Patient Assistance Programs: What Every Oncologist Should Know

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by Fran Castellow, MSEd., Chief Operating Officer, Patient Advocate Foundation

Review of the Problem
All oncologists practicing in the healthcare system today understand the sometimes paradoxical situation in which the patients find themselves. Patients rely on the oncologist’s professional guidance to recommend the most appropriate and beneficial treatment for their diagnosis, yet for many, these treatments remain out of reach because of rising drug costs.

Oncologists are practicing in an exciting era of cancer treatment, one in which cancer is often being eradicated or managed as a chronic illness for many patients. This shift in survivorship is largely due to the promising new drugs that are being developed and subsequently approved that are extending the lives of the patients being treated and are considerably less toxic than the standard chemotherapy that oncologists have been administering for decades. While this new age of a kindler, gentler treatment option promises an enhanced quality of life for the patients, many of these new cancer therapies of choice–specifically those that target the cancerous cells but don’t destroy a patient’s normal cells–come at a cost that is often out of reach for most patients.

As recently cited in the September 7, 2004 edition of the Wall Street Journal in the article entitled, "Price Becomes Factor In Cancer Treatment" by Amy Dockser Marcus, several promising oncology drugs range in retail cost from $500.00 to $17,000 a month. Gleevec, an oral drug that treats CML and Gastrointestinal Stromal tumors costs approximately $500 a month, however, a patient could be subject to that cost for years as Gleevec is frequently used on a continuous basis if the results are positive. Likewise, Erbitux, used for advanced colorectal cancer retails for $18,000-$30,000 for a seven week course. Applying these costs to the life of a possible 19-20 month regimen for advanced colorectal cancer, that treatment can reach $250,000, which is an astronomical amount of money for most Americans to even contemplate paying. Thalomid, used in the treatment of Multiple Myeloma and other cancers costs approximately $2,000 a month for a course of five (5) moths, bringing the total to $10,000. These are but a few examples of the new class of oncology drugs that are medically beneficial for many oncology patients and improving their quality of life, however, on the flipside, they are putting the financial stability of the patients and their families at risk.

It is hard to imagine that patients who have insurance through an employer sponsored group plan, or those who carry individual health coverage need assistance, however, it seems that it is this very population that is being effected the most. Patients want to access the most appropriate treatment for their illnesses, however, the rising costs of drugs are causing some patients to opt for a less effective treatment or forgo treatment all together. For example, a fully insured patient who is prescribed Iressa for treatment of non-small-cell lung cancer would be subject to co-payments of $200-$400 a month for an undetermined amount of time. Oncologist are now faced with the reality that there is a large number of educated patients who are duly employed and have health insurance, yet are simply unable to afford their share of costs of the prescribed treatments due to the high co-pay and coinsurance that the plans require and the lack of access to alternative assistance due to their financial and/or insurance status.

A study recently released by Harvard University Law and Medical schools clearly reinforces the financial realities that many patients are now facing. The results of this ground breaking study indicates that catastrophic illnesses are the root cause of over half of all personal bankruptcies. The study authors surveyed 1,771 of the 1.458 million personal bankruptcy filers from 2001 in five federal courts, including California, Illinois, Pennsylvania, Tennessee and Texas to determine the causes that contributed to the bankruptcy. Over 900 of the survey participants then agreed to provide further information via a personal interview. The results showed that illness and medical bills were a primary causational factor in 46.2 percent of the personal bankruptcies. Amazingly, 75% of those seeking relief under the bankruptcy law reported that they were insured at the outset of their illness and treatment. However, 38% had lost that coverage; at least for a period of time, prior to filing the bankruptcy due to the co-morbiditiy of major illness and job loss, thus loss of employer sponsored health benefits.

