Structured conversations about costs of care facilitate shared decision-making
Key takeaways:
- Most patients want to have conversations about costs of care.
- Fewer than 15% of patients report having these types of discussions with their care team.
Integrating structured patient-provider conversations about costs into the shared decision-making model of cancer care may help identify financial toxicity and allow for early intervention, according to a review in JCO Oncology Practice.
The prevalence — and consequences — of financial toxicity have become well established in oncology, the paper’s authors noted, but few solutions to address this exist at the point of care.
They cited multiple studies that showed more than 90% of patients with cancer expressed a desire to discuss the costs of oncology care, but fewer than 15% reported having such conversations. In contrast, oncologists self-report that they discuss costs with patients up to 60% of the time.
The infrequency of these conversations may stem from patient or oncologist reluctance to discuss money, fears that lower-cost care is less effective, or lack of clinician training to help them understand how to discuss treatment costs.
No large, randomized prospective studies have evaluated the role of structured conversations intended to discuss cancer care costs, according to the authors.
“The research shows that costs do seem to be lowered for people who have a cost conversation with their physician,” lead author Fumiko Chino, MD, cancer researcher and assistant professor in breast radiation oncology at The University of Texas MD Anderson Cancer Center, told Healio. “It’s not every single person, and it’s not lowered down to zero, but we can help many people with some of the financial friction points if we know they are there.”
Healio spoke with Chino about the state of physician-patient conversations about financial toxicity, as well as the strategies that could be implemented to increase the frequency and impact of these discussions.
Healio: What motivated you to conduct this study?
Chino: My research focuses on affordability in health care. Essentially, I am interested in the growing gap between the cost of anti-cancer treatments and the burden that it places on our patients and survivors. The costs of health care in the United States — particularly cancer care — are incredibly high. This leads to negative downstream effects for our patients, including being unable to afford medications or having to skip treatments or follow-up care. It becomes a considerable physical and psychological burden.
Healio: What has prior research shown regarding patient preferences for these discussions?
Chino: The vast majority of patients want some sort of cost conversation with someone on their clinical team, although there is some variability about who they want to talk to. Some patients are specifically interested in having this conversation with their physician, whereas others are more comfortable talking to a social worker or a financial counselor. It is not one size fits all. The gaps in knowledge that exist involve when to have that conversation and how frequently to have that conversation. It is clear from the data, however, that these conversations are not happening as often as they need to be happening.
Healio: How often and with whom are these discussions occurring?
Chino: We know that only a small percentage — less than a quarter — of patients have any kind of conversation with their physician. Less than a third have a conversation with anyone within the health care system — not a social worker, not a financial counselor, not the person who takes their copay. This is stark when you consider the percentage of people who actually will have some sort of financial hardship related to their cancer treatment. The data are variable, but many studies report that these financial hardships affect more than a third of patients. Some studies estimate it closer to half or even three-quarters of patients, depending on treatment regimen and disease status. We’re missing a lot of people who are having financial hardship related to a cancer diagnosis. It’s a missed connection — we know it’s happening, but we don’t necessarily see it.
Healio: What suggestions do you and your co-authors make about how to implement structured conversations?
Chino: Regular check-in points certainly make sense. It’s a good idea to ask patients if they are having any problems affording care, making sure we’re acknowledging patient concerns and desires. Some people do not feel comfortable talking about this with a physician, and we should respect those wishes.
We recommend checking in frequently — especially if there is a transition point, such as a change in treatment or a switch from surveillance to active treatment. Any time there could potentially be an escalation of cost is an appropriate time to check in and talk about the objective and subjective burdens of financial toxicity. There potentially are different avenues for assisting with those concerns.
We also recommend making sure we’re rallying every resource around someone. One patient might be best served by being referred to counseling, and someone else might be best suited to receiving help from American Cancer Society’s Road to Recovery, which provides free rides to and from treatment. Those are obviously two different problems that require two different solutions.
Healio: What are the next steps in research?
Chino: The evidence has focused on the burden of financial toxicity and cost conversations that affect patients directly. A larger gap is with the health care unit interacting with the family unit, such as caregivers. I am interested in exploring how the caregiver interacts with some of these cost conversations. From my experience as a treating physician, I find the caregiver is the person making many of these decisions or bearing the brunt of financial toxicity. They often are organizing things like insurance, bill paying and picking up medications from the pharmacy. I’m interested in actively engaging caregivers, and making sure whatever interventions or assistance we are providing is wrapping in not only the caregiver but the full family unit.
References:
For more information:
Fumiko Chino, MD, can be reached on X (formerly Twitter) @fumikochino or on Bluesky @fumikochino.bsky.social.
Collapse
Healio Interviews