Financial Support & Assistance in Oncology

Dr. Vaughn:

Welcome back to Cancer Shop Talk, as we are going to introduce another topic for our listeners. Today, we are going to focus on something, as physicians, we don’t always talk about with our patients, but it is very important, and that’s the cost of medical care and how it impacts their lives. And today, we’ll really focus on oncology care and the cost of treatments, and how that can affect every day of life for our patients and their families. So hopefully, today we can get a better understanding of how, as providers, we can help our patients through this difficult time, and maybe identify some resources that are available for our patients and their families.

So, I’m very excited to have Brittany Hill and Joanna Brightbill from our HOAF team to help discuss the cost of care, and some financial assistance that may be available for our patients. And also, we appreciate Donna Hebb, who’s going to be joining us from Mary Washington Hospital, she works as an oncology nurse Navigator, to also help us explore other avenues that can help with the cost of care, such as transportation or childcare, and these other things that we have to think about, as patients still have to live and function as they’re going through oncology treatments.

So, I thank you all for joining us today, and I just would like to start with Brittany. I’m going to ask a question about… She leads our oral oncology program here at HOAF, and just wanted to open the floor to Brittany and maybe discuss what your role is. I know it’s something we’ve invested a lot into at HOAF to try to provide some of the oral chemotherapy agents and other medications here at HOAF, and how hopefully that may lower the cost for some patients and help with compliance on these medications. But Brittany, if you don’t mind just talking about your role and your experience and what you’ve been doing.

Brittany Hill:

Yes, thank you, Dr. Vaughn. I am the lead Oral Oncolytic Navigator here at HOAF, and part of our job here as the oral onc navigators is to make sure that patients have access to their medication. We have a program where our physician’s dispensary here in the office, if insurance allows, we can fill prescriptions here, and that allows patients to… It improves their adherence to their therapy. So the first thing is the medication is ordered for the patient, it gets sent to our HOAF pharmacy so that we can start working on the authorization process through insurance. We can identify if that patient is eligible to fill here in our in-house pharmacy.

I believe that we see more of a success rate for patients being able to adhere to that therapy, because they have access to personalized care with the providers, if they have any concerns for the side effects or just financial toxicity is a big one because we can manage their financial assistance here better if it’s in-house versus if they’re filling at a specialty pharmacy. That reduces drug waste because if a therapy is going to be changed, like a dosing, we can switch that out fairly quickly here, instead of a specialty pharmacy processing these refills for patients back to back. So that’s a big concern now is a lot of the medication waste that’s happening.

As well as, patients can start therapy sooner by filling at HOAF pharmacy, because we have access to get their medication in-house next day, to be able to dispense to the patient versus it being sent out and having to wait to be delivered to the patient through the specialty pharmacy. So we manage refills, make sure patients have, with their specialty pharmacies or here at HOAF, and then, if they have any questions regarding their treatment at all, we’re able to get them connected with the providers and the nursing team to address their concerns.

Dr. Vaughn:

And Brittany, remind me, it’s hard enough for me to focus on the evolving landscape of oncology drugs and guidelines of them, but the oral oncolytics, as we use that term for our oral chemotherapy agents, and there are so many that are coming down the pipeline, that is not covered by usual medical plan, so these are plans that may be different in that… Correct? In how much copays are, and deductibles can be vastly different than what a medical plan may be if they’re getting an IV treatment.

Brittany Hill:

That is correct. It’s under the prescription benefit portion, so it is not covered under the medical benefit, and so it ends up costing patients more because they don’t have that medical or they don’t have the primary and secondary where it might be covered. Especially for Medicare D patients, they are the ones that are affected the most with their prescription drug program, and the way that the tiers and deductibles and co-insurance is set up.

Dr. Vaughn:

And is that something different, as far as utilizing your resources, is it different to find assistance because of it being a prescription plan?

Brittany Hill:

Absolutely. So if a patient, if they’re commercially insured, they have an option to do a copay card, it’s very simple. We can get help reduce their copay with no problem. For patients with a prescription drug plan, their access to financial assistance, it’s a little bit different in the sense where they’re limited to where they’re eligible. We have to try to find them grants, so that’s based off of whatever foundations may have assistance for their diagnosis at the time.

