Navigating the Challenges of Prescription Affordability

Regardless of the future of the ACA, prescription affordability has been and will continue to be a significant issue in American healthcare. Looking ahead, two important players in the healthcare mix—payers and the new Trump administration—will likely exert more pressure on pharmaceutical companies to lower the cost of branded medications. Just as important, physicians and their patients remain the critical participants in the equation as they choose to use or abandon specific prescription medications—often in response to price.

This focus on cost is not a new trend: Throughout the last several years, price increases on prescription drugs have been high relative to other expenditures. A Kaiser Health survey found that 26% of people taking prescription medication have difficulty affording them. Public health experts find that close to 18% of patients with chronic illnesses report they delay, underuse, or don’t fill their prescriptions because of cost.

Cost-shifting to patients and an increasing number of insured patients using high-deductible plans will undoubtedly keep patients focused on Rx prices. How should manufacturers respond? In this environment, manufacturers will do well to assess the effectiveness of all their tools that touch on patient affordability, notably co-pay programs and patient assistance programs. Most manufacturers work with vendors to develop and manage their suite of support tools for patient affordability programs (PAPs) and co-pays. As you assess current programs, consider these key points and see how your plan measures up to the challenges of visibility, access, and affordability.

Different Ways to Engage; Different Ways to Activate

Gone are the days when HCP office staff manually entered patients’ application data, faxed the form to a processing center and then waited several days—or more—for a response on a patient assistance or co-pay program. Now brands have multiple ways patients can apply for financial support, including:

  • Co-pay card: Card activation can happen by activating a physical card, generally given to the patient by his or her physician.
  • Websites: Used for access and activation.
  • Texting: The newest option.

Your choice of the tool and the technology to support it depends on your vendor’s capability and the size of your field sales force to communicate programs or distribute tools.

Regardless of the front-end offering, brands with well-designed programs should aim for a single point of contact and fewer handoffs in the process of getting financial support for patients. Ideally the brand should have a single simple application for patient assistance programs, a tool that HCPs or patients can fill out to confirm that they do not have other coverage for their medication. Once completed, the form should move rapidly through the verification process. As a patient qualifies for assistance within a particular program, and the funding source is identified, the process should then include identification of the dispensing pharmacy and a timely shipping method. Some key points to understand include:

1. Patient Affordability Programs are not just an operations problem you need to solve. Many PAP and co-pay card vendors have an operations company mentality—focusing primarily on data capture, verification, and shipment—and may lose sight of patient’s needs at times. Taking a more strategic approach and partnering with a vendor who can support multiple channels for improving patient access may prove to be of greater long-term value. For example, developing a robust web presence that will allow physicians and their patients to process their PAP application online may help streamline efficiencies. Other channels may include field and contact center support, so practitioners are aware of PAPs and can provide instruction for enrollment. The physician becomes a key part of the process, sharing information with their patients and helping them complete the PAP application.

2. Understanding the nuances of your brand and patient population will make a difference in program design. Work closely with your vendor to make sure that you are asking the questions that matter to your brand. In addition to income and typical contact information, what else do you want to know about the patient diagnosis? Does your brand have a single indication or are there multiple diseases that might be treated with your brand?

Depending on the disease state, you may be providing therapeutic care for a highly functioning or a highly dependent patient population. How you interact with the patient may make all the difference. For a client with a therapy for treating a stroke-related disability, our team realized that many of their prospective patients would not be able to sign a completed application form or submit refill requests. We helped the manufacturer design a PAP application that allowed a patient’s legally designated caregiver to sign the initial application, as well as become the ongoing contact person for requesting prescription refills and providing other feedback about the brand, which resulted in faster speed to therapy and fewer prescriptions abandoned.

3. Detailed vendor reporting can shape future program elements. While financial support tools will stay in place for the life of the brand, market dynamics will likely change as new brands enter the therapeutic space and payers continue to update formulary lists. Nimble manufacturers will need to respond to these changes.

Vendors can, and should, be tracking usage and reporting back to brands on a very detailed level. Brands should expect to get reports on total patient interactions, co-pay volume generated by specific HCPs, and how much product is being distributed. Consistent, detailed reporting can help brands deploy field resources and also help them modify business rules and program design in response to what they are learning.

A vendor partner should also provide “payer surveillance” to understand what is happening more broadly with their brand uptake, e.g. understanding the length of the prior authorization process or the appeals process and querying payers about their formulary guidelines, as these criteria can and often do change over time.

4. Address higher co-pays and patient out of pocket caps. Another trend that has emerged as more patients shoulder high-cost sharing lies in restructuring the co-pay card to an annual, rather than monthly program. One of our clients offered a co-pay card that provided monthly coverage. Throughout the next year, the coverage amount was helpful, but there was still a falloff in brand usage in the first three months of each year. Realizing that many commercially insured patients were struggling with start-of-year prescription deductibles, we suggested restructuring the co-pay card so that it remains at the same fixed amount, but is now an annual, rather than monthly amount. It has helped these patients obtain reimbursement support earlier in the calendar year and resulted in a more stable use of their prescribed therapy. The takeaway from this client: Don’t increase your co-pay card cap blindly; instead examine what is happening with reimbursement patterns first and then explore solutions.

5. Your front-line patient support team really does matter. Often, newly diagnosed patients who find their way to a call center for a brand need help in mapping out next steps. They likely have questions, including:

  • Are they uninsured or underinsured?
  • Will they require prescription cost assistance or a combination of treatment and prescription financial support?
  • Might site of care and transportation be a barrier to their care?
  • Do they need more disease state educational materials to understand their condition?

Skillful patient assistance individuals will essentially need to triage each patient to help them find the right resources for their treatment. Your brand may have a PAP or co-pay tool in place or you may need to broaden the search to other disease-state alternate funding sources. In either case, the responsive, direct contact with a knowledgeable, empathic contact center team member will be an invaluable asset for your brand.

6. Flexible, modular hub components become an increasingly important asset. As market conditions change, every constituent in the healthcare sector is watching costs. Find a vendor that can rapidly build on parts of your program that are working effectively, but add modular components that you are lacking to revitalize your program. A “plug-and play” approach will allow you to optimize operational components of your program to benefit your brand’s unique needs and offer better overall care and well-being for the patient while maximizing your brand’s potential.

  • Tom Doyle

    Tom Doyle is executive vice president of commercial solutions for H. D. Smith Specialty Solutions. He leads commercialization teams supporting customers throughout the pharmaceutical supply chain and represents key products, services and market segments. With more than 25 years of experience in the pharmaceutical industry, Tom’s roles have included directing trade and U.S. commercial operations, leading 3M’s Canadian pharmaceutical business unit, and business development and strategic planning.


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