At a time when many people are struggling to afford even the most basic necessities, patients who rely on specialty drugs may find the challenge of paying for these lifesaving medications to be insurmountable. 

Specialty therapies are abandoned more frequently than any other type of medication, and cost is often the reason why. Even when specialty therapy may mean the difference between life and death, patients simply aren’t able to afford treatment. 

Many specialty pharmacies recognize the challenge of affordability and have programs in place to help patients get the help they need. For organizations whose ethos revolves around holistic and high-level care, financial assistance is an important piece of the patient care puzzle. 

But just because a specialty pharmacy has a financial assistance program doesn’t mean it’s fully optimized. Plagued by problems such as decentralization and staffing challenges, many of these programs aren’t functioning as well as they could be—impacting both patients and the organization’s bottom line.

A financial assistance program’s maturity largely depends on the size of the organization and whether it has the people, processes, and technology in place to make the most of all available resources. Assessing the maturity level of your pharmacy’s program is the first step toward optimizing it.

Program Maturity in Four Stages 

The maturity of a specialty pharmacy’s financial assistance program can be broken down into four stages: initial, progressive, mature, and optimized.

1. Initial

Smaller infusion center organizations are most likely to be at this stage of maturity, as most larger specialty pharmacies know they’re dealing with high-cost medications, and have made patient financial assistance a top priority. 

At a smaller organization, there may be some awareness that these infusion/specialty drugs are expensive, but there aren’t resources or a standardized process to help patients with affordability—or staff specifically assigned to the task of helping patients find financial assistance.

A member of the team may review the patient’s insurance, provide an out-of-pocket estimate, and inform the patient about payment plans. They may even point patients with commercial insurance in the direction of copay cards. But they don’t help patients with the enrollment process. Staff also lack the time or training to navigate patients towards other forms of assistance, such as foundation funds.

This stage is also characterized by a lack of key performance indicators (KPIs) and methods for tracking program results, such as how many patients were assisted and how much funding was secured. 

How to level up:

  • Form a team specifically to help patients navigate financial assistance. Ensure the team has clearly defined roles and responsibilities.
  • Develop a proactive process to flag patients in need, connect them with available resources, and establish KPIs to measure success.
  • Streamline processes and maximize assistance opportunities by leveraging end-to-end financial navigation solutions.

2. Progressive

At the progressive stage, the organization may offer patients support with financial assistance, but there’s lack of clarity around which team is doing what. Financial assistance is too often handled reactively, after a patient gets a bill for a medication they can’t afford, rather than proactively at patient registration. 

Staffing gaps and lack of specialized training may make it hard for pharmacies to provide financial navigation. For some larger specialty pharmacies, staff dealing with assistance may be call center staff who may have, at best, some rudimentary experience in the medical field. Directors or Leads on those teams may have prior experience as a pharmacy tech or similar role, but aren’t sufficiently trained around financial assistance. Faced with this lack of expertise, companies work to make the process simple when it should be optimal. 

Staffing issues may mean the team recognizes gaps in the enrollment process for assistance. However, team members may not be able to guide patients through the entire process. For example, they might provide a link to the drug manufacturer’s website, but leave it to the patient to enroll in a copay card program. 

How to level up:

  • Focus on “up-training” and “up-skilling” teams that work with patients so they are more knowledgeable about financial assistance. These teams should not just know how to be empathetic and talk to patients, but also how and where to look for financial resources. 
  • Ensure patients have the support they need to follow through on assistance enrollment.
  • Create proactive vs. reactive workflows.
  • Leverage technology to identify patients at risk of nonadherence and match them with resources.

3. Mature

At this stage, organizations have a clear strategy and a proactive process that involves immediately identifying patients in need and seeking out assistance opportunities at the time of registration. Before the patient even begins therapy or medication, they have a conversation with a trained team member about financial assistance. 

The organization may have a team/s that proactively reaches out to patients who are at high risk of nonadherence due to cost. If the team sees that the drug is going to cost $10,000 a month out-of-pocket, for example, they reach out to the patient on the front end rather than waiting for the patient to call in distress because they can’t afford their medication. 

The organization uses a hands-on approach with patients by not simply identifying assistance options, but taking the process as far as they possibly can to ensure the patient actually follows through.

At this stage, the program isn’t just relying on copay cards and free drugs. They also understand the value of foundation funding. Applying for foundation funds requires more steps and greater knowledge than copay cards, and funds often open and close quickly. The organization has a team in place that not only understands the benefits of foundation funding, but also understands the process—and how to maximize the number of patients enrolled.

The program utilizes intelligent workflows and leverages technology rather than relying on outdated manual systems like spreadsheets. Applying a change management approach, the team has not only the ability but also a willingness to navigate away from outmoded systems. (Otherwise, the organization may train 200 people to use a technology solution, but only 50 will actually use it.) The program also has defined KPIs and is efficiently tracking these numbers.

How to level up:

  • Continue checking processes for standardization and enhancement opportunities. 
  • Review and audit your technology regularly to ensure it stays aligned with leading practices.
  • Assess any workforce/resource needs and consider implementing a service to address staffing gaps and optimize assistance.

3. Optimized

At this stage, key staff are firmly in place. The organization has a trained financial assistance team, staffed by professionals who understand assistance vs. staff who have a general idea. Whether working remotely or in person, this trained team has financial navigation knowledge and proactively reaches out to the patient on the front end.

Standardized processes are also firmly in place. The organization has the ability to not only set KPIs, but also to report on them. They also have a change management structure (such as a training team). 

Workflows are streamlined and highly efficient in order to maximize potential savings for the greatest number of patients, and technology is optimized.

How to level up:

  • Review KPIs and identify opportunities for further optimization.
  • Conduct time studies to assess efficiencies and effective use of technology.
  • Keep teams motivated and actively involved in program execution. 

Taking Your Program to the Next Level

Once you understand where your pharmacy’s financial assistance program lands in terms of maturity, you can work to take it to the next level. By training staff and leveraging technology to improve efficiency, you can achieve optimization—helping patients and boosting financial performance. 

Wondering how mature your pharmacy’s assistance program is? Contact our team to find out. Based on your program’s maturity stage, we offer detailed tips for optimization.