And we have seen, this year, it’s a lot less finances out there available for patients through these foundations. They’re not opening these programs, specifically for multiple myeloma, breast cancer. There’s a lot of funds that are not available this year that have been in the past, and it’s forcing a lot of patients to use the manufacturer assistance program, which we call, “Free Drug.” But this year, they have also changed some of their requirements in their financial eligibility, so it’s harder to try to get patients access to the financial assistance right now.

Dr. Vaughn:

And I think we’ll get into that some more to see how we can explore those options. But I also wanted to introduce Joanna Brightbill who actually works on… I guess, Joanna, you help not so much as the oral oncology program, but more just a general plan of care we provide to our patients, and what sort of cost that is going to have on a patient and their family, including all the deductibles and other finances need to be met when we devise a treatment plan. But can you just discuss your history at HOAF? I know you’ve evolved yourself in different roles here, but how you help as a financial advocate for our patients.

Joanna Brightbill:

Sure, Dr. Vaughan, thank you. I have been with the practice about 12 years now, and I have taken over the speaking to patients about their financial obligations for their IV treatments when doctors see the patients and put in your orders for treatments, I go over all of that to let them know where we can do some cost savings for them with different copay programs and get them enrolled. Especially with commercial insurances, we try and get everybody and anybody we can enroll in those, regardless of their financial situations. And then, when there’s the inability to cover those out-of-pocket, so we do look into what we can do for free drug.

Dr. Vaughn:

So Joanna, when I meet a patient first time and I’ll just… Let’s say someone comes in and they’re just diagnosed with lung cancer and I put together a treatment plan, of course, I have really no idea, maybe based on insurance and what deductibles they may have. You’re able to go in knowing their insurance contracts or what have you, you’re able to devise a plan of care for them so we can work with them, so financially it’s not too difficult. Make it as appealing as it can be for a patient and their families. Correct?

Joanna Brightbill:

Yes, Dr. Vaughn. That’s correct. I will look at everybody’s individual plans and see what their deductibles and co-insurances are, and I can map out what we expect their out-of-pocket to be based on their deductible and their co-insurance, subtract any copay assistance that we’re able to get, and then present those patients with an idea of what they can expect their out-of-pockets to be, after all copay assistance programs are taken into consideration. And then, help them devise a financial plan that works best for them.

Dr. Vaughn:

And I can tell you, Joanna, patients and their families have such anxiety coming in with a diagnosis of cancer, but then there’s the other real-world aspect of the cost of it. And it’s been such a help to have you, we used to be called the, “Chemotherapy Education Session,” right at teach. But part of it is not only just going through the scheduled side effects, but having a good understanding upfront maybe what kind of financial hit it could be for patients and their families, and how we can help work with them. Because that’s, just from experience, that’s just so hard sometimes with patients who aren’t only going to go through some mental and physical challenges with treatment, but then to have the extra pressure of maybe the cost of it. So it has been a great help to have this information up front for them so everyone can plan going forward.

As Brittany mentioned, is it also a challenge, as far as I know, you do such a great job exploring foundations and other means of helping fund some of the care for our patients, is it also become more restrictive, are you seeing?

Joanna Brightbill:

It really has been. It’s not exclusive to orals, it’s, like Brittany said, many diagnoses of cancer patients are restricted to the availability of funds from the foundations, especially our Medicare patients, and it is a big issue. Unfortunately, there’s just not a lot of funding out there for our patients. So what we do, what I do, is I do my best to get them on payment plan. I’ll review everything, get their financial information, and then we can put them on what we call a, “Watch list” so that when and if foundations open grants, we can attempt to take advantage and get as many patients enrolled as possible.

Dr. Vaughn:

And Joanna, and Brittany, chime in here too, but how do you keep up with if a foundation is open or closes? How do you keep abreast of that, knowing when these funds may be available? ‘Cause I imagine it may be just a short period of time.

