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A Novel Approach to Address Financial Toxicity

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Jul 28, 2022

Host Dr. John Sweetenham, of the UT Southwestern’s Harold C.
Simmons Comprehensive Cancer Center, and Dr. Bridgette Thom, of the
Memorial Sloan Kettering Cancer Center, discuss a novel
intervention to address financial toxicity and social need using
the Electronic Medical Record.

 

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TRANSCRIPT

Dr. John Sweetenham: Hello. I’m Dr. John
Sweetenham, the associate director for clinical affairs at UT
Southwestern Harold C. Simmons Comprehensive Cancer Center and host
of the ASCO Daily News podcast. My guest today is Dr.
Bridgette Thom, a researcher at Memorial Sloan Kettering (MSK)
Cancer Center. We’ll be discussing a novel approach to address
financial toxicity that uses the electronic medical record to
streamline referrals to financial assistance and counseling for
high-risk patients.

Our full disclosures are available in the show notes, and
disclosures of all guests on the podcast can be found on our
transcripts at asco.org/podcasts.

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Dr. Thom, it’s great to have you on the podcast today.

Dr. Bridgette Thom: Thanks so much for having
me.

Dr. John Sweetenham: Dr. Thom, the high costs
of cancer care have caused major financial distress for many
patients and their families. And this, of course, has been the
subject of a great deal of literature in recent years. As you noted
in your poster presentation at the recent ASCO Annual Meeting,
there are limited interventions, despite a need for patient level
and system-based solutions (Abstract
6596). Listeners to our podcast will remember a previous
discussion that we had with Dr. Derek Raghavan from the Levine
Cancer Institute, where they had instituted financial toxicity
grand rounds to partially address this problem. Can you tell us
about the novel approach that you and your colleagues explored
using the electronic medical record to streamline referrals for
financial assistance and counseling?

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Dr. Bridgette Thom: I first have to credit our
team for this work. Dr. Emeline Aviki, who is a gynecological
surgical oncologist with keen interest in affordability and payment
models, founded the MSK affordability working group several years
ago. The first priority of the group was to determine the scope of
financial hardship at our institution. At the time, we were absent
a systematic screening process. So she, our data analysts, and
representatives from our Patient Financial Services Program,
developed proxy measures to figure out which patients might be
having financial issues.

Looking through the medical record, we found those patients who
had used one of our Patient Financial Services assistance programs,
those who had billing issues, and those who had been referred
specifically to social work for a financial issue. And in doing so,
we found out that about 25% of our patients over a 2-year period
were facing some sort of financial issue. Looking closer at that
data, patients experiencing financial hardship weren’t necessarily
being connected to the resources that we had available, which
include copay assistance programs, financial assistance programs,
and support for non-medical essential needs. So, for example, we
had about 1 in 6 patients who had some sort of payment issue, but
only about 20% of them had applied for financial assistance. And we
wanted to figure out why this was happening and review the
process.

In doing so, we discovered that too much burden was being placed
on already burdened social workers who had to triage all those
issues. So Dr. Aviki in her wisdom realized that care providers,
physicians, advanced practice providers (APP), nurses needed to
make direct referrals to the resources that we had. So we had a
place for patients to go, we just needed an easier mechanism for
them to get there. And that was the birth of the financial toxicity
order set. And she and her team really powered through the
developmental and testing phases working with IT, our strategy
administration groups, clinical end users, our PFS team, that’s
Patient Financial Services.

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We built this order set that allows clinicians directly to refer
to our resources. So clinicians, either through their discussions
with patients or if patients bring up an issue, through the order
set they can select a reason for a referral, the urgency of
referral, the clinical location, etc. And then those orders go
directly to our Patient Financial Services staff who then contact
patients. We piloted this program in late 2020, early 2021 on 1
service, and then used that feedback to roll out the program first
to our outpatient clinics and then to inpatient. That process
involved a lot of educational efforts, getting the word out, and
working with IT and our strategy team to stay on top of the data
and monitor referrals over time.

Dr. John Sweetenham: Thanks. Could you say just
a little bit more about the educational process that you use? I
noticed in looking at your poster that the bulk of referrals came
either from the clinic nurse or from the APP. Did you tailor your
education in any way to the specific provider that was involved?
How did you do that piece?

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Dr. Bridgette Thom: Our affordability working
group is an interdisciplinary team and we have nurses, social
workers, physicians. So we did a lot of grand rounds work tailored
to the audience be it by disease type or clinical role.

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Dr. John Sweetenham: Great, thank you. This is
clearly great work. There’s a lot of useful and helpful information
in your abstract and in your poster. What would you say are the key
takeaways from the intervention? What would you say about the
scalability of this approach into community practice as opposed to
a very large institution such as yours?

Dr. Bridgette Thom: One key takeaway from a
process perspective was the need, like I said, for an
interdisciplinary approach to handling the issues. That might seem
obvious, but it was really crucial to the success of the project to
engage key departmental stakeholders and decision makers very early
in the process and keep them informed throughout the development of
the order set. That definitely helped us to smooth a potentially
bumpy road when we’re dealing with big systems change.

From an outcomes perspective, a key takeaway is the importance
of having actionable items to empower the care providers. So while
our institution has this amazing program, our Patient Financial
Services program which provides counseling, and connects patients
to tangible resources, this type of intervention I think could be
scalable or applicable to a community practice or smaller hospital,
provided there’s somebody, a social worker, patient navigator, [or]
nurse, that can be a connection for patients and those potential
resources that do exist out there.

For us going forward, we’re going to continue to evaluate the
order set, both from the clinical end user and then also the
Patient Financial Services staff to learn more about their
perspectives and what can be adapted in the order. We also, of
course, want to learn from our patients about their experience with
the process, and so we have projects, both research and program
evaluation, in the works to consider their perspective.

