And Brands, You Might Be the Reason Your Patients Think They Can’t Afford Their Medicines.
I miss business travel.
You learn things when you go onsite and talk to the people working at your vendors. In the pre-COVID era, I tried to avoid lunch in the conference room with the biz development team. Instead, I ate in the cafeteria and lingered by the snack machines.
I’ve learned that folks who work in Patient Support Services, particularly those in program operations, tend to be AWESOME human beings. Kindness is their core. Many of them have backgrounds as medical assistants, intake counselors, or pharmacy techs. Every time I visited a patient support hub, I was surprised by the number of staff who were also foster parents or happened to have degrees in divinity.
They are intrinsically motivated: they do this work to help people, not because they have ambitions of climbing corporate America. I’m broadly generalizing, of course. I’ve also seen newly minted MBAs working in hubs, honing their customer service skills, and building their insurance coverage chops before pursuing sales jobs. But they tend to be the exception and not the rule. The folks I’ve met while waiting in line at the vending machines or for a stall in the ladies’ room want to be of service. They tell me about coordination of benefit problems or a pesky Medicare Silver plan that has them hitting their heads against a wall. They see themselves as gladiators for patients.
I learn something new every time I talk with them.
So, it’s no surprise that anyone working in Patient Support Services will champion the notion that if it’s good for patients, it HAS to be good for the drug manufacturer in the long run, too, right? But manufacturer brand teams often de-prioritize messaging about Patient Support. They err on the side of promotional strategy, which makes sense. A brand needs to drive the decision to treat. If doctors don’t write scripts, if patients don’t ask for Medicine X, Patient Support services messaging is moot.
Ok, not so much.
- Sick Patient schedules an appointment with their health care provider (HCP).
- The HCP, thanks to your outstanding marketing campaign and a terrific sales rep, thoroughly understands the clinical efficacy and benefit of your brand’s medication for this patient’s condition. The HCP bases their decision on years of study, clinical experience, and patient assessment. The HCP decides to treat THIS patient with YOUR drug based on their previously described clinical expertise, published studies (which you may or may not have referenced in your brand materials), and your brand’s marketing campaign. Campaigns can include everything from key opinion leader conversations to targeted digital campaigns to a rep walking an HCP through a deck online.
- Sick Patient gets Medicine X without any problems.
- The pharmacy gets the sale (or, in the case of some drugs administered in a healthcare setting, the healthcare setting gets the sale).
- The patient stays on their medicine and refills it when they’re supposed to. The patient’s HCP continues to prescribe that medicine for this patient and will prescribe it again for additional new patients.
- The pharmacy purchases more medicine through the Specialty Distributor or wholesaler, who in turn buys more Medicine X from your manufacturer.
We’re cooking on all cylinders; everyone is #winning, am I right?
Except for this part: Sick Patient gets Medicine X without any problems.
Let’s be honest; this is pretty much an elusive unicorn in America’s managed care environment. Even getting a refill on an inexpensive generic can require a couple of phone calls. (Shout out to Patty for authorizing a time override so I could use my health insurance to pay for said generic.)
When I worked on the manufacturer side, I always enjoyed meeting ex-US colleagues because our worlds (as it relates to patient access) are so fundamentally different. But I digress.
Let’s get back to the not-so-easy-peasy:
🡪 Sick Patient (who has commercial health insurance provided by an employer-sponsored health plan) schedules an appointment with their HCP.
🡪 The HCP wants to prescribe Medicine X.
- The HCP can’t find Medicine X in their electronic health record (EHR) system because it’s a new product. Medicine X may not be visible in the EHR for several months thanks to drug compendia, EHR systems, and hospital IT processes. (Note: I’ll share my thoughts on e-prescribing and patient support in a future blog post.)
Let’s try to keep on the “Happy Path” and pretend that the EHR lists Medicine X. We’ll also pretend that two competitor products, Medicine Y and Medicine Z, are listed in the EHR.
🡪 The HCP checks their electronic health record (EHR) system for that patient’s formulary coverage, and Medicine X is not listed. The HCP does not know if Medicine X is unlisted because:
- Medicine X is truly not covered.
- Medicine X is covered, but the insurance plans have not updated their systems, which the EHR pulls from, to reflect coverage.
- Medicine X is covered, but the EHR system does not have real-time formulary coverage information and is only current as of the 3rd day of the preceding month (or something like this).
So, the HCP and the patient now face a decision:
- The patient can still get Medicine X, but they may have to pay for it out of their own pocket (or credit card) OR
- The HCP can prescribe something else, like Medicine Y or Medicine Z.
The list prices or wholesale acquisition costs (WAC) for one 30-day supply of these drugs:
Medicine X: $2,000 Medicine Y: $2,500 Medicine Z: $3,000
But wait. If the patient’s health insurance won’t cover Medicine X, the least expensive of the treatments available, there’s no way insurance will pay for Y or Z, Right? Wrong. Buckle up.
🡪 Sick Patient schedules an appointment with their HCP.
🡪 The HCP, based on their assessment of the patient and their clinical decision-making expertise, wants to prescribe Medicine X.
🡪 The HCP checks their EHR system for that patient’s formulary coverage. No luck on Medicine X. Medicine Y is listed as covered on the patient’s formulary as a Tier 3 drug, meaning that the patient’s out-of-pocket costs are probably a %-based co-insurance and not a flat-rate copay amount. Medicine Z is Tier 2, indicating preferred status and lower patient out-of-pocket costs. (Stay tuned for future blog posts on the how and why some drugs treating the same condition with similar price WACs end up in different formulary tiers.)
HCPs are all too aware that dollars can drive too many patient decisions. Patients facing high out-of-pocket costs are less likely to take their medicine when they should or how they should. The HCP is forced to include a nonclinical data point in their prescribing decision. Although Medicine X may be a better treatment for Sick Patient based on clinical data points, Medicine X cannot help Sick Patient if they can’t afford to fill their prescription.
What if the HCP knew that the FDA just approved the drug and Medicine X won’t show up on the EHR formulary for at least six months? What if they also knew that there is a very good chance Medicine X will be covered if the HCP submits a medical exception request to the health plan?
What if the HCP knew that Medicine X has a generous copay support program for commercially insured patients, and the patient’s out-of-pocket costs may be as low as $5/month?
Would the HCP be more likely to follow through and prescribe the medication that best matches their sick patient’s health needs in their clinical opinion?
In eight years of doing this work, only one brand director has taken me up on my standing offer to tag along during an onsite vendor visit. I recognize compliance considerations, specifically those concerns that a commercial brand leader could see patient PHI. There’s also the perception that their presence might give the program the appearance of being promotional. But, as a marketing leader, you’re not only promoting a product, Medicine X, you are also creating what the brand’s desired patient and HCP experience should be.
Successfully or not, brand messaging is communicated via imagery on copay enrollment websites, through the words chosen for a character-limited SMS reminder text or a call center agent’s tone of voice and their ease of delivery of brand talking points. As players like GoodRx and Amazon try to disrupt the pharmacy industry, brands need strong messaging about access and patient costs, or they will no longer own the story when it comes to their customer’s experience.
If you would like to discuss ways Galway Group can create Patient Support messaging that strengthens your brand’s story, email us. Let’s give your gladiators the tools they need to help your patients.