Am J Manag Care. 2021; 27 (10): In press

_____

Takeaway points

Financial toxicity – the economic impact of a disease or its treatments – is associated with adverse effects.

• As cancer care becomes regionalized and centralized, more patients travel for treatment and the associated housing costs increase the financial burden.
• Innovative models for providing affordable and accessible housing to patients and families, especially those undergoing long-term treatment away from home, are essential.
• Given their volume of patients and their scope of practice, the institutions that make up the Alliance of Dedicated Cancer Centers should play a major role in reducing the financial toxicity associated with housing during cancer treatment.

_____

Financial toxicity — the economic impact suffered by patients as a result of an illness or its treatments — has been associated with adverse outcomes in cancer patients.¹ Even in groups of highly insured patients, financial toxicity has been reported.² Racial and ethnic minority patients undergoing cancer treatment are particularly at risk, even taking into account income, education and employment.³ The financial burden is usually associated with the out-of-pocket costs of treatment, but can include all of the expenses associated with accessing and continuing treatment. Housing instability (for example, loss of housing or threat of loss of housing) and travel and temporary accommodation costs are examples of financial burdens. The costs associated with accommodation may be excessive if cancer treatment is prolonged or changed due to complications, recurrence or participation in a clinical trial. Patients with unmet housing needs are therefore particularly vulnerable to the many adverse effects associated with financial toxicity.⁴ We predict that the effects of the COVID-19 pandemic will exacerbate the financial woes of cancer patients, making it an important focus in the acute context.

With increasing regionalization and centralized care models proposed to improve the quality of cancer care delivery, it is more likely than ever that patients will need to travel outside of their area of ​​residence to receive treatment.⁴ The majority of cancer centers are located in urban areas, requiring travel for patients who live elsewhere. Although access to affordable temporary housing remains a key element in reducing the financial burden of patients undergoing treatment, there are still no strong incentive structures or shared recognition of the need for housing assistance between the major cancer centers. .

In response to this crisis, an increasing number of national programs have been put in place to address housing needs during cancer treatment. Several non-profit organizations aim to provide accommodation and support services to patients and their families. Healthcare Hospitality Network, Inc (HHN) is an association of nearly 200 nonprofit hospitality homes across the United States. The American Cancer Society (ACS) developed the Hope Lodge to provide free accommodation for patients and caregivers when the best hope for effective treatment is far from the patient’s home. Currently there are 30 Hope Lodge locations in the United States. Although HHN and ACS are valuable resources, their capacity is limited and many patients are not eligible for assistance. To help close the gap, several cancer centers have established their own housing programs and accommodation options for patients. By describing the current landscape of hospital-initiated housing programs in cancer centers, we hope to promote awareness of how health systems can improve access and affordability of cancer care for all. the patients.

When traveling for the best treatments available, many patients seek out dedicated cancer centers. The establishments of the Alliance of Dedicated Cancer Centers (ADCC) provide multidisciplinary care,⁵ integrating psychological and social considerations into cancer therapy. We studied the resources available to patients, systematically searched for online resources, and contacted each of the 11 ADCC members to determine if they had any programs to provide free or discounted accommodation to patients during treatment (Table).

A major objective of these cancer centers is to implement new and innovative models to improve patient care and reduce costs. All ADCC members have staff dedicated to providing financial assistance to patients in need. Many centers have adapted to the growing needs of their patient populations and most offer some form of discounted accommodation, either in the form of negotiated hotel rates or free apartments owned by the hospital.

At the Dana-Farber Cancer Institute, private equity partnerships with local hotels provide affordable and accessible housing options to families eligible for income; a team of resource specialists ensures that patients have access to nearby accommodation. Memorial Sloan Kettering Cancer Center (MSKCC) offers rates negotiated with hotels, as well as hospital-owned accommodation, the price of which is determined by a financial aptitude test and is, in many cases, fully covered by patient insurance. Many other members of the ADCC provide similar resources. With the closure of Hope Lodge during the COVID-19 pandemic, there has been an increase in the need for safe and convenient accommodation for patients, especially patients undergoing bone marrow transplants, who are severely immunosuppressed and pass frequently. weeks to months away from home to receive treatment. Although accommodation is offered to all MSKCC patients, during the COVID-19 pandemic, priority has been given to bone marrow transplant recipients.

