Trial takes bill shock out of cancer care

Could bundled care be the answer to financial toxicity for cancer patients?

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Hidden costs are a big problem for cancer patients. Bills for pathology, anaesthetics, surgical assistants, and post-surgical nursing care can all be unexpected. But there is a different way to do things that takes the surprise element out of it, according to surgical oncologist Professor Christobel Saunders.

Professor Saunders and her colleagues are recruiting 150 privately insured early-stage breast cancer patients in Perth, Western Australia, to take part in a 12-month bundled care pilot program.

These patients will pay a set amount of money, at a maximum of around $2,500, either upfront or over 12 months, to cover all their cancer treatment related expenses.

“And that is all they will pay,” Professor Saunders says. “The patient sees no bills. That will cover all of their surgery, radiotherapy, chemotherapy, wound care, pathology, imaging, physiotherapy, allied health, psychological support, and nursing care.”

In addition, all the participants will have a patient navigator to walk them through the experience, helping them make appointments and checking in on them along the way, and an online portal to track their treatment and access information and resources whenever needed. 

Building the program required mapping every possible care pathway and engagement with services. “We’ve signed up everyone, from radiology to nuclear medicine practices, pathology to surgeons, nursing, hospitals,” Professor Saunders says. Breast reconstruction is not currently included, she notes, “but this is the next step”.

Final dollar amounts were arrived at by talking to providers and to patients about what they considered affordable.

Cancer patients told Professor Saunders they had several problems with cancer care. “What most say is that it’s very confusing,” she tells Oncology Republic. “They feel like they’re bounced from one place to the next, unsure where they’re going next. They don’t have enough support and information, access to things like allied health and psychological support. And some say they haven’t been able to make their own decisions.”

They were often unprepared for the out-of-pocket expenses associated with cancer, and, especially in the private sector, the gap – the part of the fee that’s not covered by Medicare or the insurer, Professor Saunders says. Those, she notes, are on top of the non-medical costs: things like loss of income, extra travel and childcare.

Cancer specialists are very familiar with the “financial toxicity” associated with cancer, according to a recent survey by the Clinical Oncology Society of Australia.

The costs associated with having cancer had physical, psychological and financial impacts on patients and their families, the COSA Council noted in a paper by the Financial Toxicity Working Group. It influenced their decision making, adherence to treatment and had far reaching, long term consequences.

“Financial toxicity should not be an acceptable consequence of cancer care in Australia, where healthcare is expected to be effective, accessible, and equitable,” they wrote.

Bundled care was a model that could bring cancer costs under control, Professor Saunders tells Oncology Republic.

“We know that about 10% of patients have catastrophic costs associated with their diagnosis of cancer in the first year, which can lead to all sorts of issues. We thought we would try and design something which didn’t have any surprises.”

It’s not managed care

Bundled care is not the same as managed care, which is quite common in the US, where patients and providers have no choice but to follow the path set by their insurer.

“Our pathway is nothing like that,” Professor Saunders says. “The patient can choose to leave or join a bundle at any time. And the bundle is stretchy and elastic enough to include a whole different load of things.”

It is, she concedes, impossible to negotiate with everybody, but there is choice where possible. “And within that a patient’s journey is fairly well covered.”

For now, only private patients are involved in the pilot project. About half of Australian cancer patients choose to use the private system. And the financial risk is being carried by pilot partner GenesisCare.

But Professor Saunders says there is interest in applying bundled care in the public system and she’s had discussions with the Independent Hospital Pricing Authority.

The pilot program, which is part of the Continuous Improvement in Care Cancer Project, will measure and report on patient experience, clinical outcomes and the experience of providers and will be evaluated by The Centre for Health Economics Research and Evaluation at the University of Technology, Sydney.

“So, the patients will have a voice in this and we can make sure we get real value-based healthcare outcomes,” Professor Saunders says.