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How technology can maximize use of manufacturer copay and patient assistance programs.
Due to changes in insurance benefit design, patients now pay more in deductibles and co-insurances for their medications than ever before. As the economic fallout of the COVID-19 pandemic continues, the number of uninsured and underinsured patients resulting from job losses is rising rapidly. Twelve million people have likely lost their employer-sponsored coverage and are experiencing financial crises, leaving families unable to afford life-saving medications. This “financial toxicity” translates into an untenable position for health systems dedicated to ensuring high-quality care to all members of the community, leaving them encumbered with uncompensated care.
Healthcare institutions of all sizes nationwide are becoming more aware of opportunities that allow them to secure reimbursement or offset costs through medication assistance programs (MAPs)—but there is still significant room for improvement. Less than 1 in 5 patients are aware of the programs available to them from manufacturers, and only 40% of healthcare providers are “very aware” of manufacturer copay assistance and free drug programs. This gap in both patient and provider education has been heightened given the challenges COVID may place on a patient’s ability to pay for medications.
Leveraging a comprehensive software solution can ensure that health system–run MAPs have access to the full spectrum of programs available and that patients are educated and given an opportunity to enroll in all potential programs for which they qualify. Now more than ever, US pharmaceutical companies have an ability to positively affect patients’ lives and support them through the pandemic with MAPs.
During the 1990s, US pharmaceutical manufacturers created a simplified approach to MAPs and provided their medicines at no or low cost to patients who could not afford them based on the decision of the prescribing clinician. In contrast, the realities of how insurance companies cover medications today has caused MAPs to expand and change in design to meet the needs of both the uninsured and the underinsured. Eligibility is based on clinical, financial, and insurance-related criteria.
With the right medication assistance technology solution, hospitals and health systems can enhance their financial position while assisting patients who are eligible. Today, more than 3,000 funding sources across 18 disease states cover select drug charges and prescriptions. The responsibility falls upon various key players within health systems, including pharmacy, medication access teams, revenue cycle, and patient advocates to find a medication assistance software solution to effectively tap into these resources on behalf of patients. The ideal technology solution is one that is streamlined to match and enroll patients, identify encounters and prescriptions, and manage reimbursement from every program resource available in order to reach the maximum number of patients possible.
Health system financial counseling services are typically fragmented, with responsibility for various aspects of the process allocated across multiple departments that lack coordination among workflows. As a result, health systems face four key challenges when implementing a MAP without the use of a unique software solution:
Consequently, many organizations miss opportunities to assist patients, decrease drug spend, and improve revenue.
Health system operations are highly specialized; therefore it is key to find a technology solution partner that offers tools specifically designed to save time and health system resources. A comprehensive technology solution must include an all-inclusive list of programs that fund patient care and help advocates reach the goals of enrolling every patient in need. Utilizing all available programs will not only reduce patients’ out-of-pocket costs but decrease pharmacy drug spend, increase prescription fill-rates, and reduce bad debt. This will drive substantial impact to P&L and expand from traditional free drug programs to manufacturer copay assistance and charitable foundation funds covering the patients’ copay, deductible, and co-insurance for hundreds of medications. Key stakeholders in the revenue cycle, pharmacy, and clinical specialties can cooperatively lead the charge on solving coverage gaps holistically to help the entire organization streamline operations and increase reimbursement.
Health systems are often mired in outdated methods of manually identifying eligible patients and medication assistance resources, engaging and enrolling patients, and managing the claims reimbursement process across the system. For these reasons, health executives should look for a partner that can help them overcome the time-consuming complexities of managing a MAP. Key features to look for include:
Automation—Automated systems tap into as many MAPs as possible and enroll patients as quickly as possible. Look for a solution that automatically matches patients with all programs they may qualify for based on their insurance coverage, prescribed treatments, diagnosis, claims status, and financial demographics. The benefits of automation include increased accuracy and productivity, lower labor costs, and a stronger bottom line.
Simplified Workflow—To access untapped opportunities, the solution should employ advanced automation to transform the complex process of medication assistance matching, enrollment, and reimbursement into a simplified workflow that identifies a greater number of coverage opportunities, creating the right financial plan for each patient. This simplifies a health system’s ability to gain additional cash and inventory for operational needs.
Centralized and Coordinated—Perhaps the most important factor health systems should look for is faster integration with clinical and financial IT systems, such as EPIC, Cerner, Meditech, and others. The platform should unify separate medication assistance efforts across departments under one centralized and coordinated platform, enabling individual departments to drive cross-functional efficiencies and dramatically improve patient satisfaction.
COVID Program—A COVID program can help ensure that patients get access to the care they need regardless of income level and without surprise medical bills, enabling them to focus on their health and not financial stress. Once the right solution is implemented, it is also critical that health systems make their communities aware of their medication assistance efforts so patients know they can seek the care they need without fear of insurmountable medical debt.
It is becoming especially problematic during the COVID pandemic for hospitals and health systems to cover the cost of new and expensive treatment options, manage the rising cost of specialty drugs as they flood the market, and recover lost revenues when patients are unable to cover the cost of treatment or co-pays. As these institutions strive to provide the maximum level of financial assistance, reports from the American Hospital Association (AHA) estimate a total four-month financial impact of $202.6 billion in losses or an average of $50.7 billion per month as result of this crisis.
The current pandemic has exacerbated the longstanding challenges health systems face in optimizing MAPs in a way that benefits all stakeholders. The magnified need for a technology platform and associated services serves as an opportunity for health system leadership to take action on a project that may traditionally lack prioritization. Moving these initiatives forward will increase patient compliance and satisfaction, enhance operating margins, and vastly improve the fiscal outlook for our nation’s health systems.
Ethan Davidoff, founder and CEO, Atlas Health