Financial toxicity and cancer patients. Yu-Ning Wong MD MSCE Fox Chase Cancer Center

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1 Financial toxicity and cancer patients Yu-Ning Wong MD MSCE Fox Chase Cancer Center

2 The Brains in the Outfit

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4 Federal Reserve Survey 47% of respondents say they either could not cover an emergency expense costing $400, or would cover it by selling something or borrowing money. Over two-thirds of respondents with a household income <$40,000 report that they would sell something or borrow money to cover a $400 emergency expense or could not cover the expense at all. 31% of respondents report going without some form of medical care in the 12 months before the survey because they could not afford it. Report on the Economic Well-Being of US Households in 2014;

5 What is financial distress/ toxicity/burden? Many terms: perceived economic well-being, personal financial wellness, financial satisfaction, perceived income adequacy, financial strain, financial stress, debt stress, economic strain, and economic distress Possible definition: ratio of health-related spending to household income Financial toxicity (coined in 2009 by Mark Ratain): potential economic impact of modern oncology drug desouza, JCO 2015

6 Modern cancer drugs Increasing premiums Cost sharing (drug tiers) Donut hole for Medicare Patients 20% co-insurance for patients without Medicare Supplemental coverage High cost of new drugs often drive the discussion: e.g. bevacizumab, sunitinib, sipuleucel T, pazopanib, atezoluzimab and many more..

7 Hematuria Urologist Cystoscopy CT scan and labs Medical Oncologist How does this happen in bladder cancer? Urgent Care: Co-payment $50 $20 Co-payment $20 Co-payment Covered $20 Co-payment Other issues You have sick leave Your spouse cannot use sick leave for family care takes unpaid leave Parking at medical oncologist $20 per chemo session Parking at hospital for 1 week admission $20 per day Tolls to doctors offices, chemo and hospital $5 per visit AMVAC x 3 Cystoprostatectomy ypt0n0 Covered at 90% after deductible $250 copayment; covered at 90% after deductible $750 deductible Out of pocket maximum of $10,7000 Fears How much will this be? (close to $10,700?) When will the bills arrive? When can I go back to work?

8 Paid sick leave is not a right When Philadelphia passed its law in 5/2015, it became the 16 th city (along with three other states) to have similar laws

9 How are overall distress and financial distress related? Convenience sample survey of 120 cancer patients at FCCC Median age, Income etc Measured distress using the NCCN distress thermometer Measured emotional symptoms using the NCCN problem list Measured financial distress Incharge Financial Distress/Financial Well-Being Scale (Prawitz) Meeker, JOP 2016

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11 Sample Financial Distress Questions. How confident are you that you could find the money to pay for a financial emergency that costs about $1,000? No Little Some High Confidence Confidence Confidence Confidence How often does this happen to you? You want to go out to eat, go to a movie or do something else and don t go because you can t afford to? All the time Sometimes Rarely Never How confident are you that you could find the money to pay for a financial emergency that costs about $1,000? No Little Some High Confidence Confidence Confidence Confidence Prawitz et al J Financial Counseling Planning 2006

12 Selected patient characteristics Characteristic Median Age 62 (22-87) Male 48% White 84% Married/domestic partnership 66% College/Advanced degree 33% Retired 41% Working for wages 26% Income $75-100K 13% Income $>100K 23% Prior chemotherapy 67% Time since diagnosis >5 years 25% Metastatic disease 63% GU Cancer site 38% Meeker, JOP 2016

13 Distress Overall Distress (using Distress thermometer): 65% reported clinically significant distress ( 4) 28% reported highest range (8-10) Emotional Symptoms: 68% reported at least one symptom Worry (49%); Nervousness (38%), Fears (37%); Sadness (30%); Depression (29%); Loss of interest in usual activities (26%) Meeker, JOP 2016

14 High rates of financial distress 29% report high financial distress On this scale lower score= more financial distress 2016 by American Society of Clinical Oncology Caitlin R. Meeker et al. JOP doi: /jop

15 Financial Distress, Emotional Distress and Overall Distress are related 0.3 decrease Emotional Distress 1 unit increase 1 unit increase Financial Distress Emotional Distress accounts for 24% of impact of Financial Distress on Overall Distress Pathway C (76%) Overall Distress 0.58 increase decrease 1 unit increase Meeker, JOP 2016

16 Conclusions Financial distress may be an important component of overall distress among cancer patients It may cause overall distress directly or It can increase emotional symptoms, in turn increasing overall distress Meeker, JOP 2016

17 Conclusions Distress is considered the sixth vital sign IOM has defined 10 attributes of a health literate organizations including Communicates clearly what health plans cover and what individuals will have to pay for services Examples: Provides easy-to-understand descriptions of health insurance policies; Communicates the out-of-pocket costs for health care services before they are delivered What are the responsibilities of clinicians? Health care organizations? American College of Surgeons Attributes of a Health Literate Organization, IOM

18 To elaborate further. Rick Bangs, BCAN Patient Advocate- Living On The Edge: Patients, Financial Toxicity, and Proposed Solutions Jonas De Souza, MD, MBA U. Chicago-Financial Toxicity: Measuring its Height by the Shade it Casts. Yousuf Zafar, MD, MHS, Duke Cancer Institute - Intervening on financial toxicity: What can we do today? Lowell Schnipper, MD, Beth Israel Deaconess Medical Center - Value Frameworks in Oncology: what are they and how will they be used?