Cancer resource center of the desert patient navigator program: removing financial barriers to access to cancer care for rural Latinos.

0.2 MB·English

by  Peacher, Diana

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a SpringerOpen Journal
SHORT REPORT Open Access
Cancer resource center of the desert patient
navigator program: removing financial barriers to
access to cancer care for rural Latinos
Diana Peacher1*, Helen Palomino2, Eunjeong Ko3* and Susan I Woodruff4
Abstract
Background: Healthdisparitiesin cancer mortality for racial/ethnic minoritiesis a public health concern. Financial
barriers are themajor factors preventing cancer patients from accessing treatment in a timely manner. Thisarticle
describes the characteristicsof theCancer Resource Center of the Desert (CRCD) Patient Navigator Program (PNP)
inthe rural underserved US-Mexico border region of theImperial Valley. Financial navigation services and the
insurance conversion process for cancer treatmentare described.
Findings: CRCD data from 2010 to 2011 were analyzed to report the characteristics of cancer patients, focusing on
insurance status changes.Eighty-one to 87% of thepatientsserved were Latino/Hispanic. A case scenario is
presented to depict thefinancial navigation process in converting the patients’insurancestatus. Among thetotal
samples, about 7% (n=32) in2010 and 16% (n=68) in2011 were in need of health insuranceassistanceupon their
intake. Financialnavigators successfully converted virtually all non- or inadequately-insured rural cancer patients to
better insurance status.
Conclusion: Financial concerns are a significant thread thatruns throughout the diagnostic, treatment, and post
treatment journey of cancer patients. The complicated nature of patients’circumstances and medical systemsoften
hinders the patients going through theinsuranceconversion process. PNP plays a critical role inbridging thegap
between patients and medical systems thus promoting cancer treatment access for this vulnerable population.
Introduction multiple barriers to timely cancer care due to financial,
Health disparities in cancer mortality for racial/ethnic structural, personal, and cultural factors (American
minorities is a public health concern (American Cancer Cancer Society 2009). Latinos are more likely to work in
Society 2009). Further, minority individuals living in low wage jobs (e.g., agricultural and domestic work) and
rural areas face additional unique challenges related to are less likely to have health insurance than any other
healthcareaccess,includinglimitedhealthcarefacilities, ethnic group (American Cancer Society 2009). Among
physical distance, low socio-economic status, and rural subgroupsofHispanic/Latinos,Mexican Americans have
or cultural practices associated with health behaviors a higher percentage of poverty, less education, and a
and beliefs (Beyer et al. 2011; Eberhardt and Pamuk greater likelihood of no regular source of medical care
2004). The stage of cancer at diagnosis also differs by (American Cancer Society 2009). Inequities and dispar-
urban/rural status, with individuals who live in rural ities in access to health care may increase the cancer
areas more likely to be diagnosed with cancer at a later burden forthis at-riskpopulation,andheightentheneed
stage (Schootman et al. 2003) and less likely to utilize forpublichealtheffortstoreducethesebarriers(American
cancer screening (Coughlin et al. 2002) than people res- CancerSociety2009).
iding in urban regions. Latinos, in particular, may face
Cancernavigationprogram
*Correspondence:[email protected];[email protected] The concept of the Patient Navigation Program (PNP)
1CancerResourceCenteroftheDesert,444So.8thStreetSte.B-3,ElCentro,
was first introduced in the 1990s by Dr. Harold Freeman
CA92243,USA
Fulllistofauthorinformationisavailableattheendofthearticle as an intervention to reduce barriers among African
©2013Peacheretal.;licenseeSpringer.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommons
AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproduction
inanymedium,providedtheoriginalworkisproperlycited.
