Showing posts with label Insurance. Show all posts
Showing posts with label Insurance. Show all posts

Monday, September 18, 2017

Costly drugs to weigh on U.S. employers' expenses in 2018: survey

Costly drugs to weigh on U.S. employers' expenses in 2018: survey
(Reuters) - U.S. employers are bracing for higher health care expenses in 2018 as spending on new drugs to treat diseases such as cancer, multiple sclerosis and hepatitis C is expected to rise more than 7 percent, according to consultancy firm Mercer.
Between 40 and 50 new specialty drugs are set to hit the market each year in the next five years, which could increase costs by $25 billion annually, Mercer said.

Wednesday, July 12, 2017

Collaborative Approach to Improve Prior Authorization Efficiency in the Treatment of Hepatitis C Virus

Evaluating a Collaborative Approach to Improve Prior Authorization Efficiency in the Treatment of Hepatitis C Virus
Dunn, Emily E. PharmD; Vranek, Kathryn PharmD; Hynicka, Lauren M. PharmD, BCPS; Gripshover, Janet CRNP; Potosky, Darryn MD; Mattingly, T. Joseph II PharmD, MBA
Quality Management in Health Care: July/September 2017 - Volume 26 - Issue 3 - p 136–139
doi: 10.1097/QMH.0000000000000137

Full Text Article Online

Abstract
Objective: A team-based approach to obtaining prior authorization approval was implemented utilizing a specialty pharmacy, a clinic-based pharmacy technician specialist, and a registered nurse to work with providers to obtain approval for medications for hepatitis C virus (HCV) infection. The objective of this study was to evaluate the time to approval for prescribed treatment of HCV infection.

Methods: A retrospective observational study was conducted including patients treated for HCV infection by clinic providers who received at least 1 oral direct-acting antiviral HCV medication. Patients were divided into 2 groups, based on whether they were treated before or after the implementation of the team-based approach. Student t tests were used to compare average wait times before and after the intervention.

Results: The sample included 180 patients, 68 treated before the intervention and 112 patients who initiated therapy after. All patients sampled required prior authorization approval by a third-party payer to begin therapy. There was a statistically significant reduction (P = .02) in average wait time in the postintervention group (15.6 ± 12.1 days) once adjusted using dates of approval.

Conclusions: Pharmacy collaboration may provide increases in efficiency in provider prior authorization practices and reduced wait time for patients to begin treatment.

Chronic hepatitis C virus (HCV) infection represents a major health system challenge for the United States, with approximately 3 million prevalent cases that could increase spending on pharmaceuticals substantially to treat eligible patients.1,2 Prior to the first direct acting antiviral (DAA) medications receiving approval, this disease had classically been treated with ribavirin and pegylated interferon. Newer DAA therapies have become the standard of care for patients with chronic HCV infection due to efficacy and tolerability.3 Economic models demonstrate the cost-effectiveness of these therapies and that the decline in work productivity reported in patients with untreated HCV infection leads to an estimated $7.14 billion in lost work suggesting that treating HCV infection in these patients would lead to an annual productivity savings of $2.7 billion over a 1-year horizon.4–6 Despite potential advantages of treating patients with these new therapies, strategies to control spending have created additional restrictions that may create barriers to care for many patients.7

Prior authorization is the process by which insurance companies determine whether treatment is medically necessary for an individual based on his or her diagnosis and condition. DAA therapy usually requires prior authorization or preapproval from third-party payers due to high costs. Do et al8 found in a real-world HCV-infected cohort that 1 in 5 patients were denied access to these medications upon initial request. The majority of these initially denied patients eventually did receive prior authorization through the appeals process, with only 10% of patients unable to receive approval, indicating a potential administrative barrier that delays treatment of those who should be eligible.8

The administrative time involved in processing authorization requests to providers and health systems may impact overall clinic operations and efficiency, as well as add complexity for patients navigating the system. Communication between patients and providers throughout the HCV infection treatment cycle has been identified as a critical component of uptake and perception of patients' treatment experiences.9 Additional time spent by clinic staff on administrative burdens poses an operational challenge that could increase wait times for HCV-infected patients or reduce the amount of time spent on providing education, information, or support. Patients undergoing treatment for HCV have also expressed a desire for multidisciplinary services, so incorporating collaborative processes that include physicians, nurses, and pharmacists could help enhance the patient experience.10,11

The high cost of DAA therapy over the course of 3 to 6 months creates a situation where any factors reducing the overall effectiveness of the treatment could eliminate the downstream cost-savings as fewer patients reach clinical cure. Patient-centered research in HCV infection has identified limitations of the medical system as a potential barrier to treatment adherence and completion.9 Long wait times to receive care may diminish the real-world effectiveness of these therapies, as patients frustrated with the system may become less engaged.9 The objective of this study was to evaluate the effectiveness of one collaborative approach implemented at a large urban academic medical center (MC) to obtain prior authorization approval for HCV therapy.

