The five essential people on every patient’s cancer care team (and why a financial advocate should be one of them)

Erika Grotto: The five essential people on every cancer care team, today on HFMA’s “Voices in Healthcare Finance” podcast.

Hello, and welcome to the podcast. I’m your host, Erika Grotto. Today, I’m talking with Jada Desmairis from Baker Newman Noyes about the importance of multi-disciplinary cancer care teams and why a financial advocate should be a member. First though, let’s find out what’s happening in healthcare finance news. Here’s HFMA Senior Editor Nick Hut and HFMA Policy Director Shawn Stack.

Nick Hut: Hey, everyone. Shawn and I wanted to touch on a couple of big topics today. One which we teased last time that we’d be discussing is recent developments around the 340B drug pricing program, and the other is some key takeaways on the final rule for the hospital Inpatient Prospective Payment System in fiscal year 2023. Shawn, ready to go?

Shawn Stack: Absolutely, Nick. Let’s do it.

Hut: Excellent. Let’s start with 340B. Just to catch folks up, the Supreme Court issued a unanimous decision in June in which it ruled that the methodology that HHS used to slash the Medicare payment rate for 340B drugs was not permissible under the Medicare statute. HHS had taken the rate down by 28 percentage points, and that means this is a significant ruling and it could mean the difference of millions of dollars for some hospitals because HHS  and CMS has pledged that for 2023, they’ll restore the former payment rate of average sales price plus 6%, which is way up from average sale price minus 22.5 percent, which has been in effect for the last five payment years. So that’s great, but the news on this front isn’t entirely rosy for the hospital industry. For example, we don’t know what CMS is going to do as far as paying out remedies for the years 2018-2022, when they’ve had this unauthorized lower rate in effect. The early feedback from the agency seems to suggest that they’re going to be looking for ways to keep that amount down, possibly by using survey methodology on 340B pricing that was collected in 2020. And what’s more, in the final rule for the 2023 Outpatient Prospective Payment System, which incorporates 340B payment policy, CMS advised that heightening the 340B drug payment rate will necessitate trimming the general payment update for other outpatient payment services because of budget neutrality requirements. So some hospitals are in for cuts to their market basket update next year. For example, in early projections, CMS is estimating that rural hospitals, as a group, are going to see their update drop by 1.7%. So we’ll definitely be watching to see how all of that shakes out. Shawn, anything to add on that before we move on?

Stack: Yeah, so it is going to be interesting to see how the correction and the new motions that have been filed just actually on August 3 by AHA will play out. AHA followed up and made three motions that first week of August, this last week, talking about, you know, instructing HHS they need to halt the cuts that are currently going on in 2022, which they haven’t done yet. It’s also saying that the previous lawsuit, the previous ruling only covers those cuts from 2018 to 2019 and does not rule on the cuts from 20 to 22, which if I’m not wrong, it’s because of the survey that HHS conducted in 2020. So AHA and all the providers are asking, or most of the providers are asking, for cuts to be addressed from 2020 to 2022 as well. And then of course, as we’ve all been fighting for, saying that any underpayments that were made that need to be—the reimbursement to hospitals needs to be done in a non-budget-neutral manner. You kind of touched on this, Nick. When cuts went through, it pushed up, and rightly so, the market basket increase on other outpatient services to be met budget neutral, so AHA and providers are saying, you know, if you’re going to remedy the illegal cuts that you made to 340B, don’t also roll back those payments that you’ve made from those last five years. So lots to come on this and lots to look at and watch on what that remedy is going to be to pay those hospitals back and whether those 20 through 2022 cuts are going to be included in that ruling.

Hut: Most definitely. Yeah, thanks for that perspective. And also, I know you were going to share some insight on the IPPS final rule that was issued the first week in August.