The study also shed light on the absorbent out of pocket expenses including unaffordable co-payments, coinsurance, deductibles and non-covered services such as physical therapy and prescription drugs, which insured patients and their families are now facing. It was found that the average out of pocket medical expenses for those surveyed who had insurance at the onset of their illness and were able to maintain that coverage reached $13,460. For those with no insurance during their illness, the total out of pocket expenses dropped to $10,893. Those patients who had insurance at the beginning of treatment and subsequently lost the coverage suffered the most financially, facing, on average, $18,005 in out of pocket expenses by the time they filed for bankruptcy protection. The population that is being hardest hit is the middle class families who, in fact, do hold jobs and are paying to carry private health insurance on their families. 56% of the filers in the study had college educations and owned a home.

What Alternatives Exist?
When recommending a course of treatment for a patient, it is imperative that an open dialogue exist between the provider of care and the patient regarding the financial realities that the patient is facing. If it is determined that the patient cannot afford the prescribed drug or treatment on his/her own, it is now becoming a necessity that the provider and his/her office to assist the patient with accessing alternative payment options to ensure that the patient is receiving the appropriate care without putting at risk the very quality of life that is trying to be saved with the hardship of financial ruin.

There are some options that may benefit the uninsured patients in these situations such as, applying for assistance through an indigent drug program that is administered by the pharmaceutical manufacturer, seeking access through a charity care program at local treatment facilities, determining eligibility for Medicare, Medicaid, Social Security Income or Social Security Disability Income and/or networking through available disease specific advocacy networks that exist.

For the privately insured population the options become much more restrictive due to the fact that merely possessing insurance coverage, even when the costs relative to co-payments, premiums and non-covered services are bankrupting the patient, frequently serves as a disqualifier for many of the government sponsored programs as well as many of the pharmaceutical assistance programs. Armed with the knowledge that the insured population is at a severe disadvantage when trying to locate financial assistance for medical expenses, a groundbreaking new service has evolved and takes the form of Patient Assistance Co-Payment Programs which offer some financial relief for these patients and their families.

Patient Advocate Foundation’s Patient Assistance Program
Patient Advocate Foundation (PAF) has was one of the first non-profit organizations to launch a cash co-pay assistance program when it opened it’s Patient Assistance Program (PAP) in April of 2004. The PAF Patient Assistance Program currently provides co-pays to qualified patients for several devastating illnesses, including breast, lung and prostate cancers, macular degeneration, as well as selected secondary issues resulting from cancer treatment.

Since 1996, PAF has been providing assistance to patients struggling with chronic, life threatening or debilitating illnesses seeking to safeguard access to care. Professional case managers serve as active liaisons between the patient and their insurer, employer and/or creditors to resolve insurance, job retention, and/or debt crisis matters relative to their diagnosis. The Patient Assistance Program is the organization’s first venture into directly covering the costs of patients' treatments.

Patients who have that co-pays are causing a significant financial hardship and/or impacting their ability to pay for necessities like groceries, utility bills or their mortgage are encouraged to apply for assistance through PAP. A call counselor is available to work directly with each patient to complete the application process and determine their eligibility for the Program. Patients who financially and medically qualify will receive $2500 annually payable to the provider of service, pharmacy and in certain cases, directly to the patient with appropriate proof of expenditure. PAF currently has the ability to provide assistance to an additional twenty-three (23) diagnoses as funding becomes available. If you have patients who could benefit from financial assistance or if you wish to learn more about the Program you can contact 866-512-3861 or visit www.copays.org.

Conclusion
While it would be ideal for oncologists to devote themselves solely to providing medical care to our patients, the reality of healthcare today dictates that they factor in outside hurdles such as treatment costs in order to deliver quality care. It is becoming imperative to become engaged in the financial realities that patients are facing in order to insure the integrity of the patient’s future financial stability. Recognizing that the financial hardships are occurring when illness hits, even when private insurance is in place, is the first step towards a remedy. Networking the patients to avenues of relief, such as PAF’s Patient Assistance Program is the next step we must all take.