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American and Latino breast cancer patients in Harlem, PNP should address cultural diversity and competence
NY (Freeman 2006). The program aims to reduce the (Han et al. 2009; Petereit et al. 2008; Steinberg et al.
barriers that impede cancer patients’ access and 2006).
utilization of health care prevention, diagnostic and
treatment services, and aims to ensure that these are Cancerresourcecenterofthedesert(CRCD)patient
received in a timely manner (Robie et al. 2011), thus navigatorprogram(PNP)
filling the gap between “discovery and delivery” of health The Cancer Resource Center of the Desert (CRCD) was
careservices. established in Imperial County in September, 2006, to
Freeman (2004) indicated that the major determinants educate, guide, and empower the cancer patient and
that contribute to this gap include culture, poverty, and family through the cancer journey in a non-hospital
social injustice. Barriers associated with these factors based setting. Imperial County, California, is a desert re-
contribute to the persistent nature of health disparities. gion that is heavily based on agriculture. It is located in
Culturalbarriers found inthe scholarlyliterature include the southeast corner of California on the US/Mexico
healthliteracy,languageissues,andculturalbeliefsabout border. Over 75% of the population in Imperial County
cancer and cancer care (Freeman and Chu 2005). is Hispanic/Latino, many of whom are first generation
Poverty-related barriers include financial deficits, poor immigrants. It is the poorest county in the State and has
communication between health care providers and the highest unemployment rate at 28% (Imperial County
patients, transportation concerns, and fragmented med- Public Health Department 2008). Not surprisingly,
icalcare(FreemanandChu2005).Inparticular,financial statistics indicate that in 2005, 34% of Imperial County
barriers are the major factors preventing cancer patients adult residents were uninsured all or part of the year as
from accessing treatment in a timely manner (Lin et al. compared to 25% statewide (Imperial County Public
2008).Socialinjusticereferstostructuralbarriersinclud- HealthDepartment2008).Comparedtotheoverallstate,
ing racial discrimination and bias that disproportionately about twice as many Imperial County adult residents
affects access to health services for certain populations 19–64 years of age are Medicaid beneficiaries (Imperial
(Freeman and Chu 2005). These factors are interrelated County Public Health Department 2008). The region is
and taken as a whole, can significantly affect a range of vastly medically underserved (Office of Statewide Health
health care services and outcomes, including prevention, Planning and Development OSHPD 2010). For example,
posttreatmentmanagement,andevenmortality(Freeman although the leading cause of death in Imperial County
and Chu 2005; Freeman and Vydelingum 2006). Racial/ is cancer (American Cancer Society 2009), cancer
ethnic minority status, combined with these barriers, resources are extremely limited in that there is only one
places these individuals at a greater risk for experiencing cancer center inthe4,500square mile county.
healthdisparities. Due to the unique characteristics of the area and
A number of previous studies found positive outcomes population, the CRCD established a PNP as part of its
associated with the Patient Navigation Program. It has services. The CRCD PNP is unique in that it has been
been shown to be beneficial in increasing patients’ can- designed to address specific needs and cultural barriers
cer knowledge (Schlueter et al. 2010), decreasing emo- in the region. Some of the specific aspects of cancer care
tional distress (Davis et al. 2009; Ferrante et al. 2008; that the PNP must address include: (a) bi-national
Schlueter et al. 2010), and increasing emotional support healthcare, insofar as many of those in Imperial County
(Carroll et al. 2010; Schlueter et al. 2010). The program are initially diagnosed and receive some treatment in
also is noted to have increased patients’ completion of Mexico, (b) lack or inadequate insurance to pay de-
cancer screenings (Chen et al. 2008; Jandorf et al. 2005), ductibles, co-pays, and insurance premiums, (c) lack of
timeliness to diagnosis after abnormal cancer screenings transportation to and from diagnostic and treatment
(Ferrante et al. 2008), and increased adherence to visits both within the county and out-of-county, (d) lack
follow-up treatments (Ell et al. 2007) by providing of culturally appropriate care (e.g., bilingual health care
transportation services, education, assistance with ap- workers), and (e) geographical and climatic extremes
pointments, and coordination of services. The effects of including long distances from care and temperatures
PNP are greater when navigators are community that can well exceed 100°F much of the year. For any or
members (Steinberg et al. 2006). Community member all of the foregoing reasons, patients often skip, delay, or
navigators are resourceful in recognizing and addressing completelyforego effective cancer treatment.