Stack: Yeah, so yeah, the IPPS 2023 final rule came out and was published on August 1. We did see a little bit of increase in the market basket up to 4.1 in the final rule from 3.1 in the proposed rule. So that anticipated overall increase I believe is 2.6 for urban hospitals and 2.4% for rural hospitals respectively. Now the rule does maintain the concept of a Medicare-dependent hospital and the reversion of the low-volume adjustment, the LVA, to 2010, with the more restrictive criteria on October 1, 2022. But we were kind of expecting that because CMS doesn’t have the ability to change that subset, but we’ll be looking for Congress to address that Medicare-dependent hospital status and that low-volume adjustment piece in the next coming months. Wage index changes, you know, we’re still holding with the 5% annual decline made permanent consistent with the proposed rule, so that stays the same. Disproportionate share and uncompensated care pool payments, CMS didn’t finalize the proposed changes to Section 1, 1115 waiver for day treatment, so that was a little bit of a shock, and then some good news at the end of the disproportionate share area was that CMS finalized using the blended S-10 reporting for uncompensated care pool payments, which all hospitals and providers have been watching for the last couple of years, so that’s good. I was a little disappointed that the MSDRG rate, the outlier threshold is still way too high in my opinion. The proposed, I think, was $43,214 for 2023, and the final rule came in at $38,859, which was still, you know, a good hike, a $10,000 hike from the 2022 outlier threshold, so not good for hospitals, really not good for the program because most of those outlier costs were due to Covid, and we strongly feel that those outlier costs are going to correct themselves over the next year and a half anyway, which is going to mean that CMS overshot the outlier threshold increase, and they shouldn’t have. So just a couple of things. A couple of wins, a couple disappointments there in the IPPS final rule that have a heavy impact. But of course we’ll be watching OPPS very closely as that final rule is expected in the next 10 months as well.

Hut: And of course, as we said, the federal fiscal year starts in less than two months, so these very payment and policy changes will be in effect very soon. So Shawn, thanks a lot as always for the expertise, and we’ll talk to you all next time.

Stack: Thanks, Nick. Have a good week.

Grotto: According to the CDC, the cost of cancer care is expected to reach $240 billion by 2030, with patients paying billions out of pocket. The decline of cancer screenings during the pandemic has only exacerbated the problem, leaving many patients with advanced cancers deferring care. My guest today says financial advocates can encourage patients to get the care they need and curb costs for providers. Jada Desmairis, a senior manager in healthcare advisory group at Baker Newman Noyes talked with me recently about the importance of a financial advocate on every cancer care team.

Jada Desmairis: In cancer care, because cancer patients’ treatment tend to last for a series of weeks or months or if they’re metastatic, treatment can last for years. And with that, the more robust the care team, the more supported the patient will be. And what I mean by that is, it’s not just about having a physician or a nurse. It’s about having a financial advocate to support the patient financially. It’s about having social work in place to support the patient’s mental health needs. It’s about having a dietician to support their dietary needs because the patients don’t feel well and they can’t eat, or they have throat cancer and they can’t swallow. So the more that cancer programs can address the whole patient and all of their needs, the better they can help with the physical aspect of the care, and then again, they can have that financial advocate looking out for their financial interest as well.

Grotto: That’s actually a great segue into the next thing I wanted to get into, which is mental health. Cancer specifically has been linked to issues with mental health, but to treat someone for anxiety, depression, etc. also costs money. So if we have someone who’s already worried about the cost of their care and possibly delaying care because of the cost, what do we need to do to bring that piece together into this care team?

Desmairis: Right, so that’s where having a multi-disciplinary team with a financial advocate or financial counselor—it’s essentially the same role, they’re just called different titles at different organizations—but having that financial person working with a social worker and working together as a team to really support the patient throughout their cancer journey. And some cancer centers will provide social work services free of charge. Others will charge for counseling visits. Most insurance companies do cover some form of counseling, whether it’s a number of visits or a portion of each visit they’ll reimburse. So it’s important that the care team recognize when a patient is in that, you know, need of mental support. Often, you find that the nurses also carry some of that burden, but to have more formalized social work and counseling, it will help support them mentally and then having that financial advocate on the team continue to follow the patient and ensure that they’re doing whatever they can to help on the financial side. There are so many patient assistance programs out there for cancer patients from the pharmaceutical companies, the foundations. There’s a lot of help out there, but you need to know where to find it, and that’s where social workers and financial advocates come into play. They will look at the patient diagnosis, the patient’s insurance coverage, the patient’s social situation—meaning, does the patient have food insecurity, housing insecurity—and a good team will work together to do whatever they can to fill in wherever the gaps are. So if a patient is having food insecurity, can they get them cards to a local grocery store? Are there ways to help with utility bills so they have more money to pay for rent or food? So it’s really about that team approach. It’s having the right players involved and being part of the care team.