METHODS
In 2014, the MC implemented an interdisciplinary team-based approach to obtain prior authorization approval for HCV therapy. The authors observed the clinic's prior authorization office practice. Following an internal review of process time and workflow, the authors developed a new workflow and proposed a team-based approach by training and creating a new role for an advanced pharmacy technician as a billing specialist for the clinic. A trained pharmacy technician was designated to work within an outpatient hepatology clinic alongside a new registered nurse coordinator to obtain prior authorization approval for medications for HCV infection. Before implementation of this process, the specialty pharmacy had no direct access to patients' clinical information. Pharmacy staff relied on clinical information necessary for prior authorization approval being faxed to the pharmacy by a nurse within the clinic.

Clinic providers electronically prescribe medications for HCV infection to the MC pharmacy for patients who wished to fill their prescriptions at this pharmacy. The clinic-based pharmacy technician gathers any necessary clinical information from the providers, nursing staff, or electronic medical record (EMR) directly and coordinates the prior authorization process to obtain necessary documentation required by the patients' pharmacy benefits manager (PBM). The registered nurse assisted in ordering laboratory tests and scheduling patient visits for the clinic. The pharmacy technician also submitted information to PBMs, requiring laboratory results after 4 weeks of treatment. Examples of required clinical information include HCV genotype, HCV RNA viral load, previous treatments, biopsy results, medical history, and fibrosis score. Upon approval, the pharmacy technician communicates with the specialty pharmacy and the patient to coordinate pick up or delivery of the medication.

A retrospective, observational study design was used to describe wait times before and after process implementation. This pilot included a convenience sample of any patients treated with at least one DAA therapy from the clinic during the observation period. The interdisciplinary team-based process was implemented in November 2014. Patients treated between January 2014 and October 2014 were included in the preintervention sample to capture patients on newer DAA regimens that were approved in November and December 2013.12 Patients treated between January 2015 and April 2015 were included in the postintervention sample. Patients treated in November 2014 and December 2014 were excluded from the sample to allow for a washout period as the technician transitioned into the clinic. Patients were excluded from the study if their prescriptions for DAA therapy were not processed as of June 5, 2015.

Outcome variables
The primary outcome evaluated was the wait time between the date the prescription was written and when the prescription was approved and processed by the pharmacy. In the postintervention group, the clinic-based pharmacy technician maintained electronic records of the dates prior authorization approval was received from the PBM. For the preintervention group, the approval date was unknown but the pharmacy processing date was available. For comparison, an unadjusted average wait time was calculated using prescription written date and process date and an adjusted average wait time was determined in the postintervention group using the time from the written date to date of approval.

Data collection and analysis
Demographic information was collected from the EMR. The dates the patients' prescriptions were written and processed were obtained from pharmacy claims. Prior authorization approval dates were collected from records maintained by the clinic-based pharmacy technician. For patients on regimens that included multiple medications for HCV infection, the latest date that a DAA was approved/processed was used. The mean wait times preintervention and postintervention were compared using a t test, and categorical data were compared using the χ2 test for independence using SAS version 9.4 (Cary, North Carolina). This study received approval from the university institutional review board on April 7, 2015.

RESULTS
Sample demographics
A total of 180 patients were included in the sample; 68 patients (38%) were included in the preintervention sample, and 112 patients (62%) were included in the postintervention sample (Table 1). There were no differences in sex (P = .66), race (P = .26), and age (P = .48) between the 2 groups. The postintervention group was more likely to be infected with genotype 1 (P = .006), be prescribed a single prescription (P < .0001), and be prescribed ledipasvir/sofosbuvir (P < .0001). The differences in regimens were likely due to the fact that ledipasvir/sofosbuvir was approved in October 2014.


