Coping With the High Cost of Cancer

Let’s Talk Health Insurance

The majority of people in the United States (91.4%) have a health insurance plan of some kind. Health insurance coverage can be accessed in many ways: through an employer-sponsored plan, the federally funded marketplace, directly from private insurers, or government plans like Medicare and Medicaid. Health insurance coverage serves as the backbone of an American’s experience with healthcare costs when receiving medical care. There are many elements that make up a health insurance policy that require attention and can either serve as a lifeline toward accessing life-saving breast cancer treatment or a barrier. It is extremely important for Americans using the healthcare system to understand as much about their healthcare coverage as possible, thus becoming more informed consumers of care which would lead them toward less costly outcomes.

Where Does Your Health Insurance Plan Come From?

The majority of Americans who are employed will have access to employer-sponsored health insurance plans. Employer-sponsored health plans are offered to employees and their dependents as a benefit of employment. These plans currently provide some level of health insurance coverage for approximately 160 million Americans. Employers choose the plan and determine its benefit structure. Employers and employees typically share the cost of health insurance premiums.

The Affordable Care Act is a comprehensive health care reform law that was enacted in March 2010. The law’s primary goal is to make affordable health insurance available to more people. The law provides consumers with subsidies that lower costs for households with incomes between 100% and 400% of the federal poverty level. For Americans who do not have access to health insurance through an employer, this law has created an insurance marketplace that allows them to explore health insurance plans in their area. One can enroll in a plan during an open enrollment or special election period. Unlike commercially insured plans prior to the Affordable Care Act, insurance options available through the marketplace do not discriminate against people who have preexisting medical conditions, including cancer.

Other government-supported plans including Medicare and Medicaid may also serve as options for Americans who meet specific qualifications. At this time, those age 65 years and older or receiving Social Security disability benefits may qualify for Medicare benefits. Medicaid is available to Americans who meet income (and sometimes asset) requirements. These income requirements may vary depending on the state in which a person resides.

There are many different types of insurance plans and different ways to enroll in one. Most importantly, it is very helpful to understand which of the options listed is the best one and to take advantage of any opportunities to secure coverage designed to reduce cancer care–related costs.

It is also necessary to understand what type of benefits are available through the health insurance plan. This is an important way to become an informed healthcare consumer. Being equipped with valuable information about available health insurance options enhances your ability to prepare for any costs stemming from the cancer care received. When understanding health insurance coverage, it is recommended to identify specific key components of a plan, including plan type, plan premium, medical deductible, maximum annual out-of-pocket costs, office visit copays, and prescription benefits. Many plans will also offer dental and vision coverage. For the purpose of this chapter, the focus is on plan benefits that will most impact coverage for breast cancer treatment-related expenses.

Plan Type

Examples of plan types as defined on healthcare.gov include:

• Exclusive Provider Organization: a managed care plan where services are covered only if the patient uses doctors, specialists, or hospitals in the plan’s network (except in an emergency).

• Health Maintenance Organization (HMO): a type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally will not cover out-of-network care except in an emergency. An HMO may require a patient to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

• Point of Service (POS): a type of plan where the cost is less if the patient uses doctors, hospitals, and other healthcare providers that belong to the plan’s network. POS plans require a referral from your primary care doctor in order to see a specialist.

• Preferred Provider Organization (PPO): a type of health plan where the patient pays less if they use providers in the plan’s network. They can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.

Plan Premiums, Deductibles, Out-of-Pocket Maximums, and Copays

A health insurance plan often includes certain components that determine the costs the insured may be responsible for throughout a year of coverage. Understanding these components will help prepare patients for potential healthcare-related costs that may be incurred as a result of a person’s breast cancer care. These components are defined by healthcare.gov and are listed below:

• Insurance premium: the amount you are responsible to pay for your health insurance plan. Normally this premium is paid monthly, but some plans allow participants to pay on a quarterly or biannual schedule.

• Deductible: The amount you pay for covered health care services before your insurance plan starts to pay.

• Annual out-of-pocket costs: Copayments are fixed amounts paid for a covered healthcare service after the deductible is paid. Coinsurance is the percentage of costs of a covered healthcare service after the deductible is paid. The annual out-of-pocket maximum is the total (coinsurance plus copays) healthcare costs paid during the year.

• Prescription benefits: The majority of health insurance plans also come with prescription benefits. These benefits are managed by a pharmacy benefits manager, who determines the medications that are covered by the plan, as well as how much beneficiaries pay for the medication and the qualifying pharmacies where prescriptions can be filled.

It is important for cancer patients to have a good understanding of their health insurance benefits, as they will be better prepared to manage any bills that may arise due to their breast cancer care. Only considering the premium cost of an insurance policy would be detrimental to gaining the full value of an insurance plan. Over half of the respondents in one survey said they received a medical bill for a cost they thought was covered by their health insurance in the past 12 months, and a similar proportion reported receiving a medical bill saying the amount they owed was higher than expected. Breast cancer treatment can be very expensive, and the care received may include a wide variety of treatments ranging from surgical procedures to chemotherapy to radiation therapy, among many other medical interventions. As a result, health insurance benefits have been proven to play an integral role in covering the costs of these treatments. It is important to understand this role along with the benefits it brings, and the potential costs stemming from any deductibles, copays, and/or coinsurance you may be responsible to pay. An understanding of health insurance coverage is one of the best ways to help reduce financial hardship in the future.

Seeking Transparency in Healthcare Costs

One way to gain a better understanding of the types of healthcare costs associated with breast cancer care is to ask questions about them. In 2009, the American Society of Clinical Oncology’s (ASCO) Task Force on the Cost of Cancer Care identified patient-physician cost communication as a critical component of high-quality care. When patients were asked about their attitudes toward discussions about cost communication, 50% of patients desired these discussions but only 33% actually had them. Any step a patient can take toward a better understanding of the costs associated with their healthcare is beneficial. There is also a level of consumerism associated with health care. A breast cancer patient’s right to be informed of the potential side effects of treatment, along with a plan to address those side effects, is a vital part of a patient’s care plan. If we begin to acknowledge that the cost of such treatment can induce side effects such as financial hardship, it should be just as important to have conversations about healthcare cost transparency. As indicated in the study mentioned earlier, it is unlikely that healthcare providers will have these kinds of conversations with patients, yet they could have a significant impact on the quality of their cancer care experience.

Look Deeper Into the Healthcare System for Financial Assistance

In most healthcare systems there are financial navigators, financial counselors, or financial advocates who are available to provide assistance to cancer patients. Some systems are more developed than others and may have a combination of these specialists. Other systems may employ just one specialist who manages all billing and insurance-related matters. In most cases, one or more of these specialists should be available to help answer questions about health insurance coverage and potential healthcare costs patients may experience when starting their cancer care journey. The same concept that applies to understanding health insurance benefits applies to understanding possible costs that stem from the gaps in coverage as they pertain to the cancer treatment plan. The more a cancer patient understands their healthcare costs, the easier it will be to explore options available to help reduce them. There are often oncology social workers, nurse navigators, or lay patient navigators and public benefits specialists who are available to help patients navigate healthcare-related expenses. Taking an active approach by inquiring about the various resources and healthcare professionals in the system who can help uncover healthcare costs and answer questions about ways to reduce these expenses will go a long way toward reducing the impact of financial hardship, especially for those at most risk to experience it.