Joanna Brightbill:

They can be. You usually get email alerts when foundations open up specifically… For example, if we get a prostate grant opened by a foundation, we’ll get the emails, and usually I will stop what I am doing and enroll as many patients as I can. Sometimes those grants are only open for a matter of a few minutes, because usually, I’m not the only one that’s stopping what I’m doing, and get those grants established for patients. A nationwide, grab and growl situation, first come, first serve.

Dr. Vaughn:

Oh my gosh, I didn’t know it was that… I thought time sensitive being a couple of days, but it could be a matter of minutes?

Joanna Brightbill:

No, it’s a matter of minutes in some cases. Absolutely.

Brittany Hill:

Literally minutes. And then, there are some of the portals that we use to enroll patients, they get so overwhelmed with people logging in that it crashes the sites.

Dr. Vaughn:

Oh my gosh. And they just know our practice, and you just get alerts from, like you mentioned, foundations just will alert us if there’s funding?

Joanna Brightbill:

Yeah. We’re signed up for email alerts, so we get those email alerts as quickly as… And as quickly as we can, we will stop what we’re doing and grab our lists, and go down the list and apply for patients that we know are in dire straits and needing that help.

Dr. Vaughn:

And Brittany, is that the same for some of our oral chemotherapy agents, or is it that you get a little more time than a matter of seconds?

Brittany Hill:

No, it’s the same. It’s the same emails. Joanna and I, we get the same emails every day. But it’s the same foundations that are offering the grants, and so it’s the exact same process for the orals as well.

Dr. Vaughn:

And you mentioned, does it seem like the foundations, that the money’s not… Are you seeing a decline over the last couple of years?

Joanna Brightbill:

Yeah. It seems like every year, it gets tighter and tighter and they just don’t open. I honestly think it’s probably been since December or early January since I’ve seen a breast cancer grant open, for example, because it probably goes further back than that. So they can go six months, sometimes a year, before we see any grants open. And that’s not just for one foundation, that’s all foundations across the board.

Dr. Vaughn:

And are they, for instance, I used to do a lot of work with Lymphoma Leukemia Society, are some of the foundations specific for Virginia residents?

Joanna Brightbill:

No, they’re pretty much all nationwide. There’s probably about five or six foundations that are nationwide that it’s all diagnosis-based grants. So when one has it, sometimes two or three will have it, and then sometimes, maybe not at all. But nothing specific to Virginia residents

Dr. Vaughn:

And Brittany, it’s nothing… Anything as providers we can do to help raise the awareness of the foundations, or is it just, like you said, just luck of the draw when it opens up?

Brittany Hill:

It’s luck of the draw. I do know that one of the conferences that I went to, one of the CODA conferences, I learned that a lot of the money that gets sent to these foundations is actually through the drug manufacturers, and I didn’t know that. And so, I’m not sure if there’s something that changed there as to why. Maybe that’s some of the reason maybe they’re not sending as much funds, I’m not really sure. I’ve even tried to look into it because it had gotten bad, worse, actually. This year, a lot of things aren’t opening and I can’t figure out the reason why.

Dr. Vaughn:

Well, Donna, I know… Sorry, we got into a discussion there, wanted to get your input. I know you also have, I’m sure are in touch with other foundations through probably Mary Washington Hospital and other outlets you may have. But any other ideas or suggestions you have to help maybe find resources for our patients?

Donna Hebb:

Yes, Dr. Vaughn. Thanks for having me. I’m with the Regional Cancer Center at Mary Washington, and some of the things we do for the cancer patients in the community is try to find resources for them. So we do the same thing, as for one of the things we offer is transportation assistance. We first look towards, like Brittany and Joanna does, is we look for the insurance to see if they cover transportation at all, and if that case, then we work through their insurance company for the transportation assistance there. And then if not, we do have a fund, it’s funded by a grant that we can use to help some patients for transportation services.

But all of our services at the Regional Cancer Center are free for the cancer patients, and we do have other ways of helping, such as we have ostomy services for those patients that need it and a wig room and bra fittings and then our Navigator services. We have some other services too. But in particular, those certainly would help with finances there.

Dr. Vaughn:

I know you guys are such a great resource for me as one of our… When we see a new patient, we just click on things that, again, our extenders are going to help help the patient and their families just get through maybe four to six months of treatment, and it is great having the Navigators at Mary Washington help out any way. As you mentioned, transportation or even food costs. Is there anything as far as maybe providing meal discounts or anything for some of our patients?

