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Healthcare Challenges and Solutions Discussed at the PAN-AJMC Cost-Sharing Roundtable

Surabhi Dangi-Garimella, PhD
The event saw participation by patient advocacy groups, health economists, health policy researchers, and patient advocacy groups-the primary interest of the participants was to identify the healthcare-associated economic hardships faced by patients and their caregivers across therapeutic areas and discuss potential solutions that could help alleviate some of this burden.
The Patient Access Network (PAN) Foundation, in collaboration with The American Journal of Managed Care (AJMC), hosted a Cost-Sharing Roundtable on February 26, 2016, at the Henry J. Kaiser Family Foundation’s Barbara Jordan Conference Center. The event saw participation by patient advocacy groups, health economists, health policy researchers, and patient advocacy groups—the primary interest of the participants was to identify the healthcare-associated economic hardships faced by patients and their caregivers across therapeutic areas and discuss potential solutions that could help alleviate some of this burden.

Mollyann Brodie, PhD, executive director, Public Opinion and Survey Research, Kaiser Family Foundation (KFF), was the first speaker of the day. During her talk, Taking the Pulse of Americans: Cost-Sharing and Access, Brodie spoke about 2 recent surveys conducted by the Foundation. KFF’s tracking poll found that paying for healthcare ranks third among patients’ economic concerns,   right behind income not keeping up with prices and not having enough after retirement. Half of Americans surveyed for the study said they are either skipping or postponing care to compensate.
A variety of cost sharing can increase patient burden, Brodie said, adding that 20% of patients blamed the high deductible of their health plan while 15% blamed their health insurance premium. “What we found is that 1 in 4 surveyed, who were between 18 and 64 years old, said they had a problem paying their medical bills last year,” which included 53% of uninsured, 26% covered by private insurance, and 47% who had a disability. Coinsurance, copays, and deductibles were the major cause of economic trouble for 75% of the non-elderly insured.

Brodie noted that a majority of people who blamed seeking care from an out-of-network (OON) provider as a reason for their cost burden were just not aware the provider was OON. “Hospital and [emergency department] visits made up the largest share of their bills; as did laboratory fees and diagnostics,” she said.

However, there were those who were aware and had done their research to avoid these avoidable costs. These consumers said they:
1.      followed a cost-conscious behavior
2.      checked with doctors office and health plans to understand the cost of care beforehand
3.      shopped around for best price
4.      negotiated with the doctor/hospital

However, 49% of these individuals recounted that it was somewhat difficult to find and adequately use this information. “So consumer efforts may not be the only policy solution here,” said Brodie.

Case Studies

The next few presentations were case studies from various patient advocacy groups who shared their patient data and discussed the most common problems encountered by their patients.
Katherine Sharpe, MTS, senior vice president, Patient and Caregiver Support, American Cancer Society (ACS), said that newly diagnosed cancer patients hear only 30% of what their doctor share with them. “Then they call us at ACS,” said Sharpe. “Those that do contact us with cancer diagnosis are facing significant financial distress as a result of their diagnosis. This makes it imperative for us to make them understand the financial resources available to them. We have a Health Insurance Assistance Service (HIAS) for this, which was initiated a decade ago. What we learnt through HIAS helped position us around healthcare reform.”

“We have seen a shift over time, post [Affordable Care Act]. We have folks not able to afford their copays and deductibles—they are really strained on finances.”

However, a commonly encountered problem, Sharpe said, was being insured but not covered—insurance does not “cover” most of the services patients need for their cancer treatment. With high cost-sharing for covered benefits, lack of adequate coverage was most often encountered by patients. For patients faced with unaffordable copays and coinsurance cost sharing for chemotherapy and radiation can quickly accumulate. “This should not only be a concern for patients and caregivers, but also for the medical community and policymakers,” Sharpe added.

Representing the National Community Oncology Dispensing Association, Inc, or NCODA, was Nancy Egerton, PharmD, BCOP, manager of Pharmacy Services, New York Oncology/Hematology and vice president of NCODA.

“Oral cancer medications are exploding,” said Egerton. “We at NCODA help with in-house dispensing to reduce some of the financial burden.”

NCODA includes 2000 clinical providers from diverse practices of all sizes and it also represents a large payer mix, Egerton said, adding, “Dispensing at the physician’s office could be a very good practice.” To improve efficiency, the in-office dispensing (IOD) practice staffs completes all the pre-authorization formalities right on site, which hastens the process, said Egerton. IOD also works with clinicians and their staff to adapt to frequent dose changes based on patient outcomes, to avoid wastage.

Since Medicare patients do not qualify for assistance from pharma plans/coupons, NCODA uses foundations like PAN to help cover patients’ medication costs.

Leah McCormick Howard, JD, vice president, Government Relations and Advocacy, National Psoriasis Foundation (NPF), stressed the importance of paying attention to the patient’s overall health and not just treating the disease symptoms. “Two-thirds of patients with psoriasis complain of mental stress like anger, frustration etc.”

Controlling the intense pain and whole-body inflammation associated with the disease is important, Howard said. “The challenges is that access problems often stand in the way. In many cases, it comes down to cost.” Financial implications of their treatment often stands between patients and their drug. Once they have access, there’s utilization management issues, she said.

NPF launched a strategic plan in 2014 to improve health outcomes and accelerate discovery for psoriasis. Organizational efforts, Howard told the audience, included legislative and regulatory solutions, patient and assistance support, and engagement with health insurers.

 A group that supports hepatitis C patients, National Viral Hepatitis Roundtable (NVHR)/Project Inform, presented next. Christine Rodriguez, MPH, senior policy manager and Andrew Reynolds, hepatitis C education manager, told the audience that curing hepatitis C not only improves the quality of life for the patient, it’s also good for society, is cost effective, and reduces overall healthcare costs.

“Step therapy does not work with hepatitis C and all the new drugs are tiered,” said Rodriguez. “Medicare and commercial insurance plans have come up with utilization and cost sharing models for these expensive drugs, and patients are faced with increased cost sharing.”

They then proposed some direct service solutions to tackle this growing problem. HELP-4-HEP is a phone support line that helps people through the continuum of hepatitis C care, Rodriguez said. A policy solution, she said, include Project Inform Project Inform which provides advocacy to include hepatitis C funding and policy issues at the national and California state levels.

“NVHR serves as a convener to bring people together to share best practices, to identify and overcome barriers at the state level,” said Reynolds.

Following the case studies, the 2 winners of the PAN Challenge Grant on Cost Sharing Strategies presented their winning papers. These will be included in a special supplement to be published by AJMC in March.  

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