‘Knowledge is learning something every day. Wisdom is letting go of something every day.’—Zen proverb
It was September 2019, about six months BTP (before the pandemic). My colleagues and I, working at our cancer center, had been immersed in articles and presentations on the “financial toxicity” that was affecting a large cohort of our cancer patients. As clinicians, we certainly knew that the increasing cost of healthcare was continuing to escalate and was adversely affecting each of our patients as a major stressor in their overall care. Banding together, the financial counselors, patient navigators, hospital administrators, social workers, pharmacy staff, advanced practice nurses, surgeons, medical oncologists, radiologists, radiation oncologists and trainees decided to tackle the problem proactively, or at least retroactively, to increase understanding the toxic issues, which hopefully would lead to improved patient care and a cohesive systemic approach to these financial conundrums. Although we had 12 other multidisciplinary conferences either weekly or biweekly, we established yet another tumor board—the Financial Toxicity Tumor Board (FTTB)!
The FTTB was created to address the burgeoning issue of financial toxicity—the impact of financial burden on patients with cancer, which has been linked with bankruptcy, noncompliance with treatment, increased anxiety, worsened outcomes and increased mortality. This is now a key toxicity experienced by patients with cancer. Our intention was to find solutions to these challenges, and the FTTB was a tumor conference established to create multidisciplinary solutions. Cases are triaged by members of the finance department or financial counselors, based on acuity and severity. Simple issues (e.g., failure to secure Medicaid and lapsed insurance) are handled by financial counselors, nurse navigators or social workers without involving the FTTB. More complex issues are referred to the FTTB for review and resolution.
Over a 2.5-year period, the FTTB has identified the spectrum and frequency of issues associated with financial toxicity in our large healthcare system. This strategy has reduced patient expenditures for oncologic agents by more than $60 million in this time frame, assisting between 583 and 749 patients annually. In addition, copay assistance was found for more than 2,000 patients, providing amounts of approximately $1.4 million each year. Substituting biosimilars, generics and clinically appropriate lower-cost drugs for established, more expensive drugs was shown to be an effective way to reduce the total cost of care by 5%, while maintaining the quality of care for patients with cancer. We found that even small shifts toward lower-cost drugs resulted in significant reductions in the total cost of care.
The regular attendance at the FTTB by a high percentage of participants over a prolonged period suggests the acceptance and feasibility of this concept and the potential for adapting it to other clinical settings. During the COVID-19 pandemic, we adapted many of our clinical strategies to increase the level of safety for patients and staff, and we moved our multidisciplinary tumor conferences to virtual platforms. We also initiated this for the FTTB, without loss of attendance or the ability to carry out all its functions. Hopefully, this conference will evolve to a hybrid model in the future.
Relating to the Zen proverb above, we “learned” that multidisciplinary dialogue regarding financial toxicity is similar to the clinical management setting: It improves care for the patient, educates the hospital personnel and improves the healthcare system. We “let go” of the concept that understanding and managing financial toxicity is irrelevant for clinicians and unworkable across a large healthcare enterprise. My recommendation is to launch this model at your own facility. A surgeon-led initiative will reverberate in countless ways for all involved, especially the patients.
Dr. Greene is the senior medical advisor for General Surgery News.