developing a medication access program - ushp - home
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Developing a Medication Access Program
No Financial COI to Disclose
•While we mention situations involving off-label usage, we will not discuss the off-label usage of specific medications.
Pharmacist Objectives1)
2)
3)
4)
5)
Who are we?
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HCH Infusion Center
Factors that Generated the Need for a MAP
1.
2.
3.
4.
5.
What is Not Considered a Factor for a Medication Access Program?
a)
b)
c)
d)
Why Focus on Prior Authorizations?
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What was done before?
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What Changed?
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Patient Convenience!
Key components of a MAP program
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Medication Access Process
Continuous Improvements:
Standardized process
Dedicated PA Staff
Expanding multidisciplinary coverage
Ongoing Challenges:
New insurance hurdles
More expensive medications
More non-standard processes
ACA - ?
Bridging the Gap
CPhT
Disease state & Tx
PharmD
Pharmacist Role in PA Process
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Pharmacist
Prior Authorizations
Nurse
ProviderMAC Tech
Patient
What is Not a Pharmacist Task?
a)
b)
c)
d)
Sarcoma Clinic Flow Chart (Old Process)
Sarcoma Clinic (New process)
Pharmacist Time in Clinic
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Misc, 10%
Technical, 27%
Professional, 29%
Clinical, 34%
AMBULATORY PHARM D MARCH 2015
Misc, 9%
Technical, 5%
Professional, 42%
Clinical, 44%
AMBULATORY PHARM D NOVEMBER 2016
Benefits of a MAP•
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Technician Objectives•
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Innovative Role for CPhT
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MAC CPhT
A Day in the Life of a MAC Tech. . .
• Miscellaneous Activities
• Training & Meetings
• Lunch & Breaks
• Other Technical Activities• Documentations
• Workqueues
• Patient Interaction
• PAP Activities• PAP Enrollment
• Ordering & Inventory
• PA Activities• Benefit
Investigation
• Prior Authorizations
• Appeals
24.3%
24.3%
12.5%
38.8%
Which of the Following is an Innovative Role for a Technician?
a)
b)
c)
d)
What is Medication Access?
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Barriers to Access
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Categories of Assistance
Insurance
Copay Assistance
Access Programs
• Copay Cards
• Foundations
• Free Drug
• Replacement Drug
Definitions - Insurance Terminology
• Amount patient must pay before plan will share costs.
Deductible (Ded.)
• Flat fee for service
Copay
• Percentage-based fee for service
Co-insurance (Co-ins.)
• Once patient has paid this amount the insurance plan will pay 100% of costs for the remainder of the contract.
Out-of-Pocket Max (OOP)
Expen$afil
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•Expen$afil
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Comparison of patient costs with & without copay assistance.
$10,000
$50,000
Cost Sharing
Patient Insurance
$175
$50,000
$9,825
Cost Sharing
Patient Insurance Copay Assistance
Patient pays $10,000 total Patient pays $175 total
Getting Started: What do you need?
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Getting Started: Who do you need?
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Which of the Following is Not aFunction of a MAC Tech?
a)
b)
c)
d)
How is Success Measured by the. . .
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The Real Measure of Success.
“It has made all the difference!”
“I am awed by and grateful for your staff, in particular (Technician) whose help in finding ways to pay for and finance medications for this disease are swift, timely and compassionate.”
Measuring Success
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What Metrics Should Not Be Used to Measure Success?
a)
b)
c)
d)
Number of Prior Authorizations (IV/PO)
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
# O
F M
ED
ICA
TIO
NS
AU
TH
OR
IZE
D
# of Prior Authorizations by Month
Patient Assistance - Quantity & AWP
0
20
40
60
80
100
120
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
# O
F O
RD
ER
S
$ V
AL
UE
(A
WP
)
2016 - PAP Tracking by Month
Write-offs
-100,000.00
-50,000.00
0.00
50,000.00
100,000.00
150,000.00
200,000.00
250,000.00
300,000.00
350,000.00
400,000.00
2016/02 2016/03 2016/04 2016/05 2016/06 2016/07 2016/08 2016/09 2016/10 2016/11 2016/12 2017/01 2017/02
Conclusion•
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Questions
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