Editor’s Note: Dr. Jerilyn Arneson is a board-certified oncology pharmacist, revenue integrity pharmacist, and Medicare benefits counselor with more than 22 years of experience in healthcare. As the manager of multiple infusion center pharmacies, she initiated a Medication Assistance Program (MAP) that eventually expanded to 10 infusion centers. She’s trained medication assistance coordinators, patient advocates, and other professionals to be tenacious until their patients receive the treatment they need. Dr. Arneson serves as the Director of Sales Solutions Support at CoverMyMeds and as a board member of the National Association of Medication Access and Patient Advocacy (NAMAPA).
“Has Mr. Woods shown up yet?” I asked the infusion center pharmacy staff.
“No, the nurses marked him as a no-show again today,” the other pharmacist answered.
“Hmm, don’t you think it’s odd this is the second dose of chemo he’s skipped. No phone call or anything?”
The other pharmacist shrugged. “You’d think they’d show up for something lifesaving like chemotherapy.”
I thought the same thing, and I had to find out why. As an oncology pharmacist, I was concerned too much time had passed, allowing us to lose any progress we’d made with his previous doses. Thinking maybe he just needed a ride to the infusion center, I called Mr. Woods and asked him if everything was OK.
He bluntly replied, “No one told me how much this drug was going to cost. I got two treatments and now I owe the hospital $60,000. I can’t pay for this and I’m not leaving these bills for my kids. Now the hospital won’t stop calling me.”
A few days later, a drug rep brought in lunch and talked to us about a new drug. Coincidentally, it was the drug Mr. Woods was receiving. We were all shocked by the price tag, but the drug rep also introduced us to a new member of his team, a Field Reimbursement Manager or an “FRM.” The FRM told us about their company’s copay assistance and free drug programs. I also knew Mr. Woods quit his job when he became too sick to work and was now uninsured, so I immediately asked the FRM if he met the criteria for the free drug program. The FRM handed me the application to fill out and that was my introduction to patient assistance or “financial navigation.”
Seeking Answers to the Affordability Crisis
At the beginning of my journey in 2017, I searched across every infusion center in our health system and couldn’t find anyone who knew how to solve this trend of patients racking up exorbitant bills. Patients were refusing novel treatments with great results but also with price tags we’d never seen before. I asked more questions than I got answers:
- Why didn’t we tell patients how much their treatment cost before they received it?
- Why was it OK to assume the patient would want this treatment if they didn’t know how much it would cost?
- Would a patient buy a car without first knowing the price?
- How do we find out how much the patients owe the hospital?
- Why isn’t anyone using these financial assistance programs?
I looked everywhere for information on how to connect the dots. The Association of Community Cancer Centers (ACCC) had a great online course, but I quickly realized I was in over my head. It was tailored for people with a revenue cycle background with extensive knowledge of insurance benefit designs, the complex prior authorization process, and various aspects of billing and coding. The topic of Medicare alone was overwhelming. Senior Services of Southeastern Virginia provided me with a four-level, seventeen module course for free if I volunteered four hours of my time every week by providing Medicare benefit counseling to new beneficiaries. It was a big commitment, but I was determined to conquer Medicare.
Partnering with Revenue Cycle Teams
Most electronic health records (EHRs) keep patients’ clinical and financial records siloed from one another. This ultimately prevents clinical personnel from knowing if patients are struggling with financial toxicity. With my level of EHR access, I wasn’t able to see what a patient’s deductible, coinsurance, or out-of-pocket maximum was or how much of each remained for the year. I also had difficulty obtaining patients’ explanation of benefits (EOB), which is essential to submitting claims for manufacturer copay or foundation assistance. Finally, I couldn’t see individual accounts or if patients had an outstanding balance.
