Karma L. Kreizenbeck

Washington State Cancer Patients Found To Be At Greater Risk For Bankruptcy Than People Without A Cancer Diagnosis

Much has been written about the relationship between high medical expenses and the likelihood of filing for bankruptcy, but the relationship between receiving a cancer diagnosis and filing for bankruptcy is less well understood. We estimated the incidence and relative risk of bankruptcy for people age twenty-one or older diagnosed with cancer compared to people the same age without cancer by conducting a retrospective cohort analysis that used a variety of medical, personal, legal, and bankruptcy sources covering the Western District of Washington State in US Bankruptcy Court for the period 1995-2009. We found that cancer patients were 2.65 times more likely to go bankrupt than people without cancer. Younger cancer patients had 2-5 times higher rates of bankruptcy than cancer patients age sixty-five or older, which indicates that Medicare and Social Security may mitigate bankruptcy risk for the older group. The findings suggest that employers and governments may have a policy role to play in creating programs and incentives that could help people cover expenses in the first year following a cancer diagnosis.

Pilot Feasibility Study of an Oncology Financial Navigation Program

BACKGROUND Few studies have reported on interventions to alleviate financial toxicity in patients with cancer. We developed a financial navigation program in collaboration with our partners, Consumer Education and Training Services (CENTS) and Patient Advocate Foundation (PAF), to improve patient knowledge about treatment costs, provide financial counseling, and to help manage out-of-pocket expenses. We conducted a pilot study to assess the feasibility and impact of this program. METHODS Patients with cancer received a financial education course followed by monthly contact with a CENTS financial counselor and a PAF case manager for 6 months. We measured program adherence, self-reported financial burden and anxiety, program satisfaction, and type of assistance provided. RESULTS Thirty-four patients (median age, 60.5 years) were consented (85% white and 50% commercially insured). Debt, income declines, and loans were reported by 55%, 55%, and 30% of patients, respectively. CENTS counselors assisted most often with budgeting, retirement planning, and medical bill questions. PAF case managers assisted with applications for appropriate insurance coverage, cost of living issues (eg, housing, transportation), and disability applications. High financial burden and anxiety about costs (4 or 5 on a Likert scale) were reported at baseline by 37% and 47% of patients, respectively. Anxiety about costs decreased over time in 33% of patients, whereas self-reported financial burden did not substantially change. CONCLUSION Implementing an oncology financial navigation program is feasible, provides concrete assistance in navigating the cost of care, and mitigates anxiety about costs in a subset of patients. Future work will focus on measuring the programs impact on financial and clinical outcomes.

Value in cancer care: Regional initiative to improve care through data reporting and interventions.

34 Background: In the context of many initiatives aimed at measuring quality and value in cancer care, the Hutchinson Institute for Cancer Outcomes Research (HICOR), partnered with community members to launch a regional, stakeholder-driven initiative to define and report value metrics for cancer care for Washington State. Region-wide Summits were held in 2014 and 2015. Participants included local healthcare delivery organizations, patient advocacy groups, payers, and policymakers. The 2014 Summit identified priority metrics; these metrics were reported at the 2015 Summit. METHODS For the 2015 Summit, HICOR staff developed algorithms to measure adherence to the community-prioritized metrics using a claims-registry linked database. Metrics spanned diagnosis, treatment, continuing, and end-of-life (EOL) phases of care. After reviewing adherence at the clinic-level and for the region, attendees were invited to attend break-out sessions for metrics where there was the largest variation: hospital and ED use during treatment, hospital and ED use at EOL, and breast cancer surveillance. Within the breakout sessions, participants were asked to identify barriers to adherence and possible interventions to improve care. After discussion, participants individually ranked the top 3 interventions and estimated expected improvement to be gained by successful implementation of the intervention Results: Table. Working groups were formed to develop detailed protocols for implementable interventions. CONCLUSIONS Using an iterative, transparent, multi-stakeholder process, it is feasible build regional consensus to identify and prioritize value metrics in cancer care, and to develop consensus regarding approaches to improve adherence to those metrics. [Table: see text].

Characterizing Potentially Preventable Cancer- and Chronic Disease–Related Emergency Department Use in the Year After Treatment Initiation: A Regional Study

PURPOSE As new quality metrics and interventions for potentially preventable emergency department (ED) visits are implemented, we sought to compare methods for evaluating the prevalence and costs of potentially preventable ED visits that were related to cancer and chronic disease among a commercially insured oncology population in the year after treatment initiation. METHODS We linked SEER records in western Washington from 2011 to 2016 with claims from two commercial insurers. The study included patients who were diagnosed with a solid tumor and tracked ED utilization for 1 year after the start of chemotherapy or radiation. Cancer symptoms from the Centers for Medicare & Medicaid Services metric and a patient-reported outcome intervention were labeled potentially preventable (PpCancer). Prevention Quality Indicators of the Agency for Healthcare Research and Quality were labeled potentially preventable-chronic disease (PpChronic). We reported the primary diagnosis, all diagnosis field coding (1 to 10), and 2016 adjusted reimbursements. RESULTS Of 5,853 eligible patients, 27% had at least one ED visit, which yielded 2,400 total visits. Using primary diagnosis coding, 49.8% of ED visits had a PpCancer diagnosis, whereas 3.2% had a PpChronic diagnosis. Considering all diagnosis fields, 45.0%, 9.4%, and 18.5% included a PpCancer only, a PpChronic only, and both a PpCancer and a PpChronic diagnosis, respectively. The median reimbursement per visit was

End-of-Life Services Among Patients With Cancer: Evidence From Cancer Registry Records Linked With Commercial Health Insurance Claims

735 (interquartile ratio,

Regional initiative to use data transparency to improve cancer care.

