ack in the halcyon days of pharma marketing, the formula was pretty simple:
stick to the outcome. With insert brand
name here, patients would move from
misery to a bright, shiny future in 60
seconds. Price was generally not an issue – patients
often had low copays, if any cost share at all. At most,
some drugs included a short mention of assistance, “If
you have trouble affording your medicines, insert company name here may be able to help…”.
Today, we live in a very different world. Upheaval in
the economy, advances in precision medicine, the rise
of novel therapies, and the financing of care including
significant cost shifting to patients is giving rise to a new
dynamic we call financial toxicity. Financial toxicity is an
economic side effect that can actually impact outcomes
whereby patients forego care or make trade-offs to finance treatment of one condition but not another.
The rise of ;nancial toxicity
Who pays for care could be considered a moving target,
although it is clearly moving with speed and ferocity toward the patient. A 2014 World Bank report found that
the United States spent $9,403 per citizen on healthcare, a significant and steady rise from the $3,788 the
country spent in 1995. A follow-up PBS news report
in July 2016 estimated the 2016 healthcare spend per
capita at $10,345.
With employers and the government unable to cover
all the costs, the patient is increasingly called upon to
Pharmacy Benefit Management Institute’s 2017
Trends in Specialty Drug Benefits Report found that
coinsurance, requiring members to pay a percentage of
healthcare costs versus a traditional flat copay, is gaining popularity. Deductibles are growing too. Kaiser
Family Foundation’s 2016 Employer Health Benefits
Survey found that deductibles - 80 percent of employees have one - have grown from roughly $600 in 2006
to nearly $1,500 in 2016.
The traditional pharma go-to strategy in this high pa-
tient-cost scenario – co-pay assistance programs – is less
effective now with PBM cost-share programs precluding
assistance from contributing toward a patient’s deductible.
Financial toxicity can overwhelm even the most
significant health benefits of a medication by driving
patients to skip their medications. The relationship
between cost and nonadherence has been studied numerous times and has repeatedly found that with rising
patient costs, adherence drops. A CVS Health survey of
2,400 pharmacists found that cost was the most common barrier to patients staying adherent.
Forgoing medication has a cost as well, with one
study in the August 2016 American Journal of Man-
aged Care showed that worsening patient health out-
paces any savings.
Quite simply, the erosion of adherence impacts
patient health and brand revenue. Financial toxicity cannot be ignored. Yet the cost of care has rarely been treated in the exam room. Pharmaceutical
companies intent on bringing new therapies to patients need to facilitate the conversations that can
emerge when financial toxicity disrupts treatment
and affects outcomes.
Evolving the patient journey
The patient journey is an invaluable tool in understanding financial toxicity; it draws upon deep research with patients to reveal both the overarching
phases and the key decision points in the natural history of a disease. Over the past several years, marketers have relied on patient journey research to tease
out the psychological, social, and emotional impacts
of disease. As cost increasingly influences patient
decisions, however, the traditional patient journey
can completely miss why patients fail to hit journey
milestones and access key treatments.
Imagine the journey of a newly diagnosed patient
with metastatic breast cancer. The journey will likely
include extensive radiation therapy, surgery, and at
least monthly doctors appointments. A traditional
patient journey maps out these events together with
insights on how it impacts the patient’s emotional
and social well-being.
When we layer in the cost, the journey reveals a
potent new aspect of the true burden of disease. Radiation therapy in the first year costs, on average,
more than $33,000 according to a study in the September 2015 Journal of Oncology Practice. Monthly doctors appointments add up to another $1,800
per year, shows a study published in August 2014
in the International Journal of Breast Cancer. Surgery, if needed, is nearly $27,000 in the first year,
according to a study in the February 2016 American
Health Drug Benefits. Finally, a study in the August
2015 Journal of Comparative Effectiveness shows
that medication therapy can approach, or exceed,
$10,000 per month.
Even with insurance, these costs are substantial both
to the patient and the payer. Patient journeys are not
complete without at least making stakeholders aware
of the expenses the patient and payer may incur.
We are finding that investigating the costs associ-
Capturing these costs in a patient journey makes
ated with each phase of disease illuminates a more
complete picture of patient and caregiver experience.
Highlighting both hard costs (eg, prescriptions, sur-
gical interventions, rehabilitation services, copays)
and soft costs (eg, increased child care, transporta-
tion, skin care) helps us understand the additional
stress and potential trade-offs patients are making.
Illness remains a leading cause of bankruptcy, with
patients often describing the burden of financial
planning throughout their journey.
the journey more relevant and is crucial to provid-
ers, patients, and payers in understanding the full
course of a disease for a patient.
The resulting greater dimensionality can help
marketers design better informed services and nuanced messaging – not just to patients but also to
providers to help with what have traditionally been
difficult conversations around cost.
Uncovering the opportunity in
;nancial side e;ect management
Ultimately, our new concept of financial toxicity
bumps up against the current buzzword, patient-cen-tricity. To be fully patient-centric, a company must
develop a more comprehensive understanding of the
total impact of treatment, including financial stress.
While financial toxicity is deeply felt on a patient
level, it can also be seen on a population level as payers struggle to contain costs. Providers and hospitals
feel it as well when patients are late on payments,
or do not pay at all. The solutions will require engagement from all stakeholders: patients, providers,
manufacturers, and payers.
At the outset, there needs to be an understanding that “affordability” is a relative concept. What is
“cheap” to some is “expensive” for others. Programs
like per-claim caps, out-of-pocket maximums, and
identification of health plan members at risk represent an important step.
Price increases cannot just be “taken.” Manufacturers need to be clear-eyed about the fact that costs
are increasingly being passed to patients. In addition, a co-pay program may not be able to make up
the difference, particularly for patients under PBM
cost-share programs or on government insurance.
This should influence decisions and communications about price increases.
At the point of care, providers, in addition to all
their other responsibilities, need to have (or train
staff to have) honest conversations with patients
and their families around proposed therapy and its
attendant costs. How can HCPs help guide patients
in making choices? What resources can they point
patients toward? This represents an opportunity for
marketers to offer significant value in training, tools,
identification, and development of financial and
Practitioners are accustomed to managing side ef-
fects of medication, but little in their training gives
them to tools to address financial toxicity. Surfac-
ing the incidence via an enriched patient journey
and developing management techniques provide an
opportunity for marketers to offer a more complete
solution for care. medadnews
Enriching the patient journey: When cost creates side e;ects
The Pulse of the Pharmaceutical Industry