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Here's Your Cancer Bill, Happy New Year!

Op-Med is a collection of original articles contributed by Doximity members.

As a board-certified radiation oncologist, I’m trained to know all about cancer and its physical effects on people. Similarly, as a board-certified hospice and palliative care physician, I am well-versed in the psychosocial and spiritual trials patients go through, especially at the end of life. But a recent study I read stopped me in my tracks with a disturbing finding: cancer is bankrupting an astounding number of patients.

Adrienne Gilligan, PhD, published her research in the American Journal of Medicine. She found that 42 percent of cancer patients deplete their life savings within two years of diagnosis. This “financial toxicity” — arguably every bit as serious as the emotional and physical toxicity associated with cancer treatment — risks forcing far too many cancer patients to make an agonizing choice between almost certain death and overwhelming debt.

The Advisory Board Company, a Washington, DC-based organization that researches best practices in healthcare and other industries, highlighted in Gilligan’s article that “the direct medical costs from cancer exceed $80 billion in the United States. [The authors] cited previous research finding that up to 85% of cancer patients leave the workforce during their initial treatment, and more than 50% of cancer patients at some point experience bankruptcy, house repossession, loss of independence, and breakdowns in their relationships.”

One observation from this research is even more concerning for those of us in deep east Texas. For more vulnerable populations, like those in Angelina County and the surrounding area, with lower socioeconomic status and clinical factors such as smoking and poorer health, the risk of asset depletion is even greater. Even for those with health insurance, deductibles and copayments, costs for supportive care, as well as non-medical or indirect costs (e.g., travel, caregiver time, and lost productivity) may be financially devastating.

I see this financial burden all of the time. Monthly, I get reports from my billing office that patients are not paying despite multiple contacts. Most of the time, these are deductibles and copays that patients — who live paycheck to paycheck and who have no savings to start with — are never going to be able to pay. Sometimes it is the entire bill, in the case of uninsured and indigent patients. As a physician, I really only have two options: send them to a collection agency (that will try to get whatever proverbial blood out of the turnip they can), or write them off. That my patients should suffer not only with a cancer diagnosis and treatment side effects but also possible bankruptcy is absurd. I am rightfully appalled and angered that our federal healthcare reimbursement system and the private insurance complex have achieved “cost savings” by placing more and more of the financial burden onto patients, who are simply unable to pay. The bankruptcy monster is always at the door.

Doctors are familiar with the Latin phrase primum non nocere: “first, do no harm.” The idea is really that we should balance the risks of treatment with the benefits. I imagine when that phrase was coined the author did not have financial harm in mind. Today, it has become one of the most important “risks” when weighed against the hoped-for gains of treatment. Unfortunately, the provision of healthcare has become a commodity and providers have been reduced to revenue-producing cogs on the wheel in a system that has replaced the patient’s needs with productivity metrics. The profession of medicine is less and less in charge of the provision of medicine.

In spite of this new reality, healthcare providers — doctors, hospitals, etc. — must recognize that the mission of any healthcare organization is, first and foremost, health, not profit. When profit alone drives healthcare decisions, the cart is before the horse. And forcing patients into bankruptcy with draconian billing and collection policies benefits no one (except maybe collection agencies). Accounts that have little chance of being paid need to be written off quickly and completely.

In hospital systems, some critical services — for example, social work, patient navigation, discharge planning — may have no direct link to the bottom line in terms of a reimbursable, codable procedure or office visit, but nonetheless have a profound impact on preventing financial losses by impacting readmission rates and avoidable costs. In addition, finding sources of payment for patients can bring dollars in that would otherwise not be seen. These services must not only continue, but expand.

Ultimately, legislators need to change the way healthcare services are valued and reimbursed so that the increasingly unmanageable financial burden that falls on everyone — even the insured, and the hardworking — doesn’t bankrupt us all. This isn’t about patient responsibility; it is about preventing personal financial catastrophe. And now it’s January with high deductibles and never-ending copays to meet. I’m afraid we are in for a bumpy ride. Happy New Year!

Dr. Sid Roberts is a radiation oncologist and hospice physician in Lufkin, Texas.

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