The 4-step process for creating a hub program that actually puts patients first
By Ian Ocilka
Every patient services program, or hub program, claims to keep the patient journey in mind. But how many hub services providers actually put in the rigor required to create a journey that addresses the breadth of patient needs – much less how those needs change from therapy to therapy?
Each pharmaceutical brand’s hub program comes with its unique set of challenges, but when viewed from 10,000 feet, building one that is poised for success comprises a linear, four-step process.
It begins with enrolling the patient in the hub program; followed by verifying their benefits and tackling the managed care hurdles that too often stand between a patient and therapy; coordinating prior authorizations and affordability concerns such as copay and patient assistance program enrollment, bridge support, and alternative assistance through a third-party foundation or find- ing an alternative site of care – essentially any hurdles that may occur after the cost of therapy has been determined; and finally, fulfilling the prescription, whether that results from physician acquisition, known as buy and bill, or a specialty pharmacy, either under a pharmacy benefit or an assignment of benefits under medical benefits.
Enrollment channels continue to evolve
While the old-school method of faxing is still used as an enrollment method with-in hub programs, a provider portal offers a powerful way for physicians to enroll patients in a hub program and track their progress throughout the process. This is a particularly popular tool for buy and bill products, such as medications requiring infusions or injections, including those designed to treat MS or orthopedics.
Enrollment tools continue to evolve rapidly, and while traditional enrollment channels maintain their purpose, the market is shifting toward digital tools such as electronic patient enrollment form (ePEF) solutions. These online fill- able PDFs or webforms connect directly to the hub and launch patient intake upon submission.
Expect greater use of non-commercial pharmacies (NCPs) to enroll patients as they accept e-prescriptions directly from a prescriber’s EHRs. For products covered under pharmacy benefits in particular, including treatments such as oral oncolytics, self-injected medication, and other treatments that are not injected or infused by a physician, the NCP can serve as a valuable enrollment channel.
The NCP is a pharmacy associated with the HUB that can accept e-prescriptions, so the provider simply needs to prescribe the medication to the NCP. A hub partner works with brands to set up aware- ness and training assets regarding the NCP as the intake channel for enrollment into hub services. The NCP makes the starting process simple, automated, and seamless so the remainder of the patient support services can be put to work.
For example, physicians treating asthma patients who have found little relief from inhalers and other therapies are able to prescribe a biologic directly to the manufacturer’s HUB’s NCP. Rather than exiting the patient’s EHR and manually filling out a patient enrollment form, the physician selects the NCP to receive the prescription for the drug, just like they would any retail or specialty pharmacy at the point of prescribing.
Similarly, specialists prescribing other specialty medications, such as a self- injector product to treat osteoporosis, are able to do so via the NCP, never having to leave their existing workflow.
Providers don’t need to enter the patient data because it is already in the EHR, and the relevant information is automatically transferred to the prescription. In-workflow EHR prescribing can give patients access to the medication days or even weeks faster. The time providers would normally have spent deal- ing with enrollment can now be used where it belongs: with their patients.
Patient consent also figures into the enrollment process. Considerations need to be made in terms of what the hub services provider offers as well as how much emphasis a brand wants to place on consent in order to collect and share patient data. This data can be particularly valuable for a field reimbursement manager (FRM), who through a hub provider’s dashboard can see where a specific physician’s patients are in their prescription journey and help with any is- sues that may be holding up their access to medication.
Brands should also work with their hub partner to consider offering a mobile tool that allows patients to manage their prescription journey f rom their own de- vice, determining such a tool’s feasibility based on the type and complexity of medication, seriousness of illness, and other factors. For many patients, using a tool on their mobile device can be a sim- ple and seamless way to access support services and connect to alerts, reminders and support communities, ultimately helping to boost adherence.
Identifying patient financial options is key to the verification process
Often, there is little customization that goes into the benefit verification process f rom a patient journey standpoint. The key is understanding how a medication is covered and how to get a patient on the product. However, determining the right financial option for a patient’s course of therapy represents a critical step and can make the difference be- tween a patient starting and staying on therapy or not.
In a situation in which a patient visits the physician and then goes to another location for therapy, (i.e., an infusion clinic or center of excellence), benefit verifications can change slightly, and customization may be required. It may be necessary to identify whether a particular infusion center is considered in-network under a patient’s plan, and if not, it would be necessary to identify alternative locations. It may also be necessary to capture out-of-network benefits, because it could be more economical and convenient for the patient to pay out-of-network costs versus having to drive an extra 50 miles to go to a location that is in-network.
If patients are eligible for a copay card, hub services providers should have the ability to automatically enroll them at
the touch of a button through the hub provider’s CRM system. And whereas determining if a patient who is either un- insured or functionally uninsured (mean- ing insurance will not cover a patient’s medication, period) qualifies for f ree medication f rom the manufacturer used to mean gathering and submitting docu- mentation, online income verification now makes it possible to determine a patient’s eligibility for a patient assistance program within a matter of seconds based on demographic information, without the need for documentation.
Coordination: a payer-physician-driven interaction
Seamless coordination between the payer, patient, alternative site of care, and the physician arguably represents the most important step in the process. The physician must prove to the payer that the patient meets the clinical criteria, through submitting a prior authorization or a letter of medical necessity, and multiple care providers must be in lockstep with the HUB and the patient.
For drugs that require a patient to visit an infusion center, coordinating the movement of patient information f rom the prescribing physician to the infusion center is critical so the center can schedule the appointment and ensure a chair is available, and alerting the physician of the date the infusion appointment is taking place is equally important.
In the case of an oral drug or a self- injectable, the focus is on coordination around patient communication. Providing thoughtful updates, answering questions, and striking the right balance between not inundating patients with too much information while making sure they don’t feel their process has fallen into a black hole is crucial.
While the traditional prior authorization (PA) process of the payer sending documentation to the physician to complete by hand and fax back to the payer can take several days, pharmacy ePA incorporates the entire process into the EHR. The physician can complete the documentation and send it electronically to the payer, which can render a decision if not in real time, certainly within a much shorter time frame than the manual process. And since the hub provider can monitor the interaction within its system, it can step in when appropriate to push the process along and remind the physician to complete the PA.
Adopting a holistic approach to co- ordination that combines oversight of electronic processes, consideration of the pros and cons of bridge or quick-offer programs, and the use of advanced processing for patient assistance programs and assistance support is increasingly important. It is vital that a brand’s hub program has comprehensive processes during the coordination phase to help en- sure managed care hurdles are cleared or alternative funding is secured to transition the patient to permanent coverage.
The fulfillment process is mainly pharmacy driven. If a product is being sent to a specialty pharmacy for fulfillment, balancing the types and number of patient touchpoints is critical. What are the right communication methods for a particular patient? What are the motivational drivers that will get that patient to take action when needed and not be a passive participant in the process? Identifying the optimal combination of tools to connect with and motivate patients is an import- ant consideration.
Connecting with patients is a critical step to therapeutic success, and greater attention is being paid to the fulfillment phase of the journey where there are often delays in connecting patients with pharmacies for product shipment.
Every therapy is different, and every patient is unique. Only with a deep understanding of both can we create an effective hub program that leverages the four functional phases to ensure a recommended therapy actually gets into the hands of patients who need it.
Ian Ocilka is COO of ConnectiveRx.