So, I partnered with a member of our revenue cycle team who had access to the information I was missing. Without a clinical background, she had gaps in her knowledge as well. Unsure of whether medications were brand-name or generic or their cost, she repeatedly asked me, “How do I know whether a drug has a copay assistance or free drug program?” I explained that she could check NeedyMeds, Google it, or potentially spend hours searching manufacturer and foundation websites for affordability programs, but she might still come up empty-handed. Logistically, she also couldn’t coordinate the shipping and receiving of the free drug, whereas this is a routine task for pharmacy personnel.
By combining our individual EHR accesses, backgrounds, and training, we were able to develop a rough workflow. Those early successes were major wins for us. We started reaching out to additional stakeholders not only within our own organization, but also to outside organizations whose programs we wanted to replicate. After finding out that other organizations were granting pharmacy personnel access to key financial data in the EHR, we formally requested and were granted the same level of access.
Streamlining Navigation to Reach More Patients
After gaining insight into the patients’ financial statuses, we were shocked by the overwhelming number of patients in need. Once hospital staff members knew about our team, we became overloaded with referrals from nurses and social workers treating patients struggling with extreme debt. How were we going to reach the astonishing number of patients in need by manually searching for affordability programs and filling out countless applications with the limited number of pharmacy staff dedicated to help?
Although our goal was to screen every patient prior to treatment, we ultimately resorted to addressing the most severe cases of financial toxicity. We began to hear about software platforms that housed information on thousands of affordability programs and matched patients with relevant resources, based on their insurance coverage and other factors. Contemplating the year I’d spent learning how to manually match each patient with the correct program, I thought about how many more people we could have helped if we’d access to a tool like TailorMed.
Launching a Pharmacy-Led Navigation Program
I can attest that pharmacists and pharmacy technicians wear many hats and have a wealth of knowledge and expertise that is not always fully recognized or utilized. Hospital pharmacies are increasingly recognizing the value of pharmacy-led financial advocacy programs, which help ensure patients receive the care they need without facing undue financial burden.
I get excited now when hospital pharmacy directors and oncology and infusion center pharmacy staff reach out to me with the same struggles I faced. They often have the same question I had: “Where do I start?”
To get a pharmacy-led financial navigation program off the ground, I recommend focusing on the following four areas:
- Process: Start small by focusing on your highest dollar infusion and injectable medications that are administered most frequently in your infusion center. If your team can’t access the patient’s insurance information and/or they’re unsure which patients are eligible for each program, they should go to the manufacturers’ websites and electronically enroll or fill out the applications for patients receiving those drugs. By checking the “Benefit Investigation” box on the application, they’ll receive a “Benefit Summary” including the patient’s deductible, coinsurance, out-of-pocket maximum, and how much is remaining of each. The Benefit Summary will also let them know if the patient is eligible for copay assistance, free drug, or if no assistance is needed, as well as next steps.
- Training: While pharmacy teams often have the desire to help patients overcome affordability challenges, they may not be aware of all the financial resources available or how to identify and enroll eligible patients. They may also be unfamiliar with revenue cycle processes, like I was when I started my journey. By training pharmacy technicians to verify insurance eligibility and benefits, obtain prior authorizations, and provide financial navigation, pharmacists can start to take ownership of the entire revenue cycle for infusion drugs and help close the loop on denied claims.
- Collaboration: All too often, a hospital’s financial assistance capabilities are siloed and decentralized–with various departments and functions handling different parts of the process. Pharmacies can be instrumental in establishing a coordinated, standardized approach. Just as I partnered with my revenue cycle colleague, pharmacy staff should collaborate with counterparts to fill in knowledge gaps and combine efforts.
- Technology: Pharmacies can get a head start by utilizing financial navigation technology like TailorMed, thereby taking out the time-consuming system of manually matching patients to an available program and letting the software streamline the process. These platforms also make it possible to flag patients in need on the front end, before they face a bill they can’t afford.
By providing financial navigation services, pharmacy teams can prevent patients from skipping doses of lifesaving medications or not showing up for necessary treatments, making them invaluable allies in the fight for affordable healthcare.