When Barbara McAneny, MD, sees a patient, she focuses on the best approach for their health, including the ideal medication and referrals to the most qualified specialists. Dr McAneny, a medical oncologist from Albuquerque, New Mexico — who was also the 173rd president of the American Medical Association (AMA) — doesn’t let insurance rates influence her treatment plan.

Her patients may not have the luxury of ignoring economics, though. One study found that one-third of working-age cancer survivors went into debt, and more than half of patients in debt faced bills of $10,000 or more. Three percent had filed for bankruptcy.1 In fact, new patients at Dr McAneny’s practice, the New Mexico Cancer Center in Albuquerque, meet with financial counselors to discuss the cost of care.

Medical bills may go way over a patient’s deductible if a provider is outside one’s insurance network, or when certain drugs aren’t covered. Often these bills are unexpected. Out-of-network costs can have serious impact on patients’ mental health, and cancer patients are particularly vulnerable.

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Patients with cancer may also interact with many out-of-network specialists, such as emergency room physicians. Oncologists may be able to soften the blow by helping patients find in-network providers or afford medications. In addition, laws against surprise billing have been enacted at the state level and are under consideration in Congress.

“The surprise billing issue has not really affected oncologists as much as it has other, hospital-based specialties,” Dr McAneny told Cancer Therapy Advisor. Most oncologists see patients that are in network at their practice. Yet, the cancer field is not immune to the problem.

A survey by the American Cancer Society Cancer Action Network (CAN) laid out the impacts of out-of-network billing on cancer patients and survivors, and they are stark: Nearly one-quarter of respondents had received a surprise bill.2 Most of these bills were for more than $500 — and more than one-fifth of these bills were for $3000 or more.

Yet a 2018 Federal Reserve report said that 4 in 10 Americans couldn’t afford an unexpected bill of more than $400 without selling something or borrowing money.3 This financial toxicity can add stress for patients who are already ill, noted Daniel Polsky, PhD, a health economist at Johns Hopkins University in Baltimore, Maryland.

Indeed, the CAN survey found that 70% of surprise-bill recipients had experienced anxiety about future surprise bills. Sixty percent said they’d be less likely to follow up with a recommended specialist if the doctor were outside their network. And 42% said they were less likely to call an ambulance if they experienced a serious cancer-related issue. Almost one-third were less likely to take a certain treatment, or visit the ER, because of cost concerns.

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Another way cancer patients might face out-of-network costs is when they need to see a specific specialist, but their narrow insurance network doesn’t include that person among its oncologists. People may choose such small-network plans because they are less expensive, well before they discover they need cancer care.

This is particularly an issue with rare cancers, such as pediatric brain cancer, noted Anna Howard, JD, principal for policy development and access to and quality of care with CAN in Washington, D.C.  “You may decide you need to go to the specialist or the specialized facility,” she told Cancer Therapy Advisor.

In addition, oncologists at top hospitals — those in the National Comprehensive Cancer Care Network (NCCN) and those designated by the National Cancer Institute as official cancer centers — are less likely to be in narrower insurance networks.4