By Jeremy Schafer, senior VP; Precision for Value and Deborah Lotterman, chief creative officer, precisioneffect

Back 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 financial 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 chip in.

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 patient-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 Managed Care showed that worsening patient health outpaces 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 associated with each phase of disease illuminates a more complete picture of patient and caregiver experience. Highlighting both hard costs (eg, prescriptions, surgical interventions, rehabilitation services, copays) and soft costs (eg, increased child care, transportation, 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.

Capturing these costs in a patient journey makes the journey more relevant and is crucial to providers, 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 financial side effect management

Ultimately, our new concept of financial toxicity bumps up against the current buzzword, patient-centricity. 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 family-based resources.

Practitioners are accustomed to managing side effects of medication, but little in their training gives them to tools to address financial toxicity. Surfacing the incidence via an enriched patient journey and developing management techniques provide an opportunity for marketers to offer a more complete solution for care.