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Patient Navigation in the Specialty Pharmacy Space

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By Shelby Smoak, Ph.D. & Justin Lindhorst, MBA

The bleeding disorders community has long endured health-system-related challenges. Attending college in the early 2000s, I secured my first private insurance policy offered to students attending the university. After attempting to order factor, I was contacted and told that my policy included exclusions for pre-existing conditions and that I’d have to wait a year before the plan would cover my medication.

After one grueling year of jumping through many hoops to maintain access to my life-saving medication, I finally placed my first factor order through my insurance company. Six months after that, I hit the “lifetime max” on the plan and was forced to find coverage elsewhere. Before the passage of the Affordable Care Act, lifetime caps and pre-existing condition exclusions were some of the primary health-system-related roadblocks experienced by members of the bleeding disorder community. Today step-therapy, copay accumulators, and high out-of-pocket costs threaten or delay our access to prescribed therapies. The fact is people with chronic health conditions such as hemophilia and VWD face a range of challenges navigating our fragmented healthcare system. Patient navigation programs can help.

Patient navigation has been defined as, “Individualized assistance offered to patients, families, and caregivers to help overcome health care system barriers and facilitate timely access to quality health and psychosocial care.”1 Patient Navigators are peer, non-medical, and medical professionals who assist patients to coordinate support across the health system which can include education, removing financial and other barriers to care, assisting with insurance coverage, facilitating access to community resources, and providing emotional support.2 Research indicates patient navigation services using peer, medical, or non-medical staff are effective at resolving health-system barriers and result in improved outcomes and increased patient satisfaction.3

Within the last decades, our understanding around the positive impacts of patient navigation programs has grown. Witnessing the various forms it can take and the many different professionals who give patient navigation a voice, patient navigation continues to be a sound way to close the gaps in healthcare access and, as researchers in Cancer put it, “a strategy to improve outcomes.”4 The goal of patient navigation has remained steadfast: “to facilitate timely access for all [emphasis added] to quality standard care in a culturally sensitive manner.”5

The reality for patients is that accessing prescribed specialty therapy is challenging. Given that eighty-two percent of surveyed patients reported delays in accessing meds, a clear problem exists.6 Over half of pharmacists surveyed indicated spending 1-2 hours with patients, especially when it involves complex medications.7 An article in Journal of the National Medical Association calculated an even higher average of 2.5 hours per patient spent helping individuals reduce barriers to care.8 Today, chief among these delays are insurance issues and costs associated with medications. Pharmacies have observed these obstacles and witnessed the fragmentation of the healthcare system into compartments that do not always work well together. To reduce disruptions in treatment access, specialty pharmacies like BioMatrix are embracing patient navigation as the next evolution in high touch patient care.

Sometimes a little emotional support can go a long way. Emotional support provided by patient navigators can bolster patients as they overcome barriers. Relationship-building thus forms another root in the success of patient navigation programs. As one researcher notes, relationships between patient and navigator influenced the outcome, adding, “The process of [patient navigation] has at its core relationship-building and instrumental assistance.” 9 The success of patient navigation is shown to also depend upon the people involved. A study which examined a broad mix of patient navigation programs concluded, “The type of navigator used was not found to affect patient outcomes.” The programs studied utilized lay persons, nurses, clinicians, and physicians and indicated that the ability at relationship-building was the key factor for a patient’s success. “A common theme in each of these studies,” the authors write, “was the need for emotional or social support from the navigator.10

Patient navigation programs have proven themselves as a gateway to improved outcomes. Patients are also being more proactive and seeking avenues to gain the access to care; ninety percent of those surveyed said exactly that.11 BioMatrix has assembled a team of caring experts with years of bleeding disorder specific experience in insurance processing, social work, and education to help patients successfully resolve health system, nonclinical barriers to care. These services are offered at no cost and are available to any member of the bleeding disorder community regardless of product, pharmacy affiliation, or insurance coverage. We welcome patients to contact us so we can work together to reduce and overcome barriers to care.

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References

  1. Blackley, K., Burriss, H., Cantril, C., Kline R., Pratt-Chapman M., Rocque G., Rohan, E., Shulman, L. (2019). Patient navigation in cancer: The business case to support clinical needs. Journal of Oncology Practice. 15,11 585-590. DOI: 10.1200/JOP.19.00230

  2. McBrien KA., Ivers N., Barnieh L., Bailey JJ., Lorenzetti DL., Nicholas D., Tonelli M., Hemmelgarn B., Lewanczuk R., Edwards A., Braun T., Manns B. (2018). Patient navigators for people with chronic disease: A systematic review. PLoS One. 2018 Feb 20;13(2):e0191980. DOI: 10.1371/journal.pone.0191980.

  3. Meade CD., Wells KJ., Arevalo M, Calcano ER., Rivera M, Sarmiento Y., Freeman HP., Roetzheim RG. Lay navigator model for impacting cancer health disparities. (2014). Journal of Cancer Education. 2014 Sep;29(3):449-57. doi: 10.1007/s13187-014-0640-z.

  4. Freedman, Harold M., and Rian L. Rodriguez. “History and Principles of Patient Navigation.” Cancer. 10 July 2011. https://acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncr.26262

  5. Freeman, Harold M. “The Origin, Evolution, and Principles of Patient Navigation.” Cancer, Epidemiology, Biomarkers, and Prevention. 21.10 (2012). https://aacrjournals.org/cebp/article/21/10/1614/69026/The-Origin-Evolution-and-Principles-of-Patient

  6. Cover My Meds. “2022 Medication Access Guide.” PDF

  7. IBID.

  8. Lin, Chyongchiou J., et. al. “Factors Associated with Patient Navigators’ Time Spent on Reducing Barriers to Cancer Treatment.” Journal of the National Medical Association. 110.11 (2008). https://www.sciencedirect.com/science/article/abs/pii/S0027968415315078

  9. Jean-Pierre, Pascal., et al. “Understanding the Processes of Patient Navigation to Reduce Disparities in Cancer Care: Perspectives of Trained Patient Navigators From the Field.” Journal of Cancer Education. April 2010. https://link.springer.com/article/10.1007/s13187-010-0122-x

  10. McVay, Sheri., et. al. “The Effect of Different Types of Navigators on Patient Outcomes.” Journal of Oncology. April 2014. https://www.jons-online.com/jons-categories?view=article&artid=3665:the-effect-of-different-types-of-navigators-on-patient-outcomes&catid=18

  11. Cover My Meds. “2022 Medication Access Guide.” PDF

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