Editor’s note: At the 2023 Asembia Access to Pharmacy conference, our CEO Srulik Dvorsky discussed the challenges of healthcare affordability and the largely untapped potential of financial assistance. Drawing on data from TailorMed’s robust network, he offered a roadmap for pharmacies and providers to maximize cost-saving opportunities for patients, while improving their own financial performance. Read below and watch the presentation video above.
It’s a given at this point: Healthcare in the United States is unaffordable. I could rattle off numbers showing patients’ high out-of-pocket responsibility, rising rates of prescription abandonment, and the impact on patient care. I could even share the experiences of patients who’ve had to choose between lifesaving treatment and basic necessities like rent or groceries. But the truth is, we’ve all seen the statistics. We’ve heard the stories. And we know that affordability is a major challenge for patients, providers, pharmacies, and the entire healthcare ecosystem.
What I really want to talk about is the solution: Healthcare organizations have a massive opportunity to address cost barriers to care. Numerous financial assistance programs exist, offering a whopping $58 billion in available aid. These resources include drugmaker copay assistance, disease-specific foundation grants, government programs, free and replacement drug programs, and funds to cover living expenses.
But here’s the problem. Despite the availability of these programs, utilization rates among providers, specialty pharmacies, and retail pharmacies remain disappointingly low. This means eligible patients are not able to take full advantage of these financial resources–which has a ripple effect on all parties involved.
The question is: Why are these resources so underutilized?
At TailorMed, we’re in a unique position to answer this question. Our network includes 13.4 million patients, 133,000 physicians, 534 hospitals, 1,045 clinics, and 594 pharmacies, accounting for 87.6 million prescriptions.
Given our broad reach, we’ve come to several conclusions about the root causes of this underutilization. While many healthcare organizations have established financial navigation or advocacy programs to address affordability, these programs are often limited by three factors:
- Narrow program scope
- Lack of clearly defined business drivers
- Lack of operational alignment
To address these gaps, it’s time for providers and pharmacies to change their mindset. Here’s how:
Root Cause #1 – Narrow Scope
Financial Toxicity: Not Just a Cancer Problem
Financial toxicity is well-known in cancer care, but patients with other conditions also face significant financial burdens. For every eligible oncology patient, there are hundreds if not thousands more patients with other chronic conditions who need help accessing available resources. Plus, many cancer patients have costly, co-occurring diagnoses.
From a pharmacy perspective, this narrow view of financial toxicity leads to missed opportunities to save costs. Faced with unaffordable medications, patients may go to a different location or pharmacy–or they simply won’t get the care they need.
To put it another way, if you look at the universe of prescriptions, breaking it down by eligible patients for copay cards, foundation grants, and free drugs, we see that most healthcare organizations are only capturing a fraction of what’s available. That’s because many organizations–particularly on the provider side–are only trying to capture copay assistance for buy-and-bill cancer patients.
By working towards expanding our idea of who is affected by financial toxicity, we can reach more patients and ensure no one is left behind.
Root Cause #2 – Business Drivers Are Not Defined
Financial Toxicity: Not Just a Patient Problem
Patients are at the heart of the affordability problem. However, financial toxicity also has a huge impact on provider and pharmacy bottom lines. When patients cannot afford their medications, providers face uncompensated care and bad debt. Medication nonadherence also leads to treatment interruptions and poorer health outcomes. This, in turn, results in increased healthcare expenses down the line, such as emergency room visits or hospitalizations, which are costly for providers.
At the same time, pharmacies lose revenue when patients delay or abandon their prescriptions. In addition, the administrative burden associated with managing patients’ financial challenges can be time-consuming and resource-intensive.
Thus, administrators of financial navigation programs should orient their business drivers in a way that demonstrates the program’s contributions to their health system or pharmacy’s overall financial health. These results will motivate the organization’s leadership to support the program and invest the resources needed to scale it.
Root Cause #3: Lack of Operational Alignment
Building a Strong Foundation for Program Success
A strong foundation is key to effectively address the widespread impact of financial toxicity. To optimize financial assistance, healthcare organizations should focus on building foundational pillars in these three areas:
Across the nation, providers and pharmacies are understaffed and face skyrocketing burnout rates. Health systems are experiencing labor shortages, high turnover, and low bandwidth. Ensuring staff have the knowledge, training, and capacity to identify at-risk patients, match them with assistance programs, and guide them through the process poses a significant challenge.
Larger specialty pharmacies with dedicated, highly skilled teams are typically in a better position. But would a pharmacist in a retail store have the time or resources to address a patient’s cost concerns? Most often, the answer is no.
While financial assistance should be a coordinated, organization-wide effort, this function is often decentralized–with various teams and service lines performing similar actions reactively and in silos. Providers and pharmacies should standardize processes and adopt a proactive approach. This means developing systems that promote a holistic view of the patient, for all medication encounters–anywhere a prescription is written or dispensed. It also means evaluating patients early on and creating multiple touchpoints, so that problems are identified before they result in unpaid bills or abandoned medications.
Adopting technology solutions that streamline the process can enhance operational efficiency and reduce friction for staff already operating at full capacity. These solutions enable staff to maximize cost-saving opportunities and expedite enrollment. They also allow financial navigation programs to track results, helping leadership make data-informed decisions and demonstrate program success. Newer solutions also empower patients to find medication assistance options and take a more active role in their own financial experience.
Pave the Way to a Paradigm Shift
Addressing financial toxicity and ensuring access to affordable medications is crucial not only for patients but also for pharmacies and providers’ financial sustainability. To achieve the best outcomes for all stakeholders, we must explore the root causes of the underutilization of financial assistance programs.
From there, providers and pharmacies can develop a compelling business case for investing in the people, processes, and tech power that will increase utilization–and ultimately boost their bottom lines. Only then can we reach a much-needed paradigm shift to solve the affordability crisis plaguing patients and the entire health system.
Is your healthcare organization interested in optimizing its financial assistance capacity? We’re here to help. Get in touch with us for an opportunity assessment.