Making a Business Case for Financial Navigation

October 2021 Vol 12, No 10

Financial toxicity can be devastating for patients with cancer, but although the benefits of financial navigation in terms of patient quality of life have now been fairly well established, many cancer programs still struggle to demonstrate its value. However, according to Dan Sherman, MA, LPC, a financial navigator and president and founder of the NaVectis Group (a consulting company that assists oncology providers with training and implementation of financial navigation services), making a business case for financial navigation—and actually demonstrating a return on investment—is perhaps the most surefire way to display its value and add more financial navigators to the cancer care team.

But to do that successfully, financial navigators must have an expert-level understanding of our complex healthcare system and must be able to educate patients on those complexities, he said at the AONN+ Virtual Midyear Conference.

Models of Financial Advocacy Programs

According to Mr Sherman, the term “financial navigation” is now used very loosely in the healthcare system, but generally speaking, financial navigational services are centered around navigating the patient through the extremely complicated healthcare system in the United States. When done well, these efforts should lower the financial burden for the patient, while at the same time increasing revenue or protecting the oncology provider in the services that they are providing, from a financial standpoint.

Most oncology providers in the United States have financial counselors in place who have expertise in enrolling people into charity programs, setting up payment plans, and facilitating Medicaid enrollment for eligible patients. “However, we know that in the oncology setting, our patients need a lot more in terms of financial services than just Medicaid enrollment and charity assistance,” he said.

This is where financial advocates come in—individuals who are skilled at enrolling patients into copay assistance programs, patient assistance programs and, when necessary, programs that assist patients with basic needs.

“But unfortunately, even with these systems in place, we know that financial toxicity is still flourishing throughout the United States,” he added.

A Required Level of Expertise

A big part of financial navigation services is insurance optimization, which focuses on educating the patient about their insurance coverage so they can completely optimize their benefits and receive even better coverage than what they might have had before, he explained.

Mr Sherman emphasized the importance of financial navigators having a high level of expertise in understanding the different types of coverage available to patients for the services that they need. “I’m not just talking about a basic knowledge of Medicare or Medicaid, or the low-income subsidy program, the Medicare Savings Program, or how the Affordable Care Act works,” he said. “But actually an expert-level understanding of these systems, so that when patients are confronted with the complexities of the options available to them, there is actually an expert at the facility who can navigate these patients through these different types of systems.”

He offered an example of a patient newly diagnosed with small-cell lung cancer who asks their medical oncologist to explain the disease and offer treatment advice, and who is told to visit a website because “non-small lung cancer is complicated.” From the patient’s perspective, such a visit would not instill much trust in that oncologist.

“But in many circumstances across the United States, we do this almost every single day when it comes to questions about insurance, Medicare, or out-of-pocket responsibilities,” he said. “Way too often, our answer to those patients is to visit the Medicare website, or we refer them to an agency that might be able to answer some of their questions. Do these individuals trust the healthcare providers who don’t know the answers to their questions?”

Benefits of Financial Navigation

The benefits of providing financial navigation services in the oncology setting are numerous, but 1 major advantage is improving access to care.

Approximately 50% of all oncology patients are enrolled in the Medicare system, but Medicare coverage is complex and widely misunderstood. When a patient turns 65 and is enrolling into Medicare, they’re faced with about 50 different coverage options, on average, and the differences among those options are vast. For example, out-of-pocket responsibilities differ significantly between a Medicare Advantage plan and a Medicare supplemental plan.

“Probably 35 to 40 of those options are not going to be in the patient’s best financial interest, while a smaller percentage of options will result in a much-improved scenario for the patient from a financial standpoint,” he said. “So when a patient is approaching the age of 65, do you have a person on staff who can sit down with them and help them navigate the complexity of their choices, so that when they do make their choice, they have chosen wisely in regard to their out-of-pocket responsibilities?”

Financial navigation also leads to better health outcomes. Research has shown that financial toxicity leads to a lower subjective quality of life in terms of the patient experience; patients often experience a decrease in income, increased expenses, and an inability to pay bills and set money aside for retirement, resulting in a loss of security.

Financial navigation also impacts patients from a lower health-related quality-of-life standpoint in that it actually negatively affects their physical and mental state as well as their social well-being. “One study found that 27% of oncology patients have experienced depression secondary to financial toxicity,” Mr Sherman noted.

Finally, financial toxicity leads to lower-quality cancer care services, as research has revealed a lower level of treatment adherence among patients who experience financial toxicity. And importantly, he noted that all of these issues are tied to increased mortality among patients with cancer.

Although it may sound counterintuitive, another benefit of financial navigation is limiting the use of free drug programs. According to Mr Sherman, a financial navigator with a high-level knowledge of Medicare Part D can inform a patient when using a copay assistance program will be a better financial decision than a free drug program, actually saving the patient a substantial amount of money in out-of-pocket expenses.

Although not enough research exists in regard to the relationship between financial navigation and patient satisfaction, current research does show that patient navigation, in general, has resulted in significantly improved patient outcomes and patient satisfaction and has important financial benefits for cancer programs in the fee-for-service and alternative payment model worlds, lending support for more robust staffing of patient navigation programs, he said.

“But if you’re trying to make a business case for financial navigation, probably the biggest bang for your buck is to actually look at the financial return on investment for the provider,” Mr Sherman emphasized. “If you provide financial navigation services at the level that I’ve described, utilizing copay assistance and patient assistance, and also navigating patients through our complicated healthcare system, then you should have 1 full-time employee for every 800 to 1000 oncology patients coming through your system per year.”

In this scenario, the expected return on investment that a financial navigator will generate for the provider should be somewhere between $500,000 and $750,000 per year.

“I work with clients for which that return on investment is significantly higher than this,” he added. “But on average, we should be seeing these types of numbers.”

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Last modified: August 10, 2023

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