“You keep using that word. I do not think it means what you think it means.” –Inigo Montoya, The Princess Bride
I was in a brand meeting, and a senior leader pointed to a dashboard and very animatedly referred to BI turnaround times as catastrophic: in one case, as long as 20+ days.
I had no idea what he was talking about. I was lost. I was supposed to be leading the charge to facilitate patient access, and insurance coverage is definitely part of patient access. BI stands for Benefits Investigation, which should take, well, minutes to obtain thanks to the magic of the interwebs and health plan insurance portals… Weeks?
I want to insert an off-topic but relevant side note:
Ladies, if you are sitting at a leadership table, whether as a teammate or an external consultant, remember: someone thought it was worth paying you to be there. We all suffer from impostor syndrome. BUT, women are far too quick to doubt themselves. I know I did in this situation. It is easy to get rattled by tone or title or a question that feels like an accusation (but really, it is only a question). You may feel a burning red flush race up your cheeks (me, thanks a lot, sympathetic nervous system), but you do know what you know.
So, I asked, “What are you calling a BI? What does that mean to you?”
And it turned out that what he was calling a BI was the time elapsed from receipt of any patient referral form (not-a-correctly-filled-out-and-complete-with-signatures form) by the Hub to when the SP dispensed the drug.
My Hub and Practice Manager sisterhood can tell you: that is not a BI.
But he said so on an executive dashboard. And some decisions, specifically some important commercial strategic decisions, relied (in part) on what that dashboard communicated.
WARNING: Dropping down to sea-level for a minute.
For those of you who have never had the thrill of having to email your teammates (again) because someone changed the password for shared login credentials to an insurance portal:
- A BI is a report outlining the expected medical or prescription drug coverage through a patient’s health insurance plan.
- Back in the day, you would fax a BI request to a health plan, and they would fax a BI back. Some plans even had a fancy phone system where you could call, never speak to a human, punch a bunch of keys… and still have to wait for a fax back.
- Version 2.0 involved logging into an insurer portal to look up a BI in real-time.
- Version 2.5 is sometimes a repeat of Version 2.0, coupled with the ability to ping a BI request from within your organization’s CRM (or EHR, if you’re working with a health system) against some database of plan benefits.
- Version 2.8 is a self-service model (aspirational*) where a patient’s health care provider (HCP) can submit the BI request directly, online via a branded or brand-agnostic portal, and see BI results instantly.
- Version 3.0 is an ideal model where a prescriber or staff can run a BI instantaneously with no more than a few mouse clicks from within their EHR. If it requires prior authorization or some additional information, that process is initiated automatically without further ado.
Even the completely fax-based process from back in the olden-days typically had one-day turnarounds.
Back to our brand dashboard story. He was wrong. 😛
True, he didn’t need to know the background bulleted above.
BUT he labeled his numbers with jargon he did not understand and shared them in an incorrect context.
The good news? The correct data elements had been accurately captured, de-identified, and aggregated across multiple vendors. He had the right numbers. AND there was more good news: he wanted to learn, and he was willing to prioritize that conversation with me. THEN we could have a juicy discussion:
- Coverage: Did HCPs refer only their tough-to-crack insurance cases to the Hub? Were coverage determinations reflecting the same intel that the manufacturer’s payer accounts team had?
- Program return on objective (Hub): Would a patient get on therapy faster if the HCP sent the prescription directly to the SP? Was there one particular health plan or payer that would not respond to third-party inquiries without the patient on a conference call? Or a payer that required the HCP to use a specific ePA provider? Were we using the Hub to solve a contracting issue?
I once received a way-too-late at night email from a colleague (shame on her for writing it at that hour, and shame on me for being online, working, and ready to read it). She was reviewing my update on a new brand’s copay program. She was confused by how I determined copay program utilization. When she calculated the following,
# of patients who had used copay support at least once
total # of patients enrolled in the copay program
her number did not match mine. Her math was correct, but her understanding of what I meant by copay utilization was incorrect. And that was my fault.
I threw up Copay Utilization: xx% on a slide with no footnote, no explanation of standard industry metrics, and assumed it had relevance for the audience. Totally my bad.
Copay Utilization =
# of Rx where copay support applied
# all commercial Rx filled over the same time period
If you’re responsible for your brand’s gross-to-net revenue, you better believe that copay utilization and average benefit spend become super sexy numbers (or decidedly not).
In my experience, independent of the manufacturer, there is this weird tension between brand leadership and patient support services. One prides itself on being strategic and is quick to label the other (sometimes, dismissively) as “operations.” The other has a chip on its shoulder about doing “the real work” and rolls its eyes when their colleagues use SLAs and KPIs interchangeably. Both may agree on a common goal– patients using innovative, effective therapies to improve their health and hopefully improve or extend their lives– but how they achieve that, respectively, can be fundamentally different.
Gentle reminder (Patient Support): If you do not involve your brand leadership in your program reviews, start now. Invite them to sit in on a call calibration, where they can listen to patients and prescribers. Include them in QBR planning, and ask your vendor partners to report on changes in volume or utilization after any new brand campaigns went live (umm, which means you should know when your Brands are launching new messaging).
Not-as-gentle reminder (Brand Leadership): Involve your Patient Support colleagues in your decision-making. You are responsible not only for your brand’s look/feel but also for your patient’s experience with your brand. Especially now, in this COVID-era, your patients and prescribers want concise, accurate information about the patient experience. Your Patient Support folks can help you understand what’s happening in the real world right now.
*aspirational, because if you’ve ever worked in a clinic, you know that prescribers LOVE it when you take them out of process or force them to do something new that does not directly tie into clinical care. No, not really. THEY HATE IT. Trust me on this. Someday I’ll write about a doctor who threw a $100 bill at me when he had a tantrum over having to type in an EMR. True story. I can laugh about it now, but I was in tears at the time. Don’t make prescribers log in to your portal. Don’t ask patients to download an app. Just. Don’t. I’ll explain more in an upcoming blog post.