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Oncologists often have to deliver difficult messages to their patients. It is part of the job and part of the training. It is never easy, and some physicians are more skilled at this than others.
Increasingly, the physician's difficult message includes not just prognosis and therapeutic options, but also the estimated cost of care. While a recent study found about one quarter of surveyed oncologists rarely, if ever, discuss the financial costs of cancer treatment with their patients,1 most oncologists realize that patients need to understand the impact of their treatment choices on their personal and their family's finances.
In the United States, an estimated $209.9 billion was spent on cancer care in 2005.2 More than 40% of Medicare drug spending is for drugs prescribed by oncologists.3 In the outpatient setting, anticancer treatments account for a substantial portion of drug expenses. Research has produced new cytotoxic and biologic agents that offer improvement in survival, but carry a substantial cost. For a patient with advanced colon cancer, for example, during the past decade, the cost of a standard regimen has risen from $500 to $250,000 and survival has increased by about 12 months.4
The problem is especially critical for uninsured patients, but even patients with health insurance coverage are likely to feel the impact of out-of-pocket expenses. Insurance copayments for some cancer therapies can total $10,000 each month.
“Among physicians, there has been the feeling that we shouldn't talk about costs, but should purely focus on patient care,” says Anthony Back, MD, medical oncologist at Seattle Cancer Care Alliance (Seattle, Washington). “But oncology drugs are so expensive, it's simply not appropriate to ignore costs when talking with patients about their care.”
As a specialist in gastrointestinal and colon cancer, Back cares for many patients with metastatic or advanced disease.
“These patients often have concerns about their estates and providing for their spouse or dependants,” says Back. “The cost of care must be one factor in their decision about therapy.”
Surveys of general internists and their patients found that 63% of patients want to discuss out-of-pocket costs, yet only 15% ever did.5 Researchers identified a number of barriers preventing patient-physician communication about costs. Among the most common were discomfort by both physicians and patients over discussing finances, insufficient time during the visit, and both parties' concerns that the physician did not have a viable solution.6
Both researchers and practicing oncologists are working to identify ways to effectively communicate with patients on costs of their care. In his university-based practice, Back discusses the therapeutic aspects of treatment options first, but raises the issue of costs early in the discussion.
“Most patients want to talk about costs, and they appreciate putting the financial issues on the table,” he says, “but they seldom use cost to drive their final decision. Yet for some, the cost-benefit ratio is part of the decision-making process, and they need all the facts.”
Alexander et al6 have made a number of suggestions for breaking down communication barriers around costs. As with any new skill, physicians who regularly raise the issue may find their discomfort decreases and their skill level increases with continuing practice. Prefacing the financial question with a general observation helps decrease patients' reticence to talk about their own concerns: “Many patients will have problems with the cost of this therapy. Do you think this will be an issue for you?”
Several communication models are based on expressing empathy, which builds trust and aids disclosure. In applying empathetic communication, the physician responds to the patient's expressed or implied concerns in a way that shows an understanding and acceptance of the patient's feelings, values, and ideas. The response involves listening carefully, then either questioning (“Does the cost of your care concern you?”), seeking clarification (“Tell me more about how you think these costs will affect you.”), or responding (“It sounds like you anticipate some problems paying for your care.”).7
Empathy also can be expressed with the use of “we” statements (“Let's see if we can find an alternative.”). In the face of patient hesitancy or competing interests such as cost and therapeutic value, oncologists who respond in a manner that conveys collaboration help prevent the patient from feeling isolated. The partnership may decrease the likelihood of poor compliance.
Involving other members of the medical team in cost discussions may be an effective way to overcome the lack of time and demonstrate knowledge of solutions. For example, in some practices, the staff pharmacist can provide actual drug costs to the patient. Computerized order entry systems can be programmed to provide estimates of Medicare reimbursement rates and patient copayments. The office manager, financial advisor, or a social worker may be able to help patients connect with medication assistance programs, state Medicaid plans, and nonprofit organizations that may pay for treatment or provide services that would reduce the financial burden from indirect costs of care (for example, free transportation or child care programs).
Peter Bach, MD, Memorial Sloan-Kettering Cancer Center (New York, New York), asserts, “Patients are unfamiliar with making extraordinarily difficult trade-offs between very high out-of-pocket costs and very expensive treatments with measurable but sometimes modest health benefits.”8 Given the extraordinarily high cost of cancer care and the move by many third-party insurance plans to transfer more of the cost of care to the consumer, oncologists must be more proactive in giving patients the information they want and need to make informed decisions about care. Most patients at least want to be offered the opportunity to discuss potential trade-offs in their care, to serve the best interest of themselves and their families.