Five Keys to Maximizing a Medication Assistance Program

If a health system has not yet implemented an assistance program to help patients afford their medications, now is the time to start.

Many patients may face difficulties paying out-of-pocket costs on medications due to changes in their employment or benefits during the COVID-19 pandemic. Data shows that refill rates are declining as the pandemic continues, and cost is known to be a primary factor in medication non-adherence.

Pharmaceutical manufacturers have well-defined programs to assist patients with their medication copays. In fact, many of them are expanding their eligibility criteria or access to their programs during the pandemic. These programs aid patients via two methods: copay assistance, which typically decreases the patient’s out-of-pocket costs, and replacement medication, which more directly benefits the health system by replenishing a product that would otherwise not be reimbursed.

Dedicating resources to build a robust medication assistance program results in guaranteed revenue to health systems through drug replacement – as well as decreased costs for patients.

As an example, one organization dedicated 1.5 technician employees to its medication assistance program and secured $21 million in funding from manufacturer and foundation programs over two years. Alternatively, health systems can partner with a third-party vendor to implement a program, which offers cost savings without the upfront investment of labor resources and training.

Here are five things providers should evaluate when setting up a medication assistance program.

1. Primary Populations Served. The majority of patients will likely have a need for financial assistance with their medications. Specialty areas offer a strong opportunity to help patients afford medications, as they typically have greater use of branded, high-cost medications that are supported by manufacturer assistance programs. Also consider assessing internal population health metrics to target patients who had borderline control of their disease prior to the pandemic, and prioritize outreach to them. These patients may be at greater risk of missing a refill. [Related: Check out this blog on how ACO claims data helped Charleston Area Medical Center save at-risk patients during the pandemic.]
2. Prescriptions vs. Medical Benefit. Many patients and retail pharmacies are familiar with copay cards available for prescription drugs. These benefits are also available for medications covered through the medical benefit, such as infusions and oncology products that are typically provided in the office or infusion center. For health systems, coordination of benefits with patient access and prior authorization teams is important upstream, as well as with the revenue cycle team, to ensure funds are applied correctly downstream. Many institutions can benefit from both copay assistance and drug recovery efforts.
3. Payer Mix and Expected Shifts. Most patient assistance programs are available for patients who have commercial insurance, but not those with government payers like Medicare and Medicaid. However, programs also exist to help uninsured patients afford their medications. As patient coverage shifts over time, it will be important for medication assistance program staff to enroll the patient in the appropriate program and update their status to avoid a lapse in coverage.
4. Internal vs. External Resources. Options for starting a medication assistance program include training and deploying internal employees or implementing a program with a third-party vendor. If the health system has a specialty pharmacy, it likely already has many of the workflows in place and may just need to expand the elements of its medication assistance program to other areas, such as transplant or cardiology. Medication reconciliation workforce may be able to incorporate patient identification and initial intake into their workflow easily, while pharmacy technicians from low-census areas or student interns can be redeployed to support these services. Alternately, external vendors can implement a program rapidly with the right data access.
5. A Way to Monitor Returns. Tracking these efforts is essential to demonstrate a return on investment in the medication assistance program. In addition, when pharmacy can quantify the unrealized opportunities, such as increased volume and other service lines currently unaided, alongside the ROI, the team can make a case for increased resources devoted to the program.

As healthcare organizations emerge from the crisis, they’ll want to keep an eye on opportunities to simultaneously assist patients and maximize revenue.

Patients have plenty of worries on their minds right now and being able to afford their medications shouldn’t be one of them. Medication assistance programs can help patients navigate the various programs and access these resources, and providers can offer much of this guidance virtually.

Implementing or expanding a medication assistance program can directly impact the bottom line. The ROI for the pharmacy department should be quickly realized as drugs’ expenses are recovered and copays are collected from manufacturer programs.

Learn more.

• Refresh yourself on how to close the gaps between drugs purchased and drugs charged through patient drug charge validation.
• Contact us to learn how we can help maximize your pharmacy revenue.