Access to innovative new drugs is an issue that is hitting home for many patients today. Patients who simply want to follow their doctors’ recommendations often are confronted with the realities of today’s evolving reimbursement system. They arrive at the pharmacy and learn their health plan denied payment, switched their treatment, or that they must pay a significantly higher co-pay than other available options.
This scenario, often referred to as “non-medical switching,” is the consequence of three critical and inherently discrete components of our ever-evolving system: Innovations in care, access to these innovations, and cost of care innovations. As a result, patients need to raise their level of knowledge and savvy to navigate the system.
Patient advocacy groups are direct ambassadors to patient and caregiver communities and can help illuminate the way. How can advocates play a role in solving this “customer-service” problem? Advocacy organizations are at the forefront of raising awareness about critical and chronic disease, educating people across every step from diagnosis through survivorship.
Results of Patient Advocacy
Advocacy groups are the bridge between problems and solutions. Today, that includes gaining access to prescription drug coverage and to medications that work well for that person. In the case of non-medical switching, patient communities look to a trusted guide to understand drug formularies, the rationale or chaos resulting from switching medications, and how to make their voices heard during formulary decisions.
By understanding the system, patients and caregivers become empowered as partners in controlling the cost of their care and deciding with their doctors how best to manage their condition. While drug indications may be identical, people’s responses to drugs differ.
Advocacy around the economics of care begins with four steps: 1) Gain a stronger understanding of the health ecosystem and how formulary decision are made. 2) Recognize healthcare system limitations—in public and private health plans—and develop shareable resources. 3) Engage policymakers to anticipate ongoing medical-access changes and the constituent impact. 4) Inform and activate patient communities when pharmacy benefit management (PBM) changes impact care.
Beyond helping people discover that they have a condition and then connecting them with others within that community, the role of patient advocacy is evolving to include care, community, cost, and now, choice. When choice is suddenly removed from patients, non-compliance and poor outcomes are a possibility. Advocates are also ambassadors for their communities in preventing that risk. Consider them in your planning.