Implementing Oncology Financial Advocacy As a Standard of Care: A Qualitative Analysis of Barriers and Facilitators

Background: Sickness is the leading cause of bankruptcy in America. Loss of income and high medical costs put cancer patients at increased risk of financial hardship, which has been linked to poor health outcomes and early mortality. Preventing and treating financial hardship is essential to providing equitable cancer care.

Oncology financial advocacy (OFA) is an evidence-based practice designed to prevent and treat financial toxicity. Social workers play a key role in the development, implementation, and management of financial advocacy programs. The Financial Advocacy Network (FAN) of the Association of Community Cancer Centers (ACCC) held a summit September of 2021 where 44 financial advocates participated in a series of focus groups to discuss best practices in OFA, as well as barriers and facilitators of effective program implementation.

Methods: Nine focus groups were conducted via Zoom with 8 – 12 participants per group. Discussion guides were developed to elicit beliefs about best practices in OFA, as well as the barriers and facilitators they encountered in implementing and sustaining programs. Groups were recorded and transcripts generated. Using thematic analysis, two study team members coded each transcript. All five team members discussed the initial codes to reach consensus, develop a codebook, and re-code all transcripts. Codes were discussed until categories and themes emerged and were agreed upon. The Consolidated Framework for Implementation Research (CFIR) was used as sensitizing framework.

Findings: The 44 advocates represented a range of practice settings (20 integrated health systems; 11 community cancer centers; 4 non-profit advocacy organizations; 3 academic cancer centers; 7 other). Most participants were trained as social workers, followed by nurses, pharmacists, patient navigators, lawyers and a range of Bachelor’s and Master’s degrees. We identified salient themes related to the effective implementation of oncology financial advocacy across all five domains of the CFIR framework: (1) intervention: participants described advantages and disadvantages of adapting financial advocacy to meet the needs of the medical system; (2) outer setting: a tipping point for widespread dissemination and implementation as awareness of financial hardship grows; (3) inner setting: programs are under-resourced to assist all patients at risk of financial hardship, staffing, technology integration, and network/communication workflows are needed to support full implementation; (4) individuals: they believe strongly in the effectiveness of financial advocacy and would like to see their credibility enhanced with professional certification; (5) process: implementation strategies that target the engagement of leadership, key stakeholders, and patients to increase program reach are needed.

Conclusion and Implications: Participants believe in the effectiveness and value of OFA. Programs are unable to reach all at-risk patients at-risk because of understaffing, poor communication between departments, and a lack of intervention understanding among colleagues, key stakeholders, and patients. In order to reach full implementation they need assistance in making the case for more resources, which includes more research on patient outcomes and cost-benefit analyses, professional certification, and the use of policy to incentivize financial advocacy as a standard of care in medicine.