More than half the U.S. population lives with chronic disease, according to the Centers for Disease Control and Prevention. Patients cycle in and out of hospitals, starting and stopping treatment plans they can’t always afford, and although the specialty therapies patients need are often cost-prohibitive, many biopharma companies struggle to fund the co-pay and affordability programs that are now more important than ever, as external threats such as accumulator models and high-deductible health plans (HDHPs) make them less viable.
So, what can we do about it? Four things. Through machine learning built on proprietary data, RxCrossroads by McKesson has identified four principal affordability barriers and is tackling them with highly intelligent and targeted strategies to help emerging biopharma companies create efficient, effective affordability programs that will help patients stay on their therapies. Here’s how.
1. Addressing Prior Authorization Cost Implications
As more specialty therapies come to market, payers have attempted to control spending by increasing prior authorizations (PAs). This has placed additional burden on patients, who face therapy delays or denials. Coverage alternatives are essential for these patients.
An exclusive integration between RxCrossroads’ LoyaltyScript® co-pay program and CoverMyMeds’ PA Reach℠ technology gives patients a closed-loop solution to address the PA cost barrier. LoyaltyScript® allows patients whose PAs have been rejected to submit co-pay claims and receive the treatment they need throughout the PA appeals process. Meanwhile, their co-pay claim data triggers a notification to a PA support specialist, who attempts to resolve the issue. If their PA denial is overturned, RxCrossroads notifies the pharmacy to reverse and rerun payment under the patient’s primary coverage, lowering the brand’s expense. If the PA denial is upheld, RxCrossroads can help the patient identify other avenues to secure funding.
To date, RxCrossroads has successfully overturned 42% of PA denials and secured more than $3.5 billion in co-pay assistance for patients.
2. Mitigating Accumulator Plan Impact
Co-pay programs are often the only thing getting patients through their out-of-pocket expenses until their coverage kicks in, which means accumulators used in high-deductible health plans to prohibit co-pay program-funded expenses from applying to deductibles only exacerbate problems for patients. Payers want to minimize costs, but preventing patients from paying down their out-of-pocket costs with a co-pay program is not a good solution. In fact, it often increases costs, since when patients can’t afford their medications, they’re more likely to be nonadherent, more likely to have worsened conditions and more likely to have emergency room visits.
RxCrossroads is addressing this crucial problem with unique solutions. The Accumulator Predictor Tool™ identifies brands and patients most likely to be impacted by accumulators, allowing RxCrossroads to find alternative payment options and offer adherence support for at-risk patients. Another tool, DeductAssist®, helps patients overcome financial hurdles to minimize the accumulator impact. These tools help emerging biopharma companies maximize their access and adherence budget dollars out of the gate through strategic targeting.
3. Minimizing Questionable Cash-Card Behavior
Pharmacy-administered cash discounts that supplement or replace co-pay cards may help promote loyalty and patient traffic for the pharmacy, but they also pose threats when used in a way that diverts co-pay program funds away from their intended use.
RxCrossroads’ Cash Card Exclusion Logic℠, integrated with RelayHealth’s pharmacy technology, leverages proprietary machine-learning algorithms to minimize questionable cash-card behavior by stopping cash-card use if a patient is without commercial insurance coverage or paying for a government-funded drug, driving significant savings for brands.
4. Combating Co-Pay Program Abuse
Despite increased state and federal scrutiny, co-pay assistance programs are vulnerable to anomalous activity. Fraudulent claims have been on the rise in recent years, typically occurring at the pharmacy and varying widely in scale. These impose significant costs on the healthcare system.
A team of RxCrossroads data scientists leverages proprietary machine learning to protect co-pay programs from anomalous pharmacy activity, analyzing new trends and creating actionable algorithms to identify anomalous data patterns and score them appropriately for risk. This technology enables RxCrossroads to implement targeted co-pay protection strategies that increase program efficiency and efficacy for brands.
The Future of Co-Pay
These trends and obstacles will continue to evolve, and so must the technology to monitor them. Continued investment in advanced data analysis, multiplatform integration and proprietary technologies is essential. As a market leader in access, affordability and adherence, RxCrossroads is dedicated to combating and solving these issues.
To successfully bring new therapies to market amid ever-increasing affordability barriers, emerging biopharma companies need data-proven solutions and consultation to effectively target and fund co-pay programs. If patients can’t access the therapies they need, we don’t have a healthcare system that works. At RxCrossroads, our goal is to make sure we do. These four solutions are a good starting point.