194 to

Regional engagement to define, report, and use quality metrics to improve palliative care in oncology.

1,549). CONCLUSION The prevalence of potentially preventable ED visits was generally high, but varied depending on the diagnosis code fields and the group of codes considered. Future research is needed to understand the complex landscape of potentially preventable ED visits and measures to improve value in cancer care delivery.

Measuring adherence to a Choosing Wisely recommendation in a regional oncology clinic.

PURPOSE Despite guidelines emphasizing symptom management over aggressive treatment, end-of-life care for persons with cancer in the United States is highly variable. In consultation with a regional collaboration of patients, providers, and payers, we investigated indicators of high-quality end-of-life care to describe patterns of care, identify areas for improvement, and inform future interventions to enhance end-of-life care for patients with cancer. METHODS We linked insurance claims to clinical information from the western Washington SEER database. We included persons ≥ 18 years of age who had been diagnosed with an invasive solid tumor between January 1, 2007, and December 31, 2015, and who had a recorded death date, were enrolled in a commercial plan for the last month of life, and made at least one insurance claim in the last 90 days of life. RESULTS In the last month of life, among 6,568 commercially insured patients, 56.3% were hospitalized and 48.6% underwent at least one imaging scan. Among patients younger than 65 years of age, 31.4% were enrolled in hospice; of those younger than 65 years of age who were not enrolled in hospice, 40.5% had received an opioid prescription. Over time, opioid use in the last 30 days of life among young adults not enrolled in hospice dropped from 44.7% in the period 2007 to 2009 to 42.5% in the period 2010 to 2012 and to 36.7% in the period 2013 to 2015. CONCLUSION Hospitalization and high-cost imaging scans are burdensome to patients and caregivers at the end of life. Our findings suggest that policies that facilitate appropriate imaging, opioid, and hospice use and that encourage supportive care may improve end-of-life care and quality of life.

Using cancer registry records linked with health insurance records to measure costs and services at end-of-life.

39 Background: In the context of many initiatives aimed at measuring quality and value in cancer care, the Hutchinson Institute for Cancer Outcomes Research (HICOR) has adopted a multi-stakeholder approach to characterize oncology care, prioritize areas for improvement, design programs, and evaluate outcomes. Beginning in 2014, HICOR initiated a process to move towards data transparency in the reporting of regional quality and value metrics. METHODS The HICOR team constructed clinic-level adherence reports for community-prioritized metrics and the 2012 ASCO Choosing Wisely recommendations using a registry-claims linked database. In the fall of 2014, a national external advisory board reviewed methodology for measuring adherence. De-identified regional results were presented at a provider meeting in late 2014 to elicit provider feedback on methodology and on strategies for reporting clinic-identified adherence. Clinics were privately given their own adherence data. In 2015, revised de-identified regional reports were presented at a Value in Cancer Care Summit poster session and made available through HICOR IQ, a regional oncology informatics platform, for further discussion. RESULTS Results show that no clinic was also the best or worst performing clinic. The table shows the performance by clinic for the 5 Choosing Wisely recommendations. There is now increased demand by clinics to view their own adherence benchmarked with the region as a next step in moving towards full data transparency. Additionally, there is support from provider members in the community to re-identify clinics in order to compare results against their peers. CONCLUSIONS Using an iterative, transparent, multi-stakeholder process, it is feasible build regional consensus towards releasing clinic-level adherence to quality and value metrics. By consulting trusted experts in the field and allowing multiple opportunities to provide feedback, providers are requesting even more transparency in order use the oncology measures to improve care in their practice and the region. [Table: see text].

Health care utilization and costs at end of life among patients with leukemia or lymphoma in a regional cancer registry-insurance claims linked database.

282 Background: Palliative care in oncology encompasses a wide array of care, and optimal performance metrics remain uncertain. To address this issue we held a regional meeting that included patient advocates, clinicians, private and public payers and researchers to identify quality indicators for palliative care, discuss palliative care (PC) quality measurement in the region, review preliminary results and metrics for PC, and identify opportunities to improve care. METHODS Regional experts facilitated discussions. Data was presented from a regional insurance claims-cancer registry linked database. Participants were asked to: discuss and prioritize interventions to improve palliative care in oncology and create metric dashboards for healthcare providers. RESULTS Oncology-specific recommendations for interventions: early and continuous palliative care discussions from diagnosis through EOL; training existing care team on palliative care conversations, through standard certification programs; pair patients with an experienced patient/patient advocate; educate caregivers, patients and providers respectively on how to communicate about PC and care choices; and patient navigation to manage symptoms of advanced cancer. Feedback on prioritization of palliative care/EOL metrics: see Table. CONCLUSIONS A multi-stakeholder approach can be effective for developing metrics and interventions to improve palliative care by providing an understanding of the information needs of the community. [Table: see text].