Levine Cancer Institute Financial Toxicity Tumor Board: A Potential Solution to an Emerging Problem

Abstract

ANSWER: The LCI FTTB was established to address the burgeoning issue of financial toxicity-the impact of financial burden on patients with cancer, which has been linked with bankruptcy, noncompli-ance to treatment, increased anxiety, worsened outcomes , and increased mortality. This is now a key toxicity experienced by patients with cancer. Our intent was to find solutions to ameliorate these challenges, and the FTTB was a tumor conference established to create multidisciplinary solutions. WHAT WE DID: Previously, financial toxicity was managed in a piecemeal fashion by a range of staff. We created FTTB, involving physicians, nurses, financial counselors, nurse navigators, social workers, pharmacy staff, and administrators, to address the more complex issues of financial toxicity. Cases are triaged by members of the LCI Finance Department or financial counselors, based on acuity and severity. Simple issues (eg, failure to secure Medicaid and lapsed insurance) are handled by financial counselors, nurse navigators, or social workers without involving the FTTB. More complex issues are referred to the FTTB for review and problem-solving. The FTTB is linked to a complementary structure, the Patient Assistance Program for oncologic pharmaceutical agents, which has helped to define the spectrum of needs leading to the establishment of FTTB. In Patient Assistance Program, pharmacy technicians supervised by the Oncology Pharmacy leader manage treatment programs proactively, ensuring that all potential health insurance issues have been addressed before treatment, and that physicians are engaged in the process and have provided clinical notes that chronicle indications, evidence base, and appropri-ateness of treatment; all authorizations are meticulously completed; cost reduction includes such measures as use of biosimilars when proven to be of equivalent efficacy and toxicity to parent compounds. The existence and function of these entities are advertised widely to patients, caregivers, and staff at LCI. WHAT WE FOUND: Over a 2-year period, the FTTB has identified the spectrum and frequency of issues associated with financial toxicity in our large health care system (Table). The program has reduced patient expenditures on oncologic agents by more than $55 million and $60 million in the past 2 years, assisting between 583 and 749 patients per annum. In addition, copay assistance was found, respectively, for 1,236 and 1,000 patients, providing amounts of approximately $1.4 million each year. BIAS, CONFOUNDING FACTORS, REAL-LIFE IMPLICATIONS: LCI sees more than 19,000 new cases per year at 25 sites, with a distributed academic hybrid practice integrated by a system of Electronically Accessible Pathways. Thus, the integration of our approach may be more complete than in other distributed centers. There was no intentional case selection bias, as the cases presented to the FTTB represent a broad referral pattern, but it is possible that the triage process, in the setting of an academic hybrid oncology center, has created a distribution of key issues that is more dramatic than would be encountered in a general oncology practice. That said, a broad range of patients have been saved substantial personal expenditure by this initiative, which could easily be scaled to any large oncology practice or cancer center and the principles apply to any oncology practice. abstract PURPOSE Fiscal distress or "financial toxicity," in which patients experience challenges in paying for treatment, are becoming dominant problems for patients with cancer because of burgeoning health care costs and strategies implemented by health insurance payers to reduce their level of expenditure. We report the structure and function of the first Financial Toxicity Tumor Board (FTTB). Modeled on the concept of a conventional multidisciplinary tumor board, FTTB functions as a multidisciplinary conference providing broad problem-solving approaches to financial toxicity. METHODS The FTTB, with participation from physicians, nurses, financial counselors, nurse navigators, social workers, and administrators, meets monthly and is focused on financial toxicity and financial worry experienced by patients with cancer. It is linked to a Patient Assistance Program for oncologic pharmaceutical agents as this domain constitutes a critical area of financial toxicity for many patients. RESULTS In the first years of function, more than $55-$60 million of personal expenditure has been avoided for 1,749 and 1,819 patients, respectively, as well as more than $1.3 million copay assistance provided for financially challenged patients. Problems addressed have included payer impediments, underinsurance, complexities of certification, coding or billing issues, and inadequate internal standard operating procedures. CONCLUSION A focus on proactive management of financial toxicity through the function of multidisciplinary FTTBs substantially ameliorates this burgeoning international problem. This concept is presented early as it may be leveraged readily in other centers.