Wait times
In the unadjusted model, the change in average wait time (P = .13) between the preintervention group (23.4 ± 24.5 days) and the postintervention group (18.3 ± 15.7 days) was not statistically significant. The reduction (P = .02) in average wait time was statistically significant in the postintervention group (15.6 ± 12.1 days) once adjusted using dates of approval (Table 2).
Table 2

DISCUSSION
The average wait time observed in the preintervention group is similar to the wait times observed in other research regarding prior authorizations of HCV infection treatment.8 Do et al8 found that approximately 1 in 5 prescriptions for HCV therapy are initially denied by PBMs, which require provider appeal. Introducing a collaborative approach to processing prior authorizations between pharmacy and the clinic staff resulted in a reduction in the time between the provider ordering the medication and the pharmacy's awareness that the medication had been approved by the PBM. In addition to the reduction in mean wait time in the adjusted model, the spread in the distribution of times was reduced as seen by the reduced standard deviation in both unadjusted and adjusted models. From a customer service standpoint, more precision with wait times allows the clinic and pharmacy teams to manage patient expectations and improve satisfaction with service.13 A multidisciplinary approach may also improve the customer experience, as previous studies have found high patient satisfaction associated with collaborations between physicians, nurses, and pharmacists in the care of HCV-infected patients.9,11

This study adds a new approach using a trained clinic-based pharmacy technician resource within an outpatient clinic along with a registered nurse coordinator to facilitate prior authorization approvals. In addition to streamlining processes for prior authorization and improving communication between departments, this collaboration provided an advancement opportunity for a well-trained pharmacy technician. Pharmacy technicians have been previously utilized in billing specialist roles in health systems, but little research has been published demonstrating positive outcomes for patients or systems utilizing technicians in this role.14

The initial success of the program has encouraged expansion of a second pharmacy technician trained to serve 2 other clinics within the MC system.

Limitations include the reliance on pharmacy claims data as a proxy for approval times in the preintervention sample and the unavailability of denial information. Other variables may influence the time between insurance approval and final pharmacy processing, such as patient out-of-pocket costs or other patient-level factors. The lack of information around insurance denials or prescriber appeals in the preintervention group also limited this study in analysis of intervention effectiveness. As a retrospective observational study, patients were not randomized to the intervention and control groups, limiting the internal validity of the results provided. However, this pilot provides reasonable estimates for prior authorization times to power a stronger prospective investigation and demonstrates a potential innovation for health system pharmacy practice to improve efficiencies in this process.

Third-party payers often have different requirements for patients to be approved for therapy that may vary from medical guidelines. This study did not evaluate the appropriateness of DAA therapy selected or whether adding a trained pharmacy technician would impact compliance to payer HCV infection treatment guidelines.

Future research may warrant evaluating payer guideline compliance for initial submission for approval, as both submission and review require administrative labor and effort from providers, pharmacies, payers, and patients.

CONCLUSIONS
Designating a pharmacy technician and a registered nurse to work directly within specialty clinics may lead to system efficiencies for patients prescribed medications that require complex prior authorization processes. Pharmacy departments working directly with providers and nurses to navigate the third-party payer system may enable more prompt initiation of therapy.

REFERENCES

Thursday, April 6, 2017

VA Official: Use of Cape Regional by Vets May Be Announced in 30-60 Days

VA Official: Use of Cape Regional by Vets May Be Announced in 30-60 Days
By Al Campbell
WILMINGTON, DEL. – Vietnam veterans who rallied on March 25 in Wildwood and Ocean View for health care facilities in Cape May County may be within 60 days of having their demands met.

Vincent Kane, interim associate director of operations, Wilmington Veterans Affairs (VA) Medical Center, confirmed March 29 that discussions of partnership with Cape Regional Medical Center have been ongoing.

Kane said he had discussions with some of the veterans who voiced concerns at the rally. One, in particular, who told of wanting to be tested for Hepatitis C, and told he had to wait until December, got Kane's attention....
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Tuesday, April 4, 2017

High Drug Prices Remain a Conundrum, Analysts Say


High Drug Prices Remain a Conundrum, Analysts Say

Possible solutions: government price negotiation, bundled payments
by Joyce Frieden
News Editor, MedPage Today

WASHINGTON -- The problem of high prescription drug costs has no easy solution, analysts said Tuesday at an event here sponsored by Johns Hopkins University.

"It's a major problem ... and there's no light at end of tunnel," said Joshua Sharfstein, MD, associate dean for practice and training at Johns Hopkins University's Bloomberg School of Public Health in Baltimore.

Overall drug costs are growing 10%-12% a year, "far quicker than wages or medical cost growth," he added. "And it inhibits our ability to address public health problems. When we have a challenge like hepatitis C, when people can't get treatment because of the [high cost], we're all at risk."

Although many ideas for solving the problem are being discussed, none are moving forward, Sharfstein said. He noted that things could get worse if, for example, Congress were to pass something like the House Republicans' American Health Care Act, which would have resulted in the loss of health insurance for an estimated 24 million people.
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Friday, December 2, 2016

HCV Experts Discuss Impact of Trump Administration​ AND Got Hep B and Worried About the Trump Effect on Your Obamacare?