Dr. John Sweetenham: Great, thank you. And I
guess 1 of the other aspects of this where there is obviously
substantial opportunity is that, of course, currently, you’re still
reliant upon the provider to place the order. And I wonder whether
you feel that some form of screening for social need and financial
hardship could be embedded within the electronic health record as a
key next step, so that you proactively identify those high-risk
patients.

Dr. Bridgette Thom: Definitely. And that is, in
fact, our next step. We are currently piloting our financial
hardship screening tool on 4 large services at our institution. The
objective here is to, like you said, proactively identify patients
who might be at risk and connect them to resources, be it tangible
resources, or just counseling or insurance guidance, [and] do that
before the hardship can occur. And the goals of our pilot phase are
to (1) develop and refine a tool that’s both predictive, but also
feasible to administer within a busy clinic setting. And then also
(2) to work with our interdisciplinary team to adapt the
workflow.

We can have a great tool, but if we don’t have a way to
administer it in a clinic, it’s not going to do us any good. So for
us, that means listening to feedback from, first and foremost, our
patients and then the key stakeholders in the process. Our nurses
have been integral to this process. We also, of course, our Patient
Financial Services, staff, the clinical operations staff,
obviously, IT, social work. And once we have these processes
figured out and we have our tool solid, we will hopefully expand
the screening to all services, and then use data to figure out the
optimal screening interviews by disease and treatment type because
we feel that this could vary by a patient’s treatment
trajectory.

Dr. John Sweetenham: You note in your poster
that additional multilevel interventions are needed to address the
problem of financial toxicity at a systems level, and of course,
what you have done here is a really great and important step in
helping to identify those patients. But identifying those patients
who are at particular risk is only beginning of addressing the
issue. Could you elaborate a little bit more on other areas that
you’re exploring in terms of the interventions that you’re
using?

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Dr. Bridgette Thom: Sure. And this idea of
multi-level interventions comes from my social work training, where
there’s an emphasis on viewing the individual as being part of a
series of dynamic and interconnected relationships and systems: the
social ecological theory. So if we think of concentric circles with
the patient at the center, there are cascading relationships that
are going to impact the course of their care. We radiate out to
families and caregivers, a patient’s workplace if they’re employed,
the hospital and the providers there, and then look to bigger
systems where a patient lives, their town. If it’s in an urban
setting or a rural setting, the type of insurance that they have,
if it comes from their employer, or if it’s a different insurance
system, their community and then of course, broader, social,
societal, more macro issues.

My point and that of many others who work in this space is that
we have to consider the context. We can’t just build and test
interventions that focus on a patient because the patient isn’t
existing in a bubble. They’re existing in relationships with their
caregivers, their health care providers, their health care system.
And all of that exists in, for lack of a better word, a broken
system of structural inequality, systemic racism, and conflicting
values about health care as a right.

Patient-level interventions are indeed important, but we can’t
place the burden solely on the patient. And we, as researchers and
clinicians in this space, really need solutions that are going to
reach across systems. I think, like you said, this project
demonstrates that and this is something that I hear from patients
in other work that I’m doing. For example, I’m working on a digital
intervention to help young adult cancer survivors to build their
financial capability and build their understanding of the health
care system and insurance systems and financing and all of that. As
I co-develop this intervention with patients and survivors, I’m
hearing, ‘This is great. I’m glad I’m learning these things, but at
the same time, my co-pays are unmanageable,’ Or, ‘I might have to
skip my survivorship appointment because I can’t afford to take off
work that day.’ I think we have to really think about, like I said,
the context and the bigger picture of the scope of the problem and
build and develop interventions that acknowledge that.

Dr. John Sweetenham: Well, as you say, very
complex, multi-level problem and many interventions needed. But
congratulations and kudos to you and your colleagues for addressing
one component of this. And we’re really looking forward to seeing
how this develops and progresses in the coming years.

And I’d like to thank you, again, for sharing your insights with
us today on the ASCO Daily News podcast and telling us a
little bit more about this great work.

Dr. Bridgette Thom: Thank you so much for
having me. I want to just acknowledge all of the work of our team.
It has really been a team effort. We’re looking forward to our next
steps.

Dr. John Sweetenham: And thank you to our
listeners for joining us today. You’ll find links to the poster
discussed today on the transcript of this episode. Finally, if you
value the insights that you hear on the ASCO Daily News
podcast, please take a moment to rate, review, and subscribe
wherever you get your podcasts.

You can hear more about the MSK Affordability Working Group’s
efforts on the podcast, Cancer Straight Talk from
MSK.  

Disclosures:

Dr. John Sweetenham:

Consulting or Advisory Role: EMA Wellness

Dr. Bridgette Thom:

Stock and Other Ownership Interests (Immediate Family Member):
Caladrius Biosciences, Mediwound, Sierra Oncology, Lipocine, MEI
Pharma, Oncternal Therapeutics, Avadel Pharmaceuticals, Chimerix,
Avidity Biosciences, Sutro Biopharma, Adma Pharma, Concert
Pharmaceuticals, Processa Pharmaceuticals,
Curis          
An, IMV, Arcus Biosciences, Iovance Biotherapeutics, Qiagen,
Revance Therapeutics, DermTech, Zimmer BioMet, Axonics Modulation,
Halozyme, Autolus, Pavmed Inc       ,
Mereo BioPharma, and AADi

Disclaimer: The purpose of this podcast is to
educate and to inform. This is not a substitute for professional
medical care and is not intended for use in the diagnosis or
treatment of individual conditions.

Guests on this podcast express their own opinions, experience,
and conclusions. Guest statements on the podcast do not express the
opinions of ASCO. The mention of any product, service,
organization, activity, or therapy should not be construed as an
ASCO endorsement.

 

 

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