Avoiding copay shock

Studies have found that most oncologists rarely discuss the financial implications of cancer treatments with their patients. However, given that today's very expensive new therapies can produce copayments upward of $10,000 a month, many in the oncology community feel it is no longer appropriate to ignore costs when talking with patients about care. Cancer Care & Economics (CC&E) recently spoke with Anthony Back, MD, professor of oncology at the University of Washington, and a medical oncologist at Seattle Cancer Care Alliance, about the need to break down communication barriers around costs of care.

CC&E: Given the increasing costs of delivering cancer care, should today's oncologists discuss the financial realities of oncology treatment with their patients?

DR. BACK: On a case-by-case basis, yes. As a specialist in gastrointestinal and colon cancer, I care for many patients with advanced disease who need to understand potential trade-offs they can make when faced with significant out-of-pocket expenses. With the variation in insurance coverage and the tremendous expense of new medicines, it's important to talk about costs of care that impact the treatment and quality-of-life decisions for an individual patient.

Patients who have significant copays need to discuss whether they will be able to continue a certain therapy or should seek an alternative. Moreover, offering patients information about coverage and financial issues that they might be unfamiliar with helps them make informed decisions about their care.

CC&E: It could be off-putting to cancer patients for their oncologist to talk about money in the same context as treatment. How do you approach such a delicate subject?

DR. BACK: I always discuss the therapeutic options first, but if necessary I raise the issue of costs early in the discussion. Quite frankly, some of my patients are shocked when they find out the cost of their copay, or that a certain medication will not be covered by their insurance plan. I explain that we will check their insurance to see what percentage of the costs they would be liable for out-of-pocket, and assure them that, if it turns out to be an unmanageable amount, we'll have another visit to talk about different options. Most patients really value that kind of honest, open-ended discussion as long as they are confident that their care won't be compromised.

Conversations of this nature take a certain level of skill, and, in some cases, it's important to involve other members of the care team, such as an oncology nurse, social worker, or practice manager.

CC&E: Costs at the end of life tend to be very heavy. Some in the oncology community think we have an ingrained tendency to continue aggressive treatments for too long instead of initiating palliative care. How do you feel about that?

DR. BACK: First off, treatment decisions in advanced cancer are complicated by numerous and unpredictable factors. On the one hand, I feel that the transition from aggressive anticancer therapy to palliative care often happens too late. Frankly, cancer doctors don't like to give up. However, I know from my own practice that quite often it's the patients themselves who drive the interest in continuing anticancer therapy in the hope that it will extend their lives, even if only for a few months.

Physicians with good communication skills can often guide patients in a way that helps them accomplish important goals at the end of life even if it means stopping aggressive therapy.

CC&E: The costs of treating advanced colon cancer have risen dramatically over the past decade. Life expectancy has risen also in this population. But, from a societal point of view, do the results justify the growing costs?

DR. BACK: That's a tough question, but one that oncologists need to grapple with. We've made incredible progress in our understanding of the biology of cancer and in discoveries coming out of the labs, but we still need to ask ourselves how long we can continue to deal with the escalating costs of delivering cancer care.

For a patient with advanced colon cancer, survival has risen about 12 months over the past decade, but the costs of a standard regimen have gone from about $500 to upwards of $250,000. When I tell lay people about the costs of care, they're floored because they can't imagine this amount of money being used for the modest life extension that we're seeing.

Naturally, it's very difficult to quantify what constitutes cost-effective care in certain clinical situations in which patients are fighting to extend their lives. Moreover, most oncologists have a difficult time being gatekeepers. They want to use all the tools available, regardless of cost. Unfortunately, because of the way oncologists are paid, there's a financial incentive on the drug side. We need to restructure the system to properly pay for the complicated services we provide and reduce our fiscal dependency on cancer drugs as a main source of revenue.

CC&E: Any closing thoughts?

DR. BACK: I think that initiating sensitive discussions about the cost of care relative to outcomes could be a good thing for oncology as we move forward. In today's fiscally challenged environment, it's no longer possible to avoid the financial reality when talking about prognosis and therapeutic options. Open discussions about costs of care, as difficult as they may be, serve the best interests of our patients.