Navigating the Complex Reimbursement and Policy Landscape of Healthcare Access

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Tommy Bramley and Kristine Flemister discuss today’s increasingly complex healthcare environment, and share insights into how stakeholders should be evolving to better help patients and providers navigate barriers around access and affordability.

  Earlier this year, leaders at Lash Group and Xcenda, two AmerisourceBergen companies, Lash Group and Xcenda, were among the featured speakers at PAP 2018, CBI’s 19th Annual Patient Assistance & Access Programs conference where industry experts were invited to discuss today’s dynamic landscape of healthcare coverage, access and the next forefront of patient services and innovation.   In the following Q&A, Tommy Bramley, Ph.D, president of Lash Group, and Kristine Flemister, PharmD, president of Xcenda, examine today’s increasingly complex healthcare environment, and share insights into how stakeholders - including patient support companies – should be evolving to better help patients and providers navigate barriers around access and affordability.   

How have regulations and legislation affected access to health insurance and the demand for patient assistance program support?

Kristine Flemister:

 Recent regulatory and legislative changes could exacerbate patient access and affordability challenges, likely resulting in a heightened demand for patient support services. For example, the repeal of the ACA individual mandate has the potential to leave as many as three million more Americans uninsured by 2019, according to estimates from the Congressional Budget Office.    What’s more, the repeal of the individual mandate, coupled with additional regulatory changes - such as decreases in cost-sharing subsidies - actually poses a significant risk in the health insurance exchange market, as younger, healthier individuals may decide to forego coverage altogether, particularly in the exchanges. As a result, health insurance carriers participating in the exchange will likely be forced to raise premiums and continue to pass high out-of-pocket costs on to those remaining participating patients, many of whom are already at high health risk. Eventually, we may even start to see carriers withdraw from select counties and states, leaving prospective enrollees with limited options, limited access to prescribed therapies, or possibly without any insurance options at all.   

Tommy Bramley:

As patients face mounting financial and access barriers and the number of uninsured and underinsured individuals increases, the demand for patient support services will continue to grow. To help patients start and stay on therapy, manufacturers will, in many cases, need to provide increased patient-focused support that addresses challenges related to patient access, affordability and adherence.  Patient assistance and foundation programs play a critical role throughout the treatment journey. Whether it is providing free product to patients in need or offering services that ease the financial burden for uninsured and underinsured patients, patient support services help patients navigate and overcome the barriers they face.   

What types of “new” burdens are patients bearing? Which ones should patients be most concerned about? 



Rising copays and high-deductible insurance plans shift more of the cost burden to patients, compounding existing affordability challenges, especially among lower-income individuals. Further, we are seeing escalating use and complexity of tactics such as prior authorization and step therapies by payers as methods of cost management, creating additional barriers for patients. The evolving market pressures exacerbate current pain points throughout the patient journey, creating greater uncertainty around patient access.   


Affordability and access, of course, remain top of mind for patients. However, another burden that patients face is delayed therapy initiation. Prior authorization requirements and benefit verification processes can delay a patient’s access to treatment by days or even weeks. While benefit verification is an important process that summarizes a patient’s healthcare coverage and out-of-pocket costs for his or her medication, it can serve as a barrier – particularly for the millions of patients whose benefits are still verified manually through phone calls and paperwork exchanged among healthcare provider offices, payers and third-party hub support service providers. As a result, more patient service providers – including Lash Group – are introducing innovative technology solutions to improve turnaround time. In fact, we just launched an electronic benefit verification solution that leverages artificial intelligence and machine learning to drive faster speed to therapy and incorporates real-time payer and plan changes, updating algorithms and producing the highest quality benefit summaries.  

Given this increasing patient burden, how do patient support services and field-based teams continue to evolve in order to help alleviate those pain points and ensure patients start and stay on therapy?


There is a lot of uncertainty and complexity in today’s evolving healthcare landscape. Helping patients navigate this landscape successfully and gain access to their medications requires the ability to aggregate and connect the right people and the right information at the right time. With Fusion, Lash Group’s CRM, we’re making significant investments in technology and data analytics to enable manufacturers to take a faster, more strategic approach when designing and executing patient support programs. The patient insights gathered will further enhance patient outcomes and improve the patient and provider experience. With increased visibility through reporting and analytics, manufacturers can anticipate potential barriers for each patient – based, in part, on individual characteristics and predictive therapeutic-related risks – and optimize their strategy to ensure they engage patients at critical points throughout the treatment journey.   


Coordination is a core component of a successful approach. Field-based teams and reimbursement hubs offer a variety of services, from prior authorization and denial assistance to provider education and access to financial assistance options, which help providers navigate potential barriers. For example, the teams can educate patient care coordinators on benefit verification services, which will provide clarity into the patient’s insurance coverage, cost-sharing or PA requirements. Field reimbursement teams can not only guide staff on how to complete a PA form, but they can also educate them about payer requirements and address patient access barriers. Once product coverage is confirmed, field-based teams and reimbursement hubs can educate providers on reimbursement and access support services, such as affordability options and processes, to ensure necessary financial assistance is available for prospective patients.  

Are there other emerging market trends that could impact what patient services are offered or how they are delivered? If so, how can companies stay abreast of these emerging trends to assist in optimal access for patients? 


One area, in particular, we remain focused on is the emergence of copay accumulator programs. Introduced by pharmacy benefit managers (PBMs) and health plans, the programs do not allow a manufacturer’s payments-through manufacturer-sponsored copay programs-to count toward the patient’s deductible and out-of-pocket maximum obligations. As a result, patients will be left to bear more of the upfront financial burden. For patients who struggle to access their medications without copay assistance, these programs can lead to decreased medication adherence rates, patient frustration and confusion, and increased demand for and utilization of patient assistance programs to bridge the gap. This trend continues to evolve, which is why we’ve created a Copay Accumulator Learning Center to provide the latest insights to pharmaceutical manufacturers.   


Xcenda recently conducted a survey of representatives from 46 national and regional commercial plans, which revealed that about 40 percent of plans currently limit the use of commercial copay assistance. This research further revealed that in the next two years, that percentage could skyrocket to more than 80 percent, significantly limiting the assistance these programs bring to patients. Right now, the vast majority of the plans that restrict copay assistance use the accumulator model, while less than 10 percent just use the maximum allowable model – a program that adjusts the plan’s benefit design so that the cost-sharing amount required is set to the maximum financial amount allowed by the manufacturer.   Amid today’s fast-changing landscape, companies should monitor regulatory efforts and key developments, particularly those that impact patient access and support services. Subscribing to relevant publications and industry newsletters like Xcenda’s Health Policy Weekly, a weekly newsletter that offers analysis of legislative and regulatory developments and news that affects the healthcare industry, is an easy start. Companies should also be aware of their patient populations, know whether they will be affected by these growing practices, and adjust programs accordingly. By remaining updated on industry trends, companies can plan for and adapt to changes, and ensure they have the necessary offerings and robust financial resources to meet patient needs.