culture related barriers (e.g., health beliefs, language bar- Although CRCD PNP provides patient education,
rier) and play an important role in connecting commu- counseling, case management, and community outreach
nities and facilitating dialogues between patients and and education, it has found that that one of the most
members of the health care system. Hence, there has critical needs is “financial navigation.” While financial
been a growing recognition that the development of a navigation can include assistance and advice about
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personal budgets, taxes, financial strategies, and credit Social Work, and each have six years of experience in
options, improved insurance coverage has been the most cancer navigation.
successful financial approach for this population to Upon arriving at the CRCD office, patients are greeted
relieve the monetary stress or hardship associated with and assisted by staff. The first visit typically involves
cancer treatment. Because no insurance or inadequate usinganIntakeFormtoassesstheclient’sneeds,including
insurance profoundly affects patients’ timely treatment, theirhealthinsurancestatus.
the CRCD PNP focuses resources on mitigating or elim- If financial navigation is needed, steps to convert non-
inating potential barriers to treatment caused by lack of insured or inadequately insured to adequate insurance
adequate insurance coverage. This manuscript describes status begins immediately. Examples of issues that
the CRCD PNP clients and the results of its financial navigators consider in assisting patients for insurance
navigationefforts. conversioninclude:
CRCDPNPprogramdescription 1.Isthe patient insured?Ifnot,dothey qualifyforany
The CRCD PNP is focused on intervention for the indi- MediCal(California’sMedicaid program)category?
vidual across the cancer continuum, supporting clients 2.Ifinsured,whatisthe‘cap’forthepatient’scoverage?
who are newly diagnosed as well as those already in Isthe coverageemployer-provided?Willthepatientbe
treatment. Although it is hard to estimate the number of abletokeep the coverageshouldhe/shebecome
patients in the Imperial County catchment area who disabledforlongerthanwhattheemployer allows?
would need CRCD services, the American Cancer 3.Isthe patient coveredunderthe Imperial County
Society 2009 estimates about 500 new cancer cases each MedicalServices Program (CMSP)?Thisisapotential
year in Imperial County. CRCD PNP has served over barrier toanytreatmentoutsideofImperialCounty,as
1,300unduplicated patientssinceSeptember 2006. therearenoneighboringcountiesthataccept this
Funding for CRCD is provided primarily through insurance. Thiscoverageisalsovery limited withmany
fundraising activities, donations through the Combined diagnostictestsand medicationsnotcovered.
Federal Campaign (Federal United Way), and local foun- 4.IfthepatienthasCMSPorstateMediCal,whatis
dation grants all totaling $186,634 in 2011. Office space his/her shareofcost?Thismonthlyshareofcost can
and utilities are provided in-kind by the local Pioneers rangefrom afew dollarstothousandsofdollarsper
Memorial Hospital. Cancer patients and their families month.Navigatorsassistwith theapplicationand
are referred by word of mouth from other cancer mitigationofthe shareofcost.
patients in treatment, as well as referrals from the local 5.Isthe patient eligibleforMediCalfortheAged,
radiation clinic, the two local hospitals, local home health Blind,and Disabled,specialprogramsthatwouldfully
and community agencies, and the County Department of cover diagnostictestsand procedures?
SocialServices. 6.DoesthepatienthavestateMediCal undera“family”
The only eligibility requirement for CRCD services is code which iscontingentuponthefamily income and
anactive cancerdiagnosis. minor children?Navigatorsexplore whetheritwould
Patients who report experiencing barriers to cancer beadvantageousforpatientstoapply forMediCal
care are all eligible for enrollment in PNP. Five types of under adifferentcode. Bydoing this,anychange tothe
barriers to cancer care are assessed: (1) Financial/insur- familydoesnotchange theirMediCalstatus.
ance barriers which refer to financial need or no/inad- 7.DoesthepatientqualifyforCalifornia’sBCCTP
equate health insurance benefits to cover treatment (Breastand CervicalCancerTreatment Program) or
costs; (2) Transportation barriers, which refer to a need IMPACT(ImprovingAccess,Counseling,and
for public and/or private transportation assistance; (3) TreatmentforCalifornianswith Prostate Cancer)?
