The long-term impacts of the COVID-19 pandemic—across the globe and in the U.S.—cannot be overstated. In the U.S., 23 million people have lost their jobs pushing up a historically low unemployment rate that is now expected to remain above 14% into the fourth quarter of 2020. The ranks of the nation’s uninsured, which before coronavirus hovered around 28 million,1 is predicted to increase to nearly 40 million by some estimates2 as workers begin to lose their employer-sponsored health coverage.
Every segment of the U.S. economy will feel the aftereffects of this initial coronavirus outbreak. Some industries will recover faster than others as the nation reopens and Americans return to work. The healthcare industry, which accounted for more than 17% of U.S. gross domestic product in 2019,3 will continue to experience special challenges. Pharmaceutical and life sciences, providers, payers, suppliers, vendors, and patients can all expect to make concessions as the industry regroups after unprecedented stresses to federal, state, and community-based healthcare delivery systems.
The response from the pharma/life sciences industry in the last weeks and months has provided hope to millions in the face of uncertainty. From promising drug therapies and vital medical equipment to increased availability of patient support programs, the spotlight has been on life-saving innovations that are putting patients first. Pharma manufacturers have arguably created much goodwill amid the pandemic as many have rapidly expanded prescription assistance and patient access programs (PAPs). Over the last 10 years, such programs have helped an estimated 36 million people obtain their medications.4
In response to the outbreak, pharma manufacturers have heightened awareness around existing PAPs. As part of these initiatives, many are lowering the bar on eligibility to address the increase of patients in immediate need. As today’s PAPs move to the front lines to fill the void of the uninsured with free drugs, the financial implications for the industry will extend out to the foreseeable future. Meanwhile, for those patients who have retained their insurance; cost-cutting measures continue to expand, leaving many to shoulder the heavy financial burden of high-deductible health plans. Themes of affordability and access are expected to be reamplified as we emerge from this pandemic, not only with high numbers of uninsured but also a growing contingent of patients who are under-insured and require assistance.
Pharma manufacturers are shifting budgets to meet demand. Successfully striking a balance between offerings that address affordability and payer access, while being mindful of the growing number of patients who are fast becoming uninsured will require a revamping of PAPs in the short term.
Develop New Parameters for Old Business Rules
Before coronavirus, the PAP rules, eligibility criteria, and budgeted patient populations served were well established and flat. After coronavirus, the sudden rise in unemployment, loss of insurance, and proactive measures to reach out to those most in need has caused many more patients to qualify for PAPs.
Over the next 9-18 months, pharma manufacturers must rethink business rules and general program design to ensure sustainability; recognizing that they alone cannot fill the crater in coverage that this pandemic has created. Manufacturers must consider more frequent patient evaluations in order to confirm patient eligibility as a patient’s situation improves and health insurance coverage becomes available.
Trust But Verify Relaxed Eligibility Requirements
Previously uninsured patients will quickly migrate back to employment and seek coverage through their employer’s health plan, and some patients, whose unemployment persists, could successfully transition to Medicaid. If predictions around the unevenness of an economic recovery5 hold, workers who regain—then later lose—insurance coverage, may experience a boomerang effect that brings them back to PAPs. Pharma manufacturers should consider looking at standard procedures governing returning applicants and streamline the process to reduce operational costs.
Generally, Medicaid plan designs have been fairly generous for patients who are seeking continuation of treatment, so too has low income subsidies been toward Medicare recipients who access Part D plans. Now the coronavirus-induced reduction in revenue has caused an increasing number of states to consider deep cuts to Medicaid.6 Drug manufacturers should remain alert to shrinking Medicaid budgets as a catalyst for yet another wave of eligible patients.
Use Technology and AI Tools Speed-Up Processes and Improve Patient Experience
Patients with insurance that has been disrupted and then restored may now be subject to the entirety of their deductibles or reauthorization to use their medication. This will have multi-fold implications on manufacturer programs which seek to mitigate patient cost, but it will also create additional operational expense around helping patients to obtain authorization approval to continue their treatment. This means additional paperwork and the need to perform more frequent patient, provider, and payer outreach.
Drug manufacturers should redouble their efforts around adopting technology and digital connections to make these steps more efficient. This would include robotic process improvement for enrollment intake, transcription, case creation, insurance discovery, drug coverage, patient cost, electronic prior authorization, and estimated household income. Text and self-service expansion can also help to facilitate communications and improve process efficiency enabling more patients to be served within a limited budget.
The pandemic of 2020 has divided business operations into “Before Coronavirus and After Coronavirus,” and has changed nearly every aspect of American life. Few industries will go unscathed. As part of the new normal, pharma manufacturers must prepare to serve as the payer of last resort in support of the best outcomes for their patients. Strategies designed to preserve the integrity of PAPs should also ensure that industry players do not become the payer of convenience.
1. U.S. Census Bureau; https://www.census.gov/library/stories/2018/09/who-are-the-uninsured.html#.
2. “COVID-19 Impact on Medicaid, Marketplace, and the Uninsured, by State, Health Management Association;” https://www.healthmanagement.com/wp-content/uploads/HMA-Estimates-of-COVID-Impact-on-Coverage-public-version-for-April-3-830-CT.pdf.
3. “U.S. National Health Expenditure as Percent of GDP from 1960 to 2019;” https://www.statista.com/statistics/184968/us-health-expenditure-as-percent-of-gdp-since-1960/.
4. NeedyMeds.org; Prescription Assistance Information; https://www.needymeds.org/pap.
5. “Economists See Uneven Jobs Recovery, High U.S. Unemployment Through 2021;” Reuters; https://www.reuters.com/article/us-health-coronavirus-usa-forecast/economists-see-uneven-jobs-recovery-high-u-s-unemployment-through-2021-idUSKCN21S0BL.
6. “States Cut Medicaid as Millions of Jobless Workers Look to Safety Net;” Politico; https://www.politico.com/news/2020/05/05/states-cut-medicaid-programs-239208.