Cumulative % Increase 5/20/2015 STRATEGIES FOR ASSESSING THE PATIENT-LEVEL ECONOMIC IMPACT OF CANCER DIAGNOSIS ISPOR 20 th Annual International Meeting -- Philadelphia, PA May 20 th 2015 Workshop Moderators: Amy Davidoff, Don Ekwueme, Veena Shankaran Cancer Care Spending Relative to Overall Healthcare Spending Cancer Drugs Cancer Medical Healthcare US GDP Source: Blue Cross Blue Shield Association 1
Prescription Drugs and Tiered Formularies 2
Financial Impact of Cancer Conceptual Model Patient & Disease Related Factors Baseline financial status Age, income, savings Employment Other fixed expenses Cancer Diagnosis High Out-of-Pocket Spending Medical Non-medical Lost work / income Clinic & Health System Related Lack of cost transparency Limits financial planning No discussion about less costly alternatives Treatment chronicity Financial Hardship Debt Defaults / Liens Foreclosures Depletion of Savings Bankruptcy Lack of financial literacy resources Financial planning Transparency about insurance & disability/employment benefits Treatment urgency Perceived lack of options Uncertain outcomes Worse Clinical outcomes QOL Adherence Survival Lack of consistent access to patient assistance programs Copay assistance Transporation 6 3
Measuring the Economic Impact of Cancer Existing and Emerging Data Sources Populations Types of Measures Advantages and Limitations Future Directions Session Outline Don Ekwueme (CDC) Medical Expenditures Panel Survey (MEPS) Experiences with Cancer Survivorship Supplement National Health Interview Survey (NHIS) Amy Davidoff (Yale) Medicare Current Beneficiary Survey SEER-Medicare / Medicare Part D Health and Retirement Study Veena Shankaran (Fred Hutchinson) SEER-Bankruptcy Linkage (Washington State) Commercial Credit Reports Prospective Questionnaires Interactive Discussion 4
STRATEGIES FOR ASSESSING THE PATIENT-LEVEL ECONOMIC IMPACT OF CANCER DIAGNOSIS Veena Shankaran MD, MS Assistant Professor, Medical Oncology University of Washington Assistant Member, Clinical Research Division Fred Hutchinson Cancer Research Center ISPOR 20 th Annual International Meeting -- Philadelphia, PA Alternative Approaches to Measuring Patient Financial Burden Novel Linkages to SEER Cancer Registry Bankruptcy Records Commercial Credit Reports (TransUnion, Equifax) Home and Property Value (Dataquick) Questionnaires in Development Financial Impact Tool SWOG S1417 COST Measure (Financial toxicity patientreported outcome measure) 1 Kaiser Family Foundation (KFF) 1 De Souza, JA et al. Cancer. 120(20): 3245-53. 2014, Oct. 5
Bankruptcy Example Objectives To determine rate of bankruptcy after cancer diagnosis, compared with the general population To determine cancer-related and other factors that increase risk of bankruptcy Ramsey et al. Health Aff June 2013 32:1143-1152. Bankruptcy Example U.S. Bankruptcy Court, Western District of Washington (UBC-WDW) Records Linked to: Records for cancer cases age 21 identified from Western Washington SEER registry Records for non-cancer cases from LexisNexis, a large and commercially available public record data repository (http://www.lexisnexis.com) 6
Incidence of Personal Bankruptcy (%) Incidence of Personal Bankruptcy (%) Proportion filing for bankruptcy 5/20/2015 Bankruptcy Example 3.0 Bankruptcy Abuse Prevention & Consumer Protection Act 2.5 2.0 1.5 Financial Crisis 1.0 0.5 0.0 Year of Bankruptcy Filing Rate in 13 Western WA counties 1 year after diagnosis 3 years after diagnosis 5 years after diagnosis Bankruptcy Example 3.0 2.5 2.5 2.0 2.0 1.5 1.5 1.0 1.0 0.5 Age at Diagnosis: All cases Cases alive at 1 year 21-44 45-64 65+ 0.0 0.5 Year of Bankruptcy Filing 0.0 Lung N=150 Rate in 13 Western WA counties 1 year after diagnosis Breast Prostate Colorectal Thyroid 3 years after N=194 diagnosis N=129 5 years N=94 after diagnosis N=43 Leukemia/ Lymphoma N=109 7
