Program provides effective, cost-efficient way to help patients overcome affordability barriers and obtain the critical medicines they need.
As drug therapies become increasingly more complex and expensive, there is a need to help patients who cannot afford vital medications. Drug manufacturers have closed this gap through patient assistance programs (PAP) that provide individuals without insurance coverage or the financial means to purchase products access to free medications. As the need for patient support continues to grow, there is a strong focus on the development of new tools to streamline the PAP process and improve patient access to critical medications.
The PAP Evolution
Manufacturer-sponsored PAPs provide subsidies, free or discounted medications to patients who have inadequate means to obtain needed drug products. Eligible patients range from low-income individuals to those who have insurance coverage, but still cannot afford to buy their medication.
“Companies like Triplefin and other patient service providers work with patients to help them to navigate various options to find some form of alternative coverage,” explains Tom Doyle, executive vice president, commercial solutions of Triplefin. “The patient might be eligible for a foundation or a federal program and not even be aware of it. The goal is to provide a high level of service to effectively and cost-efficiently enable patients who cannot afford the drugs to obtain access to these products.”
Triplefin, headquartered in Cincinnati, OH, has been involved in the PAP market since 1999 through its purchase of RxHope, a central landing point where patients can search for manufacturers’ offerings of free medications. Much has changed since then. With the expansion of the biologics and specialty drug markets, drugs are significantly more complex and expensive today than they were in the past. At the same time, the uninsured population has continued to grow, and many patients are falling through the cracks.
PAPs, too, are in transition. The administration of PAPs has historically been a tedious, manual process. As a result, it was expensive and inefficient to screen and qualify patients for programs. Thus, Doyle says Triplefin saw the need to increase efficiency and reduce costs through automation.
Additionally, there has been increased scrutiny by the government to ensure that free goods programs are operated independently of the commercial business. Such challenges have prompted manufacturers to build firewalls between commercial reimbursements for patients and the free goods program. Triplefin is also responding to manufacturers’ needs to streamline this experience and to make it as integrated, seamless and efficient as possible.
Improving patient access to products through web-based or e-solutions has been a major area of focus for patient support companies. Most of these efforts have centered on reimbursement programs where patients can enroll in programs through web portals or providers can utilize electronic benefit verification (eBV) or electronic prior authorization (ePA) to navigate reimbursement challenges. Programs that provide access to real-time information and, in some cases, are integrated into the physician workflow are reducing barriers to access for patients with insurance. PAPs are ripe for similar innovations.
Historically, patient assistance programs have relied heavily on fax or paper enrollment and often required W2s or other supporting documents before a patient was granted access to a program. With advances in both real-time benefit and income verification, PAPs are positioned to improve patient access and reduce program cost.
To improve the patient experience, programs need to move beyond web-based portal enrollment to solutions that enable patients to receive real-time eligibility information specific to the drugs they need. With advances in real-time eBV for both pharmacy and medical benefits, solutions are being created that enable PAPs to determine if the patient has any insurance coverage to support access to critical medicines. Combining this with a real-time soft credit check enables the patient to quickly determine if he or she qualifies for a support program.
Doyle says, “It is cumbersome for the patient to try and track down all of that information and challenging to synchronize it with what the physician’s office is sending in with the prescription. The situation is not good for the patient, it is not good for the provider and it is a drain on the resources of the manufacturer and service provider who are trying to provide a good experience and help patients to gain access to much-needed drugs.”
Equally important to automating the front-end patient enrollment process is the use of technology to improve the overall management of the patient and provider experience. The same automation of income validation and benefit verification can reduce the time it takes to process and approve patient applications received through traditional fax processes.
Triplefin’s propriety platform Rx365® supports all aspects of patient, provider, and contact center engagement by automating and integrating each step of the patient journey, from program enrolment through delivery of product and ongoing patient support. Doyle notes, “One major key to success is balancing the need for automation while ensuring every patient, caregiver and provider has an exceptional experience with the PAP. Automation that reduces inefficiency and enables the contact center associates to focus on providing each patient with service improves access and helps patients benefit from these often lifesaving therapies.”
The Need for Separation
Compliance requirements are driving more separation between historical program structures in which commercial teams also manage giving free product to patients. This is leading to the creation of additional and more distinct separation of manufacturer-supported foundations from the commercial business. This structure has benefitted patients by serving organizations that are laser-focused on taking care of the needs of the patients at the most risk of not receiving product.
At the same time, it is important for service providers to focus on providing a similar level of separation, ensuring that reimbursement programs are not comingled with patient assistance programs. This is also driving more interest in creating an environment where both the front-end patient support for program qualification and the physical distribution of PAP product is provided by a service provider that is solely focused in those areas. Service providers go to great lengths to ensure they are fully compliant with these requirements and are continuing to transition to a PAP pharmacy environment where the pharmacy’s focus centers on only providing free product and is not comingled with commercial business.
Foundations, often involved with specific disease states, are typically funded by multiple manufacturers and other donors and play a key role in supporting patients unable to afford their medicines. While manufacturers grant funding to them, foundations provide a way to ensure separation to keep the decision to fund patients completely unbiased. The focus is simply on patients who lack affordability options for their medications.
In some cases, patients who do not qualify for the manufacturer’s PAP because their income is above the threshold of the government program still qualify for the foundation program. Foundations give patients multiple avenues to exhaust.
Simply put, if foundations receive support, they can help more people. If the PAP model can become more efficient and less expensive to administer, it would free up funds that could potentially help the foundations or other organizations trying to assist patients with access to their medications, Doyle believes.
PAPs in the Future
The next-generation of PAP solutions must consider having a patient-driven website that supports real-time enrollment, provides automation that a supplier can access internally, and initiates outreach to healthcare providers with minimal intervention. Automation will touch every aspect of the process.
“We often hear that everything is going to be electronic and automated and that is a silver bullet. The reality is that, particularly in this space, it often remains a very manual process with patients still wanting to talk with someone,” Doyle says. Thus, companies need access to improved tools and systems that are geared to increase efficiencies.
According to Doyle, “The industry is really in flux, and there is a need for improvement. We are all asking the same questions: How can we make this better? What can we do differently? How can we serve patients while controlling costs and making the process as simple and efficient as possible?”
Doyle concludes, “There is a need for an overall smoother, more integrated and consolidated approach. PAP is a space that we, as an industry, we as a society, should embrace to help patients, the people who are truly in need.”
Published December 2017 | Reproduced with permission by Pharmaceutical Executive