Donna Hebb:

We do have agencies that we work with for food assistance, and when we get a patient, we screen them for all their needs as Navigators. There’s four of us and we go through… Well, some of the services we provide are our navigation services, we have a licensed therapist counselor, which has one-on-one for mental health counseling. We do have a registered dietician for nutritional services. We offer integrative medicine services, genetic counseling, we have support groups we used to help them set up with, we have access to a clinical research team that conduct clinical trials, and we have a survivor support group.

So we try to, when we get the patient, look at them and see what all their needs are and reach out. And if food is in need, then we scout out for the resources in the community to help us out. So when you send them to us as a referral, we also look beyond our means into the community for what we can pull in that’s free to help them out. We also fill out or help them assist for financial services through the applications on Mary Washington Healthcare, as well as an application for other medical imaging of Fredericksburg. And we refer and help set up for Moss screening if they’re a candidate for that. We help them apply for disability services and Medicaid services. So it just depends on each individual patient’s need.

Dr. Vaughn:

And you mentioned, Donna, does Mayor Washington have their own community oncology fund, or are you trying to… I know there’s the Fredericksburg Community Foundation, are there funds through the specific network you’re using or is this just you have funds already there at Mary Washington Hospital?

Donna Hebb:

Well, we fill out an application for financial assistance through Mary Washington, and we use the patient financial navigation services at the hospital for that. And then, if they qualify for that, it’s the same thing with the medical imaging, there’s an application they fill out.

Dr. Vaughn:

I know, just going back, just Joanna, a quick question, I think as far as trying to try to reduce costs as much as we can on patients, I know we, and you help us out, making sure that using maybe even more some generic anti-nausea medicines or limiting some of the, maybe the growth, these other hidden expenses that may be a part of the treatment plan that we could maybe cut back or change that helps with the care. But can you describe how you go about that?

Joanna Brightbill:

Sure. So when I review the treatment plans, I meet with the patients, go over their financial concerns with them. If I notice a financial concern and I feel that there’s going to be a financial issue for the patient, I’ll come talk to you, I’ll come talk to the others and see what we can do to change out to maybe a generic medication or something that may be lesser expensive, but still meets the needs and the goals that you are trying to reach for the patients. So we’ll come to the doctors and then we’ll figure it out together, what is the best route for the patient. And then, I can go back to the patients with some minor changes to their treatment plan, but might be a significant impact to their overall out-of-pocket.

Dr. Vaughn:

And Brittany, one of the things I wanted to ask you, because this comes up a lot, sometimes we have these patients on these oral medicines. I’m thinking of, for instance, CLL or CML, which are now all oral oncolytic agents. They’re on it indefinitely because we’ve had such success with these diseases. But I know patients get nervous because I think they may get approved for about a year, and then as a year comes up, they may not be approved. Describe to me how that happens each year. Does it change? Because patients always seem to get nervous when the year’s up. Because are they allotted assistance maybe for a full year and then it may change?

Brittany Hill:

Yes. So if it is assistance through the manufacturer for free drug, the program will usually run for that calendar year and expire at the end of the year. And so, you’re right, patients do get really nervous because they’re wondering if something’s going to change within their financial situation, or if the program’s eligibility requirements may change. And they get really nervous around enrollment time. But for the most part, once they’re in, they can go ahead and re-enroll for the next year without any issues. We haven’t had anyone be kicked out. Unless there’s a foundation that’s available, then, at that time, the manufacturing, the free drug program will require the patient to try to use that assistance and use those funds first.

But yes, it usually does expire towards the end of the year. And with the grant, so the foundation assistance, they’re allotted a dollar amount, or a specific time period. So their grant may be, they may be allotted a six-month period before it expires, and so either it will expire first or they will use all of their funds. So those programs do differ.

Dr. Vaughn:

And then, if they get the grant for a period of time, let’s say six months, will they then automatically be re-enrolled in the free manufacturing drug?