Article Published Online @ Healio
HCV experts discuss impact of Trump administration​
Results of a Reuters/Ipsos poll taken during Nov. 9-14, 2016 indicated that more than 20% of Americans wanted President-elect Donald J. Trump to focus on health care in his first 100 days in office. However, when HCV Next reached out to a cross-section of experts for commentary on exactly what Trump could realistically expect to accomplish in health care, and how he would accomplish it, there were more questions than answers. Of note, some experts declined to comment.
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Article Published Online @ Hepatitis C Foundation
Got Hep B and Worried About the Trump Effect on Your Obamacare? Experts Say No Changes Expected Before 2018
By Christine Kukka
It is time to sign up, re-enroll or change your health insurance plan in the Affordable Care Act’s Health Insurance Marketplace, also known as Obamacare. Millions of Americans – many of them with pre-existing medical conditions such as hepatitis B — get their much-needed health insurance through this plan.

But President-elect Donald Trump has promised to repeal the Affordable Care Act (ACA), which funds the program, and now Republicans will have control of the House and Senate. What should we, who require health insurance to cover our doctor visits, lab tests and costly antiviral treatment to keep our livers healthy, do? Should we sign up for 2017?
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Friday, July 4, 2014

Canada's public drug plans ranked from best to worst

Canada's public drug plans ranked from best to worst

Good afternoon folks, our friends in Canada may be interested in new data; Comparing Access to New Drugs in Canada's Federal and Provincial Public Drug Plans, released by the Canadian Health Policy Institute (CHPI).

The institute looked at how long patients must wait for new drugs to be funded by Canada's public drug programs, using information from Health Canada, and IMS Brogan spanning from January 1, 2004 to December 1, 2013.  Apparently, Quebec appeared to have the best access to new drugs, timely reimbursement, and best coverage rates. You may remember that Quebec was the first Canadian province to provide access to Sovaldi (June 2, 2014) for treatment-naïve patients with genotypes 1 and 4 regardless of liver severity. The authors write;

Researchers found that the quality of insured access to new drugs varies significantly between public drug plans. Some jurisdictions provide much better access for their publicly insured populations than do other jurisdictions.
Quebec and Ontario had the best coverage rates – publicly insuring the highest number of available new drugs, while Manitoba, Alberta, British Columbia and the federal NIHB had the lowest coverage rates for new drugs.

Press Release: 

Study ranks Canada's public drug plans from best to worst on access to new drugs: Canadian Health Policy Institute (CHPI)

July 3, 2014

New research published by the Canadian Health Policy Institute (CHPI) shows that Quebec's publicly funded drug plan provides the best access to new drugs among all the federal and provincial public drug plans in Canada.

The study compares Canada's public drug programs in terms of the number of new drugs approved for public insurance coverage, as well as the time that patients must wait for publicly insured access to new drugs. It ranks the quality of coverage for new drugs under federal and provincial public drug plans from best to worst.

The findings are relevant to the health of a large number of Canadians. It is roughly estimated that as of 2012, 11.3 million Canadians were eligible for coverage under public drug insurance programs.

The study uses the most recent data from Health Canada and IMS Brogan covering the period from January 1, 2004 to December 1, 2013.

Researchers found that the quality of insured access to new drugs varies significantly between public drug plans. Some jurisdictions provide much better access for their publicly insured populations than do other jurisdictions.

Quebec and Ontario had the best coverage rates – publicly insuring the highest number of available new drugs, while Manitoba, Alberta, British Columbia and the federal NIHB had the lowest coverage rates for new drugs.

Quebec had the shortest delays to listing new drugs for reimbursement on its public drug plan, while New Brunswick, PEI and Ontario had the longest delays to listing.

New Brunswick and Quebec had the highest number of new drugs listed for full reimbursement, while Manitoba, British Columbia, the NIHB, Ontario and Saskatchewan had the lowest number of full reimbursements.

Overall, Quebec appears to provide the best access to new drugs under its public drug plan. However, it is important to put the performance of all public drug plans in the context of benchmarks set by private sector insurance plans. Other CHPI research confirms that all public drug plans in Canada provide much lower quality of coverage for new drugs than do private sector drug insurance plans.

The study, Comparing Access to New Drugs in Canada's Federal and Provincial Public Drug Plans, is part of an annual series of papers released under the title: How Good Is Your Drug Insurance? It was published at CHPI's free access online journal, Canadian Health Policy and can be downloaded