Given the rising costs of cancer care, many patients with cancer and cancer survivors are challenged by financial toxicity, the burden of care costs. Many struggle to choose a health insurance plan that best meets their needs. Moreover, these challenges are often exacerbated by limited health insurance literacy and a lack of decision support.
Mary C. Politi, PhD
To help address this critical issue, a group of researchers from Washington University developed a Web-based decision aid and evaluated it in a randomized trial. The ASCO Post recently spoke with the trial’s lead author, Mary C. Politi, PhD, Professor, Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, about the study’s findings and their clinical implications.
Please tell our readers a bit about your research.
My research explores ways to improve our health communication and support people’s decisions when there is uncertainty and two or more options with different pros and cons. There are ways to help people think through those choices and make decisions that are consistent with their personal values and preferences.
What Is ‘I Can PIC’?
How was the I Can PIC tool developed, and how best can it be used?
Years ago, when the Affordable Care Act was first passed, we realized that many people would have access to insurance, some for the first time in the private market. Making insurance decisions is so complicated, even for people who make them each year. We developed a tool for those individuals who were new to health insurance.
As we worked to help support decisions in the broader population, we kept hearing from people with chronic and expensive health conditions like cancer. They struggled to find ways to pay for their care. Some people were choosing insurance plans that looked like a good deal because of a low monthly premium, but those patients ended up having very high bills every time they went to the doctor or filled a prescription. Cancer care can be so expensive for people, and finding the right coverage can make a big difference in their out-of-pocket costs. It can also help them to prepare for what to expect.
So, we developed a cancer-specific tool called “I Can PIC: Improving Cancer Patients’ Insurance Choices.” I Can PIC provides plain language
education about health insurance and care costs and then helps to estimate how much the user might pay for care that year. The cost estimates are based on national averages of how much people pay given their age, gender, cancer type, and other health conditions. You can get an estimate overall and then by insurance plan. It also helps people talk to their doctors and care team about the cost of care, so they can better plan for costs or even ask about making slight adjustments to care plans to reduce those costs.
Please describe the trial’s design, methods, and key results.
We started out working with a team of experts—researchers, clinicians, patients, hospital administrators—people who could tell us what it’s really like to shop for insurance or use insurance to pay for cancer care. Then, we randomly assigned people in the study. We assigned people either to I Can PIC or an American Cancer Society health insurance worksheet. We wanted to learn whether I Can PIC—with the personalized cost estimates and the plain language education about insurance and care costs—did better than a simple worksheet.
Financial toxicity is an issue at the fore of ASCO’s initiatives toward more equitable cancer care. Did your study shed light on this critical challenge?
We found that I Can PIC helped people learn more about health insurance and think about their preferences. Unfortunately, when people told us they wanted to change insurance plans, they often didn’t have any other better options, or they just weren’t yet in open enrollment when they used I Can PIC. So, we didn’t significantly impact financial toxicity, the burden of care costs for people.
We have since adjusted our tool to focus more on the cost conversations patients can have with their care team to lower the costs of some of their care (with or without changing any care details—sometimes it is possible to lower costs without a treatment plan change). We provide a lot of resources to help with care costs. Then, users can go through the insurance selection part if it is relevant to them, if they have other options, or they are in open enrollment. They still learn a lot about how to use insurance to manage care costs and then can choose a different plan if one is available to them. We are currently testing this improved I Can PIC tool in a study of patients with lung, colorectal, or gynecologic cancer. We will have results from that study next year.
Link Between Knowledge and Outcomes?
Have you found any correlation between improving health insurance knowledge and clinical outcomes among community practices?
In other projects, we have found that high health-care costs lead people to delay or avoid needed care. Choosing a good-fit insurance plan to help offset those high costs might improve clinical outcomes.
In our randomized study of I Can PIC, we did not follow people long enough to look at clinical outcomes. Clinical outcomes are determined by so many factors, but it is possible to make a difference in these outcomes. If we can help people afford care, they are less likely to suffer or get hit with surprise bills. In turn, this can help people to stay on track with their needed care. I Can PIC may even take a little bit of a burden off patients while they are coping with an already stressful illness.
More Work to Do
Please share some closing thoughts on this issue.
There is a lot more work to be done to reduce patients’ financial toxicity from cancer. I Can PIC is just one intervention that can help. We also need to focus on system interventions to make care more affordable and ensure people have access to the care they need, at a cost they can afford.
DISCLOSURE: Dr. Politi has received research funding from Merck (for research unrelated to the study discussed in this article).