Lackluster patient experiences in access programs

Programs developed for specialty medicines suffer from negative patient experiences, according to recent research.

Recent poster abstracts peer reviewed by The Association of Managed Care Pharmacy included research on patient experience with specialty medicine alternative funding programs (AFPs), variations in payer prior authorization rates, and patient experience data in payer decision-making.

Alternative funding programs

The ongoing trend of employers trying to lower their health plan costs by excluding specialty medicines from their employee/beneficiary plan coverage, instead shifts patients toward alternative sources. These take the form of manufacturer patient assistance programs, usually delivered by an alternative funding program (AFP) vendor.

To delve into the results of this trend, the poster abstract “Access to specialty medicines with alternative funding programs: A descriptive survey of patient experiences” featured research from Hope Charities, which conducted a survey of 227 US patients to evaluate the following:

• awareness of AFPs
• experience with the patient assistance program application process via the AFP vendor
• timeliness of medication access if granted, and/or the health impact of any delay in medication access.

The survey revealed 54% of patients were uncomfortable with the AFP vendor representative, including feeling hesitation giving them their sensitive information. Taking into consideration that 61% of patients did not learn of the AFP’s role from their employer or health plan until they tried to obtain their specialty medicine, a degree of discomfort could be warranted.

It also took on average two months (68.2 days) for patients to receive their medication. Based on the delay, 24% reported worsening conditions and 64% reported that it led to stress and/or anxiety. Further, those waits led to patients considering leaving or having left their job at a rate 3-5 times higher than those who did not.

The researchers suggested “employers should consider delays in medication access along with the potential downstream impacts on employee retention and employee-employer relationships when considering implementing an AFP into their health plans.”

Prior authorization variations
Researchers from Johnson & Johnson Innovative Medicine and Symphony Health, an ICON plc company, tackled the variation of prior authorization (PA) by payers (pharmacy benefit managers and managed care organizations) to see if it contributed to inconsistencies in patient access to and treatment with specialty pharmacy products.

In the poster abstract “Variation in payer prior authorization rates is an unequal barrier to patient care,” a retrospective analysis of ICON’s Symphony Health Integrated Dataverse compared differences in PA-associated rates for seven therapeutic areas specialty pharmacy products. These included adjuvant treatment, autoimmune, blood oncology/hematology, hepatitis C, hypercholesterolemia, migraine, and solid tumor.

The patient claims were included if they had at least three claims for at least one product and the primary endpoints were PA rejection rate, abandonment rate, time to overcome a PA, and the ability of patients to overcome PA or pull through rate.

Overall, 12.69% of all claims were subjected to PA, which represented over 2 million patient lives, and resulted in the following:

• Rejected claims: ranged from 0.14% to 48% for PBMs, and 22.34% to 57.15% for MCOs.
• Abandonment rates: less than 10% for all PBMs, and MCOs ranged from 3.11% to 8.33%.
• Pull-through rates greater than 50% were found in 40% of PBMs and 20% of MCOs.
• The overall time to overcome a PA ranged from zero to 21 days.

Based on these data results, researchers concluded that the inability of patients and their providers to overcome strict PA criteria, resulting in treatment delays to patient access to medicine and treatment amplified existing health disparities.

Patient experience data in payer decision-making
The 21st Century Cures Act defines patient experience data (PED) as data collected “to provide information about patients’ experiences with a disease or condition including the impact on patients’ lives and patient preferences with respect to treatment.”

In the poster abstract “The role of patient experience data in payer decision-making,” researchers also sought to understand challenges in the implementation process and how to ensure the patient voice is captured in coverage and management decisions.

A web-based survey collected insights from 43 US payers from health plans, integrated delivery networks, and pharmacy benefit managers. An additional five more payers were interviewed via phone. Of these, 21% reported their organization has already incorporated PED in coverage decisions, 14% have plans to begin incorporating PED, and 40% are in the discussion stages. More than half (53%) expect PED to play a larger role in their decision-making over the next five years.

Clinician-reported outcomes and patient-reported outcomes are the most likely used PED. Payers would like to use PED in the following decisions:

• patient adherence (72%)
• clinical outcome assessment (65%)
• cell and gene therapy evaluation (45%)
• digital therapeutic evaluation (44%)

Data quality, reliability and lack of understanding, and interpretability were cited most likely as barriers for implementing PED in decision-making.

Payers also reported they would like to receive the following data from manufacturers:

• Data that demonstrates improved patient adherence to therapy (67%)
• Published in relevant peer-reviewed journals (67%)
• PED used in clinical trials (58%)

Based on the data above, the researchers concluded that ways of overcoming current barriers to incorporating PED should be the focus of future research.

A selection of poster abstracts is accessible in the Journal of Managed Care Pharmacy supplement. https://www.jmcp.org/doi/epdf/10.18553/jmcp.2024.30.10-c.s1