Communication/cultural barriers, which include ThesearespecialstateMediCalprogramsthat serveas
language barriers, health literacy, and communication safeguards forcancer patientswhoare uninsured or
issues with health care providers related to diagnosis underinsured.
and treatment; (4) Physical needs which include, assist-
ance with housing, food, prosthesis, and extended care; As an example of the types and breadth of financial
and (5) Other needs such as referral for mental health navigation provided by the CRCD PNP, we provide a
counseling. description of an actual patient. This patient had
CRCD’s PNP is staffed by two full time navigators. employer-provided health insurance but its coverage
Both Patient Navigators are bilingual speakers in English would cap out during her hospital stay when she was re-
and Spanish; one is certified in the Patient Navigator ferred to CRCD. Mrs. P., a married non-English
program by the Harold P. Freeman Institute, New York. speaking, immigrant farm worker of Mexican descent
Both hold degrees in the field of Human Services or was admitted to the emergency room of the local
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Imperial Valley hospital with severe abdominal pain. the patient was considered terminal, the patient was
While hospitalized, it was found that she had stage III given presumptive State MediCal by the County. Since it
colon cancer. The social worker referred the patient to is Presumptive only, the share of cost continued to be
CRCD for psychological counseling, cancer education, charged to the patient until a final determination was
and financial navigation services. CRCD followed up by made by the state. Once the state made the determin-
contacting the patient while she was in the hospital, and ation, the budget was re-worked to accommodate a
family members came to the CRCD office to initiate
enrollment in CRCD PNP navigation. Upon discharge Table1Characteristicsofcancerpatientsreceiving
from the hospital, Mrs. P. met with CRCD staff for servicesattheCRCDPNPin2010and2011
further needs assessment. The navigator identified Participantcharacteristics n(%)
multiple issues that could impact the patient’s course of 2010 2011
treatment: (a) both the patient and her husband had (n=457) (n=428)
limited knowledge about her cancer diagnosis, the Age
course of treatment, and her prognosis; (b) her insur- 0–19 11(2) 11(2.6)
ance coveragewaslimited andhad cappedwhileshe was 20–39 23(5) 25(5.8)
in the hospital; and (c) she would no longer be able to
40–49 45(10) 64(15.0)
work, thus changing the family income and ability to
50–59 95(21) 105(24.5)
pay out of pocket expenses. With the given
circumstances, the imminent issues Mrs. P. faced were: 60–69 104(23) 94(22.0)
the continuation of her medical follow-up and 70andolder 136(30) 102(23.8)
treatments including seeking consultations from Unknownage 43(9) 27(6.3)
specialists in another county; completion of diagnostic
Gender
tests; adherence to cancer treatment; and medication
Female 276(60) 266(62.2)
management.
First Step: Based on the CRCD financial navigator’s Male 181(40) 162(37.8)
assessment of the patient’s income, assets, and property Race/Ethnicity
holdings,thefinancialnavigatorfacilitatedanapplication Latino 370(81) 371(86.7)
for MediCal. By applying before the end of the month, Whitenon-Latino 69(15) 42(9.8)
MediCal coverage extended retroactively to the first day
AfricanAmerican 10(2) 10(2.3)
of the same month, thereby acting as secondary insur-
Asian/PacificIslander 7(2) 2(0.5)
ance until the primary’s cap was reached. Within 48
Other 1(0.1) 3(0.7)
hours of the submission of the application, Mrs. P. was
found to qualify for County MediCal (CMSP). Regard- MajorTypesofCancer
less, insurance barriers remained. CMSP is limited to in- Breast 142(31) 141(32.9)
county coverage only and, while Mrs. P. was deemed to Blooda 64(14) 56(13.2)
be medically needy, she had a $700 monthly share of
Prostate 49(11) 45(10.5)
cost or co-pay because the family income exceeded the
Colorectal 44(10) 38(8.9)
program limit by $700. This monthly out of pocket ex-
Lung 30(7) 21(4.9)
pense must be paid first, before CMSP pays the
provider. Pancreatic 12(3) 15(3.5)
Second Step. Given the severity of Mrs. P’s cancer Cervical 11(2) 12(2.8)
diagnosis and inability to resume her work as a farm Other/unknown 105(23) 100(23.4)
worker, CRCD financial navigators concurrently faci-
PrimaryLanguage
litated an application for the special MediCal category
English 178(39) 157(37)
for the Aged, Blind, and Disabled, and also for Social
Spanish 279(61) 271(63)
SecurityDisability Insurance(SSDI).