Brittany Hill:

So if the grant expires or they use the funds at that time, then they will not be automatically enrolled into another grant or the free drug program. We will then have to start the process for the paperwork. And so, we will have the patient come in, sign paperwork and provide any financial documents if needed, obtain the signature from the provider, and then fax it off to the program at that time. But it’s not automatically done.

Dr. Vaughn:

I must commend you Brittany, because all this goes on, we just send the prescription over to you and then you have to figure all this out. And I know patients are so appreciative of your work and effort. So explain to me, what happens when I send a prescription over to the pharmacy? Just maybe just the regular flow that you have to do initially to get the prescription, the timeliness, and find out how to get it covered, what happens?

Brittany Hill:

Yes, sir. So the first step is to obtain authorization through the insurance. So we submit prior authorization for that approval. Once that’s done, we’ll have it processed through our dispensary here in-house, because one, that will notify us if the insurance company is mandating a specific pharmacy can be used, or if we can fill in-house if the patient chooses. That also will allow us to find out what the patient’s copay is at that time. So if it’s something that can be filled, the insurance company will usually let us know what the patient’s copay is, and then we can start the process.

So our goal is to already have the paperwork and complete it, or have our plan before we speak to the patient. That way, it avoids that fear of the financial toxicity, because if we just call them and say, “You have a $3,000 copay,” and we don’t already have a plan in line, we’re adding undue stress to our patients. So we’ll let them know, “This is the copay, however we do have paperwork filled out, we just need you to come sign. We’re going to submit to see if you’re eligible.” Or we’ll say, “Hey, we have a couple questions. There is a foundation with a grant available now, and we’re going to go ahead and try to see if we can get you enrolled while we’re on the phone.” So there is a plan in place so that they know that we will do whatever it takes to alleviate any of that financial distress. And if we can’t get it down to zero, we’re going to try to get it as close as possible to where they don’t have to pay anything at all. That’s our goal.

Dr. Vaughn:

That’s amazing. And I think all this is done. You have all this information, ’cause we’ve tried to really, almost even more importantly, to have a chemotherapy, we call it an, “Oral Chemotherapy Education Session” with our patients. We may set up, say if I see a patient and we’re talking about a new treatment that’s oral, we’ll maybe set up a teach session, like seven or 10 days. And I think, Brittany, you have all that information by the time they come back for the teach.

Brittany Hill:

Yes, we do. We try to have everything here by the time that teach appointment, so that way, if we need any paperwork or anything signed, we can get it taken care of, if it’s not something that we can do ahead of time as far as the foundation assistance. But we want the patient to know that they’re not alone. It’s a difficult time and we’re here to do whatever we can. So I feel that they trust the providers, they trust us here at the office and know that we’re here to try to help, and that they don’t have to make the decision whether they’re going to get treated or keep the lights on. That’s really important. Really, really important.

Dr. Vaughn:

Yes. That’s such an important point there, I think. Just as a provider, I hate for patients to mention to me that they’re not sure they can do this because of the cost of it, and how it’s going to affect their family or their spouse, their children. And it’s wonderful that I think we have a Joanna and Brittany and Donna from Mary Washington. We try to explore every avenue possible, so we allow patients to be treated and stay on treatment and it’s so important. So it’s an important point there, Brittany.

Donna, is there anything from, let me ask you this question, from our end? Anything that, as providers here at HOAF, we can help explore some of the resources you have? What’s the best way for us to utilize your navigational services to help with some of the financial costs of oncology care?

Donna Hebb:

I think the best way would be just to refer them to the Regional Cancer Center. We can screen them and see what we can do with what their needs are. And as I said, our services are free to anybody, they don’t even have to have a referral from the physician. So if somebody is listening and they have a friend that might need additional help that has cancer, they can call us and we’d be happy to screen them and see what we can do.

Dr. Vaughn:

Well, thank you for that. It’s great having that relationship with Mary Washington to help, because they really do provide a lot of services to our patients and that’s really… One of the important things is we’ve had such, I think, success in our evolving therapeutic gains and medications. Unfortunately, that also means they could be more expensive, but it doesn’t help if we allow patients to continue to live and function and work and be parents and spouses. And so, trying to maintain the cost of this is essential as we move forward.

