Approximately 116 million prescriptions for specialty therapies are filled in the U.S. every year, write Erica Conroy and Meagan Sampogna in Pharmaceutical Commerce.
The rate of prescription cancellation for specialty drugs tends to be higher than the rate for non-specialty medications. Even when these prescriptions are filled, the time between prescription and the first paid fill is often longer than it is for non-specialty treatments.
There are several hurdles that can result in prescriptions going unfilled. These include challenges in meeting administrative requirements, securing preauthorization and finding funding.
The 2022 CoverMyMeds Medication Access Report reveals that 49 percent of surveyed providers feel they lack access to the benefits information they need to start patients on specialty therapies. To get this information, 61 percent of providers say they work with patient support services whom they typically contact manually, whether online, by phone, by fax or even through the mail. Only 10 percent said they contact patient support services through an EHR or EMR system.
Enrollment in patient support services can reduce time to first paid fill and increase paid fill rates, but only if enrollment itself does not become an issue. When providers communicate with patient support services manually, the process is somewhat opaque. The patient or the support services team may fail to complete enrollment for any number of reasons, none of which may be apparent to a provider or practice manager.
Using the Hub can make enrollment hurdles easier for providers and practice managers to spot. When enrollment isn’t completed, missing information is flagged automatically. Practice managers or providers can then reach out to patients or other involved parties to complete the enrollment process.
Better transparency and enrollment support appeals to providers as well. A Decision Resources Group study found that 68 percent of responding physicians preferred to prescribe treatments when the manufacturer offered strong patient support services. Patients are also more inclined in a tech-driven world to participate in their own care with one-stop platforms and app use, writes Aaron Crittenden, GM of manufacturer solutions at GoodRx.
Coverage for Specialty Therapies
“Will the patient’s insurance cover this treatment?” That’s a common question in rare disease treatment, and it’s also one that arises relatively early in the treatment process. By analyzing Claritas Rx internal data, we’ve found that among patients with non-life-threatening illnesses who do not fill their prescription, 80 percent cite coverage issues as the reason.
The coverage question can influence providers’ decision-making when it comes to prescribing treatments — and delays in answering the question can lengthen the time to first paid fill or result in a prescription cancellation rather than a paid fill.
“Prior authorization helps plans and PBMs [pharmacy benefit managers] to proactively limit excessive costs and inefficient utilization for expensive specialty drugs,” writes Jonathan Starr at Cotiviti. To achieve this goal, prior authorization systems require patients and treatments to meet certain criteria before the payer will agree to pay for the cost of a specialty treatment.
Although less than 2 percent of the population relies on specialty medications, these drugs account for over half of all annual pharmaceutical spending, writes Jennie Iverson, senior director of product management at Evernorth Health Services. These cost discrepancies mean that payers’ use of prior authorization processes will likely persist.
For providers and patients, however, prior authorizations often present more in the way of obstacles than solutions. Payers’ lack of tools to track the outcomes of prior authorization decisions also result in a lack of data about the relationship between prior authorizations and their stated goals of improving efficiency and utilization, writes Starr.
Within a comprehensive platform, information about prior authorizations and payer policies is easier to access. Notice of an incomplete prior authorization application is immediate, and the ability to file an appeal is right at the user’s fingertips. Better payer engagement can shorten the time to first paid fill and increase the paid fill rate.
Once granted, a prior authorization may answer the question “How will the patient afford this treatment?” for some patients with private insurance. Yet not all payers may cover a particular treatment at 100 percent, even if they grant a prior authorization.
Some patients may be left to make up the difference. Others never have the option to access private insurance; these patients may rely on public payer plans or have no coverage at all. The rise of specialty carve-outs in private payer plans has also created situations in which insured patients nevertheless do not have the funding support they need to access a particular treatment, says Adam J. Fein, CEO of Drug Channels Institute.
The Patient Advocate Foundation lists several ways patients may meet funding needs for a particular medication or medical supplies. These include using:
- Disease- and location-specific drug assistance programs.
- Store loyalty programs.
- Manufacturers’ drug assistance programs.
The burden of seeking out each program, assessing eligibility and applying can prove daunting for patients, even with support.
To improve access to specialty medications, the National Council for Prescription Drug Programs recommends in a 2022 white paper that “a frequently maintained, accurate central repository” offering access to patients, providers and payers be used to share information related to funding, distribution and patient support services.
Such a central digital repository can collect funding support information from a broad range of sources. It can also determine quickly whether a particular patient meets each source’s eligibility criteria and, if so, how much financial support that source can provide.
Patients who successfully enroll in the Hub or other forms of patient support, secure prior authorizations and address funding support needs can still find their time to first paid fill delayed by factors outside their control.
These factors include any number of non-clinical delays or holds, like supply chain issues, inclement weather and other distribution challenges. For instance, an October 2022 shortage of medications including Adderall was traced back to a shortage in amphetamine mixed salts, a key ingredient, as manufacturer Teva experienced “ongoing intermittent manufacturing delays,” according to a release from the FDA.
Limited distribution networks (LDNs) may help manufacturers overcome certain challenges related to distribution. Yet they can hinder or baffle providers and patients. Incorporating the work of integrated health system specialty pharmacists can improve communication and reduce barriers that lengthen time to first paid fill or result in a prescription never being filled, write Megan E. Peter and fellow researchers in a 2022 article in PLoS One.
The factors that can lengthen time to first paid fill or turn a fill into a cancellation are legion. Yet at least one common solution can address all these issues: Improved communication among patients, providers, practices, payers, pharmacies, distributors and manufacturers.
In a 2022 study, Meghan Hufstader Gabriel and fellow researchers concluded that “multidisciplinary coordination between pharmacies, physicians, and managed care organizations is essential to ensure patients receive medications in the necessary time frame to optimize health outcomes.”
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