Third Step. During the process of the MediCal appli- Neededfinancial/insurancenavigation 32(7.0) 68(15.9)
cation, Mrs. P’s cancer stage changed to Stage IV. Finan- InsuranceStatuspriortoPNP(thosewhowereinneed
cial navigators immediately forwarded the new medical offinancialnavigation)
information to a local MediCal eligibility analyst for the Uninsured 15(3.3) 32(7.5)
purpose of establishing presumptive State MediCal PartiallyInsured 11(2.4) 25(5.8)
Status (if approved, the patient would now be able to
FullyInsured,buthadlimitedcoverage 6(1.3) 11(2.6)
attend medical appointments to out-of-county medical
aIncludesLeukemia,HodgkinsLymphoma,Non-HodgkinsLymphoma,and
providers as referred by the local oncologist). Because MultipleMyeloma.
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higher need threshold. The end result was a zero share variables collected on the Intake Form for 457 patients
of cost for the patient. Another outcome was that the in 2010 and 428 patients in2011. Socio-demographic in-
Mrs. P. was eligible to receive reimbursement for the formation of the patients was similar in both years.
previous share of cost payments. With this changed in- About 70% of the patients were 50 years old and about
surance status, the patient (and CRCD financial two-thirds were female. The great majority of patients
navigators) could now contact medical billers to mitigate (81% in 2010; 86.7% in 2011) were Latino, with 10% in
the over $80,000 in medical bills incurred since Mrs. P.’s 2011 and 15% in 2011 reporting being White non-
hospitalization. The entire insurance conversion process Latino. About two thirds (61% in 2010; 63% in 2011)
took about 6 weeks from the first date of financial navi- identified Spanish as their primary language. With re-
gation at CRCDPNPuntilMediCalwasapproved. gard to the types of cancer diagnoses, about one third of
the patients were diagnosed with breast cancer, followed
Methodology by blood-related cancers and prostate cancer in both
Patientnavigationdata years.
To describe the characteristics of patients and the out-
come of their financial navigation, data were obtained
from the Patient Navigation Vista Share Outcome Insuranceconversion
Tracker database. This database contains patients’ In 2010, the CRCD served 457 patients, about half
sociodemographic characteristics, cancer related infor- (n=241) of which were newly referred patients. Among
mation, and barriers and needs to cancer treatment. In- those, records indicate that 32 patients (7%) reported a
take was conducted via face to face interview by staff financial barrier and were in need of financial navigation
members using a structured intake form. Once the in- (seeTable 1). There were37 insurance changes made for
take was completed, all patients’ information was these patients. However, this is an underestimated num-
entered into the Vista Share database. Data from 2010 ber of patients receiving financial navigation in 2010,
and 2011 were extracted, converted to an Excel file by a because electronic tracking of this information was not
staff member at CRCD, and patient identifying informa- implemented until the end of 2010. Fifteen of the 32
tion (e.g., name, address, contact number) was removed. were initially uninsured. Among them, 12 were
The data was then converted into the SPSS program. converted to full insurance coverage (e.g., the BCCTP
This study was approved by the Institutional Review program), and three were converted to partial coverage
Board(IRB# 691078). such as through the County Medical Services Program.
For the 11 who had partial insurance, all were converted
Results to full insurance. Six patients with full insurance cover-
CharacteristicsofpatientsreferredtotheCRCD age were converted to full insurance with better benefits
To describe the type of patients referred to the CRCD, which typically meant more treatment options and no
Table 1 shows the distribution of several background premiumorco-payment.
Figure1InsuranceStatusBeforeandAfterPatientFinancialNavigationforTwoYears.
