Speeding Access to Therapy—How Prescribers, Specialty Pharmacies, and Patients Can Work Together

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Patients benefit from accessing a prescribed therapy quickly - but many are faced with barriers that can delay the start of treatment.

According to a survey of specialty pharmacy industry professionals, 70% felt that there is room for improvement in speed-to-therapy.1 It’s critical for patients, prescribers, and specialty pharmacists to understand their role in minimizing barriers to timely treatment. Here, we discuss three of these barriers and how they can be minimized.

1. Communication Barriers

In an ideal world, every stakeholder does what they can to get patients their medication as quickly as possible. However, missing or incorrect patient information on referrals1 as well as lack of communication from the patient can slow down the process. Here are some tips on how each stakeholder can improve their communication.

Patient
Prior to starting treatment, the pharmacist typically reaches out to the patient to discuss insurance coverage of the prescribed medication, review the therapy plan, answer any questions, and schedule the best time and place to receive the medication. Picking up the phone and/or returning these phone calls from the pharmacist ensures that treatment can begin as quickly as possible.

Pharmacy
Pharmacists can help improve communication with prescribers by confirming information from a referral and collecting any missing information as soon as possible. When contacting prescribers to manage drug interactions or suggest changes to therapy, pharmacists should never assume the prescriber will recall the patient, their health information, and/or prescribed therapy. Prescribers typically have a high volume of patients and may need to be informed of an individual’s scenario. Pharmacists should describe the patient and their issue succinctly and accurately.2

Prescriber
One common culprit in slowing down start to therapy on the prescriber side is the use of error prone abbreviations. For example, ‘TIW’ (3 times a week) can be commonly mistaken for ‘3 times a day’ or ‘twice in a week’.3 This chart contains instances commonly reported through the ISMP National Medication Errors Reporting Program (ISMP MERP) as being frequently misinterpreted. Prescribers should avoid abbreviations, if possible, when submitting referrals.

2. Payer Related Barriers

Payers need to verify that a certain drug, procedure, or treatment is medically necessary before extending coverage—i.e., prior authorization. However, prior authorization as well as denials and appeals can slow down access to therapy. Some data suggests that prior authorization issues account for nearly 50% of delays in treatment1. Here are some tips on how each stakeholder can help minimize these challenges.

Patient
Dealing with insurance issues or appeals can be a frustrating and challenging process for the patient. To proactively navigate coverage challenges, the patient can:

  • Make tracking a part of everyday life:
    - Keep detailed records, and document every call with the insurer
    - Document the medical necessity of the treatment
  • Appeal payer denials. Sometimes patients realize denials can be appealed. Every plan’s process for filing an appeal varies. Patients should check with their insurance provider to determine the specific appeal process. Patients can involve their medical provider and specialty pharmacy for additional assistance.
  • Understand how prior authorizations function within one’s coverage—especially during open enrollment. Patients can learn more about identifying prior authorizations and other mechanisms that can cause ‘slow downs’ in health care here.

For more helpful tips on how patients can navigate payer related barriers, click here.

Pharmacist
It’s important for the pharmacist to help the patient understand their specialty insurance coverage. This includes support in therapy initiation, payer outreach, benefit investigation, prior authorization, appeals management, and connectivity to manufacturer patient access services. The pharmacy team can also help support prescribers during the prior authorization/appeals process.

Prescriber
For prior authorization, the insurance company will generally require the prescriber to submit notes and/or lab results documenting the patient’s condition and treatment history. This takes a lot of time to manage. To minimize prior authorization denials the prescriber can4:

  • Implement an electronic prior authorization filing system. This avoids manual error of inputting wrong or missing patient information.
  • Be familiar with the payer policy, prior authorization process, and requirements
  • Make a list of the drugs payers will cover for common diseases and/or rare diseases within the prescriber’s specialty

3. Financial Barriers

High deductibles and coinsurance are being shifted at higher rates from employers and payers to the patient5. Many patients with chronic conditions requiring costly treatment simply can’t afford these cost-sharing requirements, delaying much needed treatment. Both the patient and specialty pharmacy can help minimize these financial barriers.

Patient
If a patient has insurance gaps or is uninsured, patient assistance programs (PAPs) step in to provide financial assistance for treatments at little to no cost. PAPs can also help chronically ill patients and their families pay for utilities and other non-healthcare related items that fulfill vital needs and improve quality of life.

Here are some examples of patient assistance programs:

To learn more about patient assistance programs, click here.

Pharmacist
While PAPs can help speed access to therapy for patients, the application process is generally complicated. Specialty pharmacies can help identify co-pay assistance programs and connect patients with the right resources for enrollment.

If the patient is using a manufacturer or other third-party copay assistance program, pharmacists can also check for copay accumulators—i.e. whether or not payments from their assistance program are being applied to their out-of-pocket costs.

At BioMatrix, we value timely access to care. This is how we help maximize speed to therapy:

  • The patient’s prescription is set up in our system after receiving a referral within 2 to 4 hours. We contact their prescriber to confirm we received the referral and collect any missing information.

  • After confirming information with the prescriber, we reach out to the patient directly to review their referral, set expectations, and make sure they have all of our relevant contact information.

  • During this time the BioMatrix team also performs a benefits investigation to determine the patient’s insurance plan design, coverage of prescribed medication, and home nursing services (if applicable). We share with them how and where the therapy is covered and explore options for financial assistance and co-pay support where applicable.

  • For specialty drugs that require a prior authorization, we work with the prescriber and insurance plan to facilitate timely approval.

  • If needed, we find and qualify home nursing for the patient’s home infusion/injection.

  • Prior to dispensing therapy, we schedule a call with the patient to review their therapy plan and answer any questions they may have. We conduct a brief clinical assessment and final quality and safety checks. We then schedule the best time and place for the patient to receive their medication.

  • We provide tracking information for the medication shipment and confirm delivery upon receipt. As the patient begins treatment, the BioMatrix clinical team is available around-the-clock to support them on their journey to better health.

Our services are designed to remove burden, improve health, and make life easier for patients with chronic, difficult to treat conditions. BioMatrix is proud to make a difference in the communities we serve, one patient at a time.

1. Duey M. (2013). Speed-to-Therapy Insights in Specialty Pharmacy. Pharmacy Times. https://www.pharmacytimes.com/news/speed-to-therapy-insights-in-specialty-pharmacy

2. (2019). Tips For Effective Communication Between Pharmacists and Prescribers. Pharmacy Connection. https://pharmacyconnection.ca/communication-between-pharmacists-prescribers-summer-2019/

3. (2014). Prescriber–patient–pharmacist communication is crucial. APhA. https://www.pharmacist.com/article/prescriber-patient-pharmacist-communication-crucial

4. Ward V. The Shocking Truth about Prior Authorization Process in Healthcare. ReferralMD. https://getreferralmd.com/2018/04/prior-authorization-problems-healthcare-2/#:~:text=At%20this%20stage%2C%20the%20patient,Ultimately%2C%20the%20product%20is%20approved

5.Partnership to Fight Chronic Disease. (2019). Framework to Address High Cost Burden for People with Serious Chronic Conditions. https://www.fightchronicdisease.org/resources/framework-address-high-cost-burden-people-serious-chronic-conditions

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