Cancer patients should be able to take the best treatments available, regardless of their financial resources or geographic location. Providing access to affordable housing to patients in treatment should be a priority for institutions, insurance companies and provider networks. Recently, Gondi et al described that investments in hospital-owned housing can create conflicts of interest if they are financially motivated.⁶ Further study and analysis of the financial toxicity of housing costs for cancer patients and investigation of cost-cutting interventions should be carried out.

Our hope is that cancer care providers, administrators and insurers recognize the benefits of providing reliable and affordable accommodation for patients during treatment. Although some centers have started to address the financial burden associated with housing, it remains a growing problem. With the onset of COVID-19, safe and accessible housing is more important than ever. However, many private nursing homes have had to suspend their activities due to concerns for the health and safety of patients, volunteers and staff. Over time, we will begin to understand the impact of the pandemic on our healthcare system. Nevertheless, we must continue to fight against financial toxicity and improve patient care. Given the volume of patients and the extent of practice among ADCC members, these cancer centers are expected to play a major role in utilizing economies of scale to reduce the financial toxicity associated with housing during the period. cancer treatment.

Thanks

Sushmita Gordhandas, MD, and Sarah Lee, MD, MBA, contributed equally to this work and are listed as co-first authors.

Author affiliations: Department of Gynecology, Department of Surgery (SG, EMA) and Health Outcomes Research Group, Department of Epidemiology and Biostatistics (EMA), Memorial Sloan Kettering Cancer Center, New York, NY; New York University (SL) Langone Medical Center, New York, NY.

Source of funding: This study was funded in part by the National Institutes of Health / National Cancer Institute Support Grant P30 CA008748.

Author disclosures: The authors do not report any relationship or financial interest with any entity that would pose a conflict of interest with the subject of this article.

Paternity Information: Conception and conception (SG, SL, EMA); drafting of the manuscript (SG, SL, EMA); and critical review of the manuscript for significant intellectual content (SG, SL, EMA).

Address Correspondence to: Emeline M. Aviki, MD, MBA, Department of Gynecology, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065. Email: [email protected]

THE REFERENCES

1. Ramsey SD, Bansal A, Fedorenko CR, et al. Financial insolvency as a risk factor for early mortality in cancer patients. J Clin Oncol. 2016; 34 (9): 980-986. doi: 10.1200 / JCO.2015.64.6620

2. Bouberhan S, Shea M, Kennedy A, et al. Financial toxicity in gynecological oncology. Gyncol Oncol. 2019; 154 (1): 8-12. doi: 10.1016 / j.ygyno.2019.04.003

3. Jagsi R, Pottow JAE, Griffith KA, et al. Long-term financial burden of breast cancer: experiences of a diverse cohort of survivors identified through population-based registries. J Clin Oncol. 2014; 32 (12): 1269-1276. doi: 10.1200 / JCO.2013.53.0956

4. Costas-Muniz R, Leng J, Aragones A, et al. Association of unmet socioeconomic and practical needs with self-reported non-adherence to cancer treatment appointments in low-income Latino and Black cancer patients. Ethnic health. 2016; 21 (2): 118-128. doi: 10.1080 / 13557858.2015.1034658

5. Hillner BE, Smith TJ, Desch CE. Volume or specialization of hospitals and physicians and results in cancer treatment: importance in the quality of cancer care. J Clin Oncol. 2000; 18 (11): 2327-2340. doi: 10.1200 / JCO.2000.18.11.2327

6. Gondi S, Beckman AL, McWilliams JM. Hospital investment in housing: banner of change or red flag? JAMA Med Intern. 2020; 180 (9): 1143-1144. doi: 10.1001 / jamainternmed.2020.2348