SEER-Bankruptcy - Limitations Not publicly accessible Single measure of financial hardship i.e. bankruptcy Lack of information about pre-dx financial status Not (yet) linked to claims data Other Linkages to SEER Commercial Credit Reports (TransUnion / Equifax) and Home/Property Value Records (Dataquick) Income indicator Longitudinal data (prior to and following diagnosis) Archived reports can be obtained at any frequency (monthly, quarterly, yearly) 8
Credit Reports and Property Value TransUnion / Equifax (Credit) Current credit score Current balance and payment status for revolving debt (e.g., credit cards) and installment debt (e.g., auto loans) Current balance, interest rate, and payment status for mortgages Current available limits on credit cards Bankruptcies Judgments Liens Collections Repossessions Dataquick (Property) Mortgage amount at origination Mortgage date Date of any notice of delinquency Foreclosure date Ownership and occupancy changes Neighborhood-level home price indexes Payments for rent, utilities, renters insurance Other Methods - Questionnaires Measuring financial burden in real time is critical Identify high out-of-pocket spending on drugs Identify potential non-adherence due to cost Opportunities for financial assistance Identify potential employment issues assistance with disability filings, etc. Quality of life and psychosocial aspects 9
SWOG S1417: Implementation of a Prospective Financial Impact Assessment Tool in Patients with Metastatic Colorectal Cancer Primary Objective: To estimate the incidence of treatment-related financial hardship over 12 months, among patients with newly diagnosed metastatic colorectal cancer (mcrc) treated at SWOG-affiliated NCI Community Oncology Research Program (NCORP) and minority/underserved NCORP sites. SWOG S1417: Implementation of a Prospective Financial Impact Assessment Tool in Patients with Metastatic Colorectal Cancer Financial Impact Questionnaire Health and Retirement Study (HRS) Medical Expenditures Panel Survey (MEPS) Caregiver Strain Index Evercare / National Alliance for Caregiving EORTC QLQ-C30 Linkage with Credit Report Data Corroborate self-reports of financial hardship 10
SWOG S1417: Implementation of a Prospective Financial Impact Assessment Tool in Patients with Metastatic Colorectal Cancer Inclusion Age 18 Able to speak and read English Newly diagnosed metastatic colon or rectal cancer (within 90 days of diagnosis) Planned systemic chemotherapy Willing to give SSN (for credit report linkage) Exclusion Unable to provide written informed consent Palliative or hospice care only (no chemotherapy planned) SWOG S1417: Implementation of a Prospective Financial Impact Assessment Tool in Patients with Metastatic Colorectal Cancer Questionnaire Administration Schedule Baseline Financial/Employment Impact Dx 3 mo 6 mo 9 mo 12 mo Insurance Impact Quality of life Attitudes about treatment cost Caregiver 11
Future Directions Prospective financial toxicity assesssments - SWOG S1417 - COST PRO Out-of-pocket cost apps Future Directions 12
STRATEGIES FOR ASSESSING THE PATIENT-LEVEL ECONOMIC IMPACT OF CANCER DIAGNOSIS ISPOR 20 th Annual International Meeting -- Philadelphia, PA May 20 th 2015 Workshop Moderators: Amy Davidoff, Don Ekwueme, Veena Shankaran INTERACTIVE DISCUSSION Objectives Discuss future strategies/interventions to decrease the financial burden of cancer Discuss additional measures of financial burden 13
Interventions at the National/Policy Level Affordable Care Act Establishment of annual OOP limits No limits on lifetime healthcare spending Pharmaceutical Drug Pricing Value-based insurance design Medicare negotiation of drug prices Clinic-Level Interventions Improve Cost Transparency Patient out-of-pocket costs Total costs for various evidence-based regimens Financial Navigation programs Link patients with available assistance Financial Literacy Financial counseling and budget planning Other ideas? 14
Contact Information Amy Davidoff (amy.davidoff@yale.edu) Donatus Ekwueme (dce3@cdc.gov) Veena Shankaran (vshank@u.washington.edu) 15