Page 37 Complete Your CE Test Online - Click Here The nurse can ask the patient and family about financial concerns. One way to open the discussion is to ask whether patients and caregivers are worried about how the costs of cancer treatment are affecting the ability to support themselves or their family. Or the nurse could inquire if they are concerned about their financial future because of cancer treatment costs. Patient costs can often be reduced without sacrificing quality of care. This is an important message for patients with financial concerns. Depending on the patient’s concerns and priorities, the nurse can encourage discussions with the oncologist about treatment goals and different options that might work for the patient. It is important to be sure that the patient is empowered to ask about the purpose of a medicine or procedure, and exactly how it is expected to contribute to the patient’s quantity and quality of life. Many patients would be surprised to know that for some of the newer and very expensive cancer drugs, studies have documented only a median of an extra couple of months of life (sometimes less) above the older treatment regimens. On the other hand, some of the new drugs offer a median survival improvement of two years or more for those who can afford and tolerate the drug. Another reason for the expensiveness of new drugs is side effects. For example, a drug may costs 50 times more than the drug that it is designed to replace and not work any better; however, the new drug may have a smaller incidence of a certain side effect. Doctors have the option of trying the older drug to find out if that effect is a problem for the patient before switching to the newer and more expensive one. Choosing drugs that can still meet the patient’s needs and cost less money requires the active assistance of the doctor or care provider. This is a highly personal decision, which greatly depends on the patient’s medical situation. A very expensive drug may be worthwhile to some people because of the expected benefit, but not so much for others. For any of these options and choices to be available, the patient must have a frank discussion with the doctor about the proven benefits of the recommended treatment options and why one drug might be better than or equivalent to another. This is also an aspect of ongoing informed consent. When current financial barriers are identified, it can also help to refer the patient to the financial staff to find out about working with her insurance coverage. A medical social worker might be appropriate to refer the patient to other sources of help, such as prescription assistance programs, local charity funding, and government programs for which they might qualify. People with health insurance nearly always have the right to make an appeal if coverage for an essential service is denied. Medical social workers or financial counselors at the facility can also help with this, and more information can be found online at http://www. Case Study: Robert is a 62-year-old man with extensive-stage small cell lung cancer. He has had combination chemotherapy with carboplatin, etoposide, cyclophosphamide, doxorubicin, and vincristine. He is back in the hospital with pneumonia three months after completing four cycles of chemotherapy. Scans have shown some progression of his disease, with larger metastases in his other lung. His doctor has now recommended a second-line treatment of IV paclitaxel weekly for eight doses after he goes home. When you talk with Robert about going home, he says that he does not think he wants this treatment and he is thinking of asking his doctor about “one of those new targeted pills I’ve heard so much about” from his lung cancer support group. He thinks it might produce a cure, and he is hoping it will cost less than the IV treatment. You are concerned about this and recommend that Robert talk with his doctor about the goals of treatment. You further explain that most people with extensive-stage small cell lung cancer are treated to slow the growth of the cancer. When you come in again later, he and his wife are talking about taking out a second mortgage on the house to cover the cancer treatment he has already received and to help with future costs. You ask them if their finances are causing problems and find out that he has learned his private health insurance plan counted some of his visits to specialists as out of network. Even for in-network care, copays have added up quickly. His illness is also causing him trouble at work, and he is afraid he will lose his job and his health insurance. What do you do now? 1. Ask him if he has talked with his insurance administrator about his billing, and whether he has appealed the decision of his insurance company to withhold payment for his prescribed specialty care. 2. You explain that even though targeted drugs are helpful in non- small cell lung cancer, most have not been shown to be as helpful in small cell cancer, although research is still ongoing. You further mention that most of the targeted oral drugs are reimbursed in a different way than IV drugs are so that they often cost the patient more. This is also something he could discuss with his doctor. 3. Because you have already spoken with him about talking with his doctor about goals of treatment, and he is not asking more about that, do not bring it up again unless he has specific questions. 4. You ask if he has ever thought about clinical trials for people with extensive small cell lung cancer in his situation because some of the expenses might be covered by the trial administrators. This is something else he could bring up with his doctor. 5. Suggest that he discuss his health coverage and job situation with a medical social worker. Let the couple know that if he does quit or lose his job, he has 60 days to enroll in a new health plan on the Health Insurance Marketplace, even if it does not happen during the annual open enrollment period. He can call 1-800-318-2596 or go online to to get started. This is called a Special Enrollment Period. 6. All of the earlier suggestions. Depending on how much time you have, and how he responds to the discussion, Answer 6 may be most appropriate. You are concerned that Robert does not understand that his prognosis is very limited, but you have already given him some information and suggested that he discuss this with his doctor. Now there is the additional issue that he is looking for less expensive treatments by asking for a treatment that not only is likely to cost him more but also unlikely to accomplish what he hopes it might. A lot of people do not know that they can appeal an insurance plan’s decision. Most holders of health insurance plans are required to review their decisions when asked, and in some cases the patient can even request an external review. It could be very useful for this patient to pursue an internal appeal, and if that does not work, resort to an external appeal. More information can be found online at if he searches “appeal a health plan decision.” The financial staff or medical social worker should be able to help too. Although some 60% of children with cancer are enrolled in clinical trials, fewer than 5% of adults are. This is likely one of the reasons that cancer treatment has evolved more slowly in adult care. Health insurance companies in the past sometimes denied treatment coverage to people who were in clinical trials, but regulations have changed with the Affordable Care Act. Now health insurance plans largely do not put up barriers to participation in clinical trials. The difficulty is finding one for which the patient qualifies because some exclude patients on certain medications or with comorbidities. Patients can find out about clinical trials and possible matches using the Clinical Trials Matching Service from the American Cancer Society (see “Patient Resources”). Most people who have health insurance coverage at work can keep their health coverage, even if they lose or must quit their jobs, through a program called COBRA. However, this tends to be a fairly costly option for most people. Another option for them might be the State Health Care Marketplace, which has an annual open enrollment period near the end of each year during which people who do not qualify for other health coverage can sign up. But people who have changes in their life situation during the year that results in loss of health coverage (or if they gain an immediate family member through marriage, childbirth, or adoption) typically qualify for a special enrollment period on the marketplace. The patient must sign up within 60 days after his coverage is lost. However, if a person loses health coverage because he did not pay premiums, he does not qualify for a special enrollment period. If Robert loses his job and his spouse is employed in a workplace that offers family or dependent health plans to employees, he may be able to sign on to his spouse’s workplace policy. However, that option must be exercised even more quickly than the marketplace option, as the special