Addressing Financial Toxicity Through Systematic Change

Meg Barbor, MPH

December 2018, Vol 9, No 4 - Value-Based Care


Although the cost of care can have severe effects on patients with cancer and their families, oncologists rarely address financial toxicity, according to Hanna K. Sanoff, MD, MPH, Medical Director, University of North Carolina (UNC) NC Cancer Hospital Clinics.

“Even the most financially educated healthcare providers cannot solve this complex problem by addressing it with individual patients on a case-by-case basis,” she said. “Only systematic change in how oncology practices and institutions address financial toxicity will have a substantive effect on the financial well-being of patients with cancer.”

At the 2018 ASCO Quality Care Symposium, Dr Sanoff described the challenges that she and her colleagues faced after realizing that they were not offering sufficient, if any, financial assistance to their patients most in need, and then making the decision to do a complete overhaul of their financial navigation program.

Prerequisites for Change

The recognition of the financial assistance problem at UNC came from a rising national awareness of the importance of financial toxicity, which was compounded by a general dissatisfaction among the clinical team and their patients about how their institution addressed financial issues.

In 2017, UNC brought in a consulting group to discuss the problem. “I, naively, thought we could just hire some people and throw some money into it—boom, done,” said Dr Sanoff. “Unfortunately, that idea was completely dead in the water. We hadn’t done the legwork; we didn’t bring in all of the stakeholders involved with the problem at UNC to think about potential solutions in a collaborative fashion.”

They quickly realized that the people involved in financial navigation were incredibly siloed, and their patient-centered operational team and business team were faced with competing demands and limited resources.

“A really important part of this is that these silos didn’t have any touch points,” Dr Sanoff said. “Even with the nurse navigators, social workers, and financial counselors in constant communication, there were no touch points above that to look at quality concerns on a regular basis.”

Enhanced Financial Navigation

For fiscal year 2018, the UNC Cancer Hospital selected “enhancing financial navigation” as its primary improvement goal. This spurred the development of a goal team, which was comprised of the business and clinical teams, as well as members of the Patient Family Advisory Board. Trained quality coaches also worked with the teams, using rigorous A3 problem-solving methodology to define the scope of the problem, goals, metrics, and pilot solutions.

“This was one of our first successes,” Dr Sanoff said. “It brought the problem to the attention of people at the vice president level and above in our big health system, and it defined a means of bringing stakeholders together from a variety of different perspectives.”

The work from the goal team led to the approval for an increase from 3 to 9 oncology-dedicated financial counselors at UNC (they now have 13). Meanwhile, the revenue cycle team worked on improving the patient experience side of financial navigation.

The team is now working to develop and implement a new financial navigation process through more unified collaboration. The reinforced financial navigation team now reports to the Director of Cancer Services on the operations side.

Implementation Hurdles

According to Dr Sanoff, 2 central themes should be the focus when deploying new hires—patient-centered financial navigation, and the maximization of revenue so the mission of the hospital remains supported.

To address these themes head-on, UNC divided its newly trained personnel between a non–patient-facing financial clearance team and a patient-facing financial navigation team. When a patient is scheduled for a hospital visit or procedure, the financial clearance team is alerted to complete an insurance verification authorization and to talk to the patient about his or her financial responsibility. The team is then tasked with referring individuals with considerable insurance issues to the financial navigation team.

The financial navigation team can also be accessed via the clinical team. If nurses, social workers, or patients themselves identify a financial assistance need, they can request a referral to the financial counselors.

“This process does not offer navigation to all our patients,” Dr Sanoff noted. “Frankly, with our current staffing and where we are in our program, we simply can’t do that. This is a major issue that we see in our program, and one that we hope to be able to slowly improve as we go forward over the next few years.”

Another hurdle they encountered was finding the best way to provide patients with cost estimates for their treatment. Providing an accurate ­estimate for an entire course of care is extremely resource-heavy and time-­consuming. Their solution was acceptance of the “nonideal state”: provide patients with short-term estimates, with a focus on their out-of-pocket responsibility. Although this is an imperfect plan, they hope to be able to expand it in the future.

To add value to the health system, UNC Cancer Hospital is working from the business end to develop dashboards that measure aspects such as the conversion of a patient’s balance to bad debt and lost revenue that results from a lack of authorization. They hope that “the combination of these things is going to help provide impetus for continued support of our program,” Dr Sanoff observed.

Implementation Tips

Dr Sanoff advised oncology providers and practices to take the time to meet with all stakeholders from business and from patient-centered perspectives. She listed several suggestions:

  • Including patients and/or caregivers in this discussion can make the argument for the value of patient-centered financial navigation
  • If possible, work with trained quality staff to define problems and to pilot solutions
  • Use data, when available, to support the business argument, and utilize existing training resources if you cannot afford to bring in outside help
  • Finally, accept incremental change.

“True financial navigation is a new field. All of us are starting from scratch in addressing these hurdles as we try to build our programs, but we all must work to systematically define the value of financial navigation programs,” Dr Sanoff said. “I think the more that we can do that as a quality community, the less activation energy is going to be required for there to be a nationwide change in how we address financial toxicity in clinical care.”