Grotto: It also sounds like thinking about these things at the moment of diagnosis is important, rather than waiting until a patient comes and says, “I’m struggling with…”

Desmairis: For several years, I ran cancer centers, and that was part of our model. It was to ensure that right at the very beginning, that the financial counselor was introduced to the patient as part of the care team. So it was, this is your physician, this is going to be the nurse that’s going to work closely with you, here’s social work, here’s our dietician, and here’s a financial counselor. We are your team, and we are here to support you, and that financial counselor would start working right away from Day 1, looking at insurance. Is the patient underinsured? Not even knowing what the treatment plan was yet. There are still some things that a financial advocate could start doing right on Day 1, and then as soon as that diagnosis and care plan is in the system and the orders are made, that’s when the financial advocate will look at the patient’s insurance, what’s being prescribed for the patient. Some of these drugs are so expensive. There are immunotherapy drugs that cost over $10,000 a treatment, and the patient’s going to get those treatments every three weeks. So think of how those costs are going to add up, and that’s where a financial advocate is such an important part of the team. And it needs to be somebody who’s part of the team. That’s another important distinction. It needs to be somebody who is part of the cancer center and the cancer care team, not somebody working in the billing office in another building. It’s really somebody who is part of the care team and works elbow to elbow with the physicians, with the nurses, with the APPs. They all work together to care for the patient.

Grotto: You touched on this a little bit, but can we get a little more in depth to the benefit to the provider organizations when they assemble a care team as you’ve talked about?

Desmairis: Sure. So having the financial advocate as part of the care team not only addresses financial toxicity for patients, but it also benefits your organization. And what I mean by that is, it’s going to help maximize revenue. It’s going to optimize insurance coverage. It’s going to—and when I say “it,” I mean this resource, a financial advocate—will help us take copay assistance for the patient. And other programs that will actually assist them with paying their bills. There are foundations that will help patients pay for their portion of their medical bills. And so these financial interventions will reduce denials and bad debt write-offs. They’re going to reduce charity care. So many hospitals have what I’ll call a bucket of money, which they give charity care to patients, which is essentially free care. It’s going to reduce charity care. And then on top of that, it’s going to increase patient satisfaction. A satisfied patient is a loyal patient. It’s somebody you’re going to retain within your health system, and they will come back for more than their cancer care. They will come back for their labs, their radiology scans. They will tell their friends and their family members, “That is where you should go because they provide the best care there.” So I think, you know, with all the challenges within the healthcare industry financially right now, the system is really worth having a financial navigator as part of your care team, is really worth the time and investment. These positions pay for themselves five times over. So even though nobody wants to talk about adding an additional staff member, and I do understand it’s very difficult to get staff right now. But if there’s a program that does not have a financial advocate in place, putting one in place, that person will pay for themselves over and over and over again. The ROI is absolutely there. So there’s the financial benefit to the organization and then there’s the larger benefit that I see, and that’s to help the patient in their care journey.

Grotto: Jada Desmairis, thank you so much for joining me today.

Desmairis: Thank you for having me.

On a recent episode of HFMA’s “Voices in Healthcare Finance” podcast, Jada Desmarais, a senior manager in the healthcare advisory group at Baker Newman Noyes, discussed the mental and financial toll cancer treatment can take on a patient as well as the importance of assembling a team that anticipates and addresses these issues.

The patient burden of cancer care

Cancer treatment can last weeks, months or even years, and the challenges of that length of time can add up, Desmarais said.

“The more robust the care team, the more supported the patient will be,” she said. “It’s not just about having a physician or a nurse. It’s about having a financial advocate to support the patient financially. It’s about having social work in place to support the patient’s mental health needs. It’s about having a dietician to support their dietary needs.”

Not only is it important to have the appropriate people, but those people also should be able to anticipate patients’ needs rather than putting the burden on the patient to ask for help, Desmarais said. This is especially important when dealing with the financial side of cancer treatment, she said.

“There are some things that a financial advocate could start doing right on Day One,” she said. “As soon as that diagnosis and care plan is in the system and the orders are made, that’s when the financial advocate will look at the patient’s insurance, what’s being prescribed for the patient.”

Benefits to the organization

Placing a financial advocate on every patient’s care team ensures maximum payment as well, Desmarais said. Someone who can help patients look for financial assistance will reduce bad debt and charity care costs, she said. In addition, caring for a patient holistically in this manner contributes to patient satisfaction, which can turn into new business as friends and family members come into the system.

Desmarais acknowledged the difficulty of finding staff but said the ROI for hiring financial advocates is significant.

“These positions pay for themselves five times over,” she said. “There’s the financial benefit to the organization and the larger benefit that I see, and that’s to help the patient in their care journey.”