The purpose of collecting cost data is to provide information to help decision-makers evaluate the economic impact as well as the cost-effectiveness of a PN program and to decide whether such programs should be sustained or perhaps replicated at additional sites. To facilitate economic evaluation of PN programs, the collection of cost data should be discussed at the program planning stage so that data collection tools can be identified or developed and the core cost items standardized across sites. In our experience, collection of cost data retrospectively is difficult, at best. Moreover, the accuracy and reliability of such data might be questionable.
Once the cost data are collected, sites that only have capacity to gather core cost items need to be aware that cost estimated from all core items is underestimated. For a comprehensive economic assessment, it is necessary to add estimates of costs associated with optional cost items obtained from other sites. Through the establishment of common cost measures, our ultimate goal is to generate high-quality data to allow us to build a reference case for cost-effectiveness of PN programs, such as the reference cases presented by the Panel on Cost-Effectiveness in Health and Medicine.16
In addition, to facilitate information exchange across sites with varying levels of sophistication of data collection, it is recommended that costs be presented in a disaggregated format, stratified by cost categories and separate for core and optional items respectively. This disaggregated format will not only make estimates of optional cost items available to sites that have only collected core items, it also allows decision-makers to identify the most relevant cost components for their assessment.
Compared with other measures discussed in this supplement issue, the analysis of cost data is more complex because the relevant cost elements included in the analysis differ by stakeholder perspectives. For example, from a payors’ (e.g., Medicare) perspective, only costs that are potentially reimbursable under the agreement with third-party payors will be included. From a health care providers’ (e.g., hospitals or community health centers) perspective, costs associated with hiring and training patient navigators will need to be considered, as well as any potential reduction in the time that clinical or administrative staff spend in helping patients navigate through the health care system or in the number of “no shows” at the facility. From a societal perspective, all cost items, irrespective of whether they are reimbursable, should be included.
The analytical approach employed by decision-makers to determine the economic value further complicates the analysis of cost data. Despite the popularity of cost-effectiveness analysis (CEA), many decision-makers pay equal or more attention to the financial impact of an intervention and seek such information from budget impact analysis (BIA).17
While CEA evaluates the additional costs to achieve an unit of improvement in effectiveness (e.g., qualify-adjusted life years),18
BIA estimates the financial consequences of adoption of a new technology or implementation of a new intervention within a specific healthcare setting.19
The ability for BIA to address the issue of affordability has motivated an increasing number of payers to request evidence from BIA in addition to CEA when making coverage decisions since it is possible that a new medical technology or intervention can be cost-effective and yet unaffordable. This practical aspect likely makes BIA an appealing analytical approach to those who are involved in the decision-making of whether to initiate and/or continue a PN program. The various combinations of study perspective with analytical approach will likely result in stakeholders reaching different conclusions regarding the economic value of PN programs.
When studying the economics of PN programs, an important aspect to consider is the aspect of human capital investment. The hiring, training, supervision and retention of patient navigators represent investment in human capital for organizations that employ these patient navigators, and turnover adds additional costs to the organizations due to the need for additional recruitment and training. Even in the case of volunteer patient navigators, these organizations still invest in training and also assume the costs of turnover.
With the exception of volunteer work, there are in general two forms of employment for patient navigators. Some are hired by health care providers, whereas others are employees of organizations that champion a PN program. Examples of the former model are patient navigators employed by hospitals. Examples of the latter model are patient navigators hired by the American Cancer Society to work at community hospitals or cancer centers. A third, less common model are patient navigators that are employed by community based organizations, most often engaged in navigation to cancer screening.
It is possible that a program might be considered cost-effective from a societal perspective, but is deemed neither cost-saving nor cost-neutral by decision-makers at a community hospital. In this case, regardless of the favorable cost-effective conclusion for society, the PN program may not be sustained if patient navigators are employed by the community hospital. The above scenario speaks to the importance of considering the human capital investment aspect in studies assessing the economic value of PN programs, because these programs cannot exist without patient navigators. As discussed in the previous section, the human capital costs of patient navigators vary by the qualification and type of navigators employed. The cost can vary substantially between a nurse navigator and a lay navigator. Given the wide range of activities involved in patient navigation services, an efficient allocation of resources will require better alignment of navigator qualifications with their anticipated job functions. The heterogeneity among navigators thus adds to the level of complexity in the analysis of the economic value of PN programs.
Another important aspect to consider is the timeframe applied to the assessment of the economics of PN programs. The purpose of PN services is to assist patients in conquering access barriers; therefore, a successful PN program most likely will lead to an immediate increase in the utilization of medical care services. Due to the nature of PN services, studies with a short study timeframe are unlikely to find PN programs cost-effective, as many benefits associated with PN services may not be realized in the short term. This concern is especially pertinent if a PN program targets efforts to improve cancer screenings. It should be noted that cost measures discussed in our paper are applicable to short-term studies and may not provide sufficient information for long-term economic evaluations. As mentioned in Ramsey et al.,6
such evaluations often involve development of mathematical models that describe the natural history of a disease process and thus can capture the effect of PN services in altering the disease process through early detection and timely treatment. However, it is not realistic to expect each site to collect cost data for long-terms evaluations. Researchers will have to rely on other sources, such as published studies or secondary data, to extract relevant cost information for the model.
A number of large scale PN programs, such as the Patient Navigation Research Program sponsored by the NCI and the Centers for Medicare and Medicaid Services (CMS) Patient Navigation Demonstration Project, have reached or are soon reaching the point that a funding or reimbursement decision must be made regarding whether these programs are to be sustained. The timing of decisions critical to the future of PN programs coincides with the period of healthcare reform, making economic information about PN programs even more important. Sustainability of these programs likely hinges upon the ability of these programs to demonstrate clinical and economic value in meaningful ways to multiple stakeholders, including healthcare providers, healthcare systems, payers and policymakers. Our recommendation of common cost metrics is timely and highly significant in today’s health care environment as collective understanding of the value of PN will be enhanced by the adoption of common measures to facilitate comparability across heterogeneous PN programs.