Well, Brittany, anything else you’d like to add? I’m really so thankful for your participation today, but anything else that we need to think about, or any resources, even, for our patients or families that they can look at, as far as any websites or other foundations that they could do on their end too to help them out?

Brittany Hill:

Yes, for sure. The patients calling in to some of the programs, because, as mentioned before, there’s other things than just the assistance to pay for the prescription. If there’s nothing available and they do have a high cost for their medication, they may still qualify for other services, like transportation services and things like that, for patients who may not be hooked up to be able to get with Donna and learn those things. So yes, just having our patients stay.

And then, letting us know if any of their financial concern, if anything changes. So we have patients who may change insurance and we’re not aware, so they were able to get a copay card before and now they’re no longer eligible. But they don’t know to let us know, so we can’t then enroll them into a foundation assistance, or enroll them in free drugs. So letting them know we’re here for anything, it’s not just sending your refill out. Just let us know if there’s anything, any changes or any concerns, because if we can’t give them them the answer right away, then we’ll definitely look into it to try to help.

And then, being able to fill at our in-house dispensary is another thing that patients can utilize if their insurance allows them to, because we can get ahead of some of the financial… If their grant is getting ready to run out, we may not always know that if they’re filling their medication with a different pharmacy, because we don’t see the copays and the refills, and if they feel… Here in-house, we can try to keep ahead of that, so that way, when their balance is getting low, we can start the process to get them into free drug, or to try to find another grant for them.

We can look to see if, sometimes there’s medications that are cheaper without their insurance, and then we can offer to allow them to have that prescription at post price for what HOAF pays for the medication, it can be drastically different. That actually happened, Dr. Vaughn, for one of your patients here recently. She had $180 copay for one of her medications through her insurance, but without her insurance, HOAF pharmacy could fill it for $60.

Dr. Vaughn:

Right. And that’s what I commend you, Brittany and Joanna. These are things that you’re constantly doing behind the scenes, finding the best price for our patients, not changing the efficacy of the treatment, but really you guys do so much legwork to limit the costs as much as you can. And Joanna, can you, I’m sure, add anything else to what Brittany talked about? Just from a… I know you do more of the medical plan, anything else that, as providers, we need to do to help make your job easier, if that’s possible?

Joanna Brightbill:

I think you guys do a great job and you’re open to communicating with us, that’s a big help. I think the biggest thing that I can drive home to the patients is to just stay in touch, reach out. If you don’t know, call us, ask us the questions, and we’ll do the best we can to answer those questions or find answers for those questions. And let us know about changes, any changes in your insurance, we need to know those things because those can make significant changes in financial plans and what we’re doing for our patients as well.

Dr. Vaughn:

And Donna, anything else you’d like to talk about? I just thank you so much for your participation here today, but anything else from a resource standpoint, from Mary Washington?

Donna Hebb:

I agree with them about the communication piece. We all need the communication between the physicians’ offices and staff and ourselves and the patients to keep everything working for them. And we appreciate you referring patients to us and working with us as well.

Dr. Vaughn:

Well, thank you. I just appreciate all of you joining us today. And it’s really an important topic that as, unfortunately, the cost of some of the medicines are just going to continue to escalate, just because they’re novel and usually that means price can go up. But we do our best here, I know, at HOAF and at Mary Washington, to try to find resources we can to make it as acceptable for patients, because it really does matter for them to stay on treatment. It doesn’t help if they can’t afford it. So thank you all for joining us today and that was really a good discussion.

Brittany Hill:

Thank you for having us.

Donna Hebb:

Thank you, Dr. Vaughn.

Dr. Vaughn:

I would like to thank you again for our participants, Joanna, Brittany, and Donna, for sharing their insight on helping find financial resources for our patients. The cost of oncology care is rising and we really utilize their insight to help find resources for our patients and their families. So again, we thank them so much for joining us today.

Our next topic is going to be a deep dive into lung cancer, and the new strategies and evolving landscape in both surgical techniques and radiation oncology techniques. And so, we’ll be thrilled to have Dr. Sherwood here to talk about lung cancer and the new surgical advancements, and also our radiation oncologist here in the community.