provide some additional support while they're undergoing active treatment, so [patients] don't have to worry as much about missing work and not being able to provide for themselves or their family.

In larger centers, you're often going to be seeing patients who have the financial resources to travel. Generally, that's a very different situation. But many of these patients are flying in and out, and their time is very critical. If they have to stay overnight, that's more cost accrued in terms of hotel space. There's a lot more pressure to get large volumes of patients through the system efficiently. That can also create some additional challenges that I don't face anymore.

If you could make one change to affect the financial side of oncology, what would it be?

People are going to be much more sensitive to the challenges each American [patient experiences] if they just spent a little time in an infusion center or waiting room in a cancer center. I think you see humanity there. You see a lot of people who are struggling. You see people who are sometimes hopeful and excited because they've done well, and they want to share that with others. But if people who are involved in our policymaking could just spend a little bit of time in these clinics, they'd have a much better understanding of why we fight so hard for our patients and to be able to maintain the viability of our practice. If all these clinics start to close, then these patients have to travel even farther distances.