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In 2011, the CRCD served 428 patients, 221 of which complex nature of patient circumstances and limited
were newly referred. Among the total patients in 2011, length of hospitalization often make it difficult for
68 patients (15.9%) reported facing financial barriers and them to navigate this insurance maze and successfully
were in need of financial navigation (seeTable 1). There convert the patients’ insurance status in a timely fash-
were 83 insurance changes made for these patients. ion, particularly after hospital discharge. The onus
Thirty-two patients were initially uninsured; 31 of them then is often on the shoulders of the patient to figure
became fully insured as a result of the CRCD PNP, and out how to access treatment and pay for his/her often
one gained partial coverage. Among 25 patients initially enormous medical bills.
partially insured, 24 were converted to full insurance, Although the CRCD PNP greatly enhanced access to
and one was converted to partial insurance with better care for these rural, primarily Latino patients, the study
benefits. Among those 11 patients initially with full in- is preliminary and has several limitations. The CRCD
surance, nine were converted to full insurance with bet- does not have the ability to measure the cost of treat-
ter benefits. Figure 1 graphically shows the change in ment and payment to providers because those costs vary
groups’ needing financial navigation in 2010 and 2011. with the cancer diagnosis, stage at diagnosis, treatment
Relativelydarkershadingindicates amorepositivestatus plan, and many other variables. While long-term
ininsurance coverage. outcomes are not known, the fact that many of its
patients would not have had timely cancer treatment
Discussion without CRCD insurance conversion intervention and
The purpose of this article was to describe the that generally, the insurance that is obtained for them is
characteristics of an innovative patient navigation pro- optimum for their needs, is reason to believe that there
gram in a relatively poor rural agricultural border arelong-term benefits.
county, and to report on the program’s success in Financial concerns are a significant thread that runs
converting cancer patients’ insurance status. In all but throughout the diagnostic, treatment, and post treat-
two instances of documented financial need, the CRCD ment journey of cancer patients. When obstacles arise, it
PNP improved the patient’s insurance status. Although isvitalthattherebeanadvocate/partnerwiththepatient
more data need to be collected, the CRCD PNP to mitigate or remove the financial barriers to ensure
estimates that approximately 1 out of 5 of their patients continuum of care. To that end, the CRCD PNP
will need financial navigation for cancer care in the provides a strategic partnership with consumers in its
future. ruralborder area.
Insurance conversion from employer-provided private
insurance to MediCal allowed the patient to receive can- Competinginterests
Thereisnocompetinginterestamongauthors.
cer treatment without being limited to geographic loca-
tion or the burden of having to pay a share of the cost.
Authors’contribution
The case study illustrated the way that financial naviga-
DPwasmainlyinvolvedincollectingdata,interpretingdata,anddraftingthe
tion often plays an important role in helping patients re- manuscript.HPwasinvolvedincollectingdata,interpretingdataand
ceive cancer treatment in a timely manner by alleviating draftingthemanuscript.EKwasinvolvedinconceptualizinganddesigning
thestudy,analyzingdataandrevisingthemanuscript.SWwasinvolvedin
financial burdens. In the case of Mrs. P., without finan-
designingthestudy,analyzingdata,andrevisingthemanuscript.
cial navigation intervention, she would not have known
to apply for the different categories of MediCal and Authordetails
1CancerResourceCenteroftheDesert,444So.8thStreetSte.B-3,ElCentro,
would not have been able to follow the treatment plan CA92243,USA.2CancerResourceCenteroftheDesert,444So.8thStreetSte.
with out-of-county oncologists. The patient had com- B-3,ElCentro,CA92243,USA.3SanDiegoStateUniversity,SchoolofSocial
plete coverage with zero share of cost effective the Work,5500CampanileDrive,SanDiego,CA92182-4119,USA.4Centerfor
AlcoholandDrugStudies,SanDiegoStateUniversity,SchoolofSocialWork,
first day of the month that the patient entered into the
6386AlvaradoCourtSte224,SanDiego,CA92120,USA.
hospital. The patient was able to see any physician
accepting MediCal and obtain prescriptions covered Received:16October2012Accepted:11January2013
Published:18January2013
under theState MediCalplan.
CRCD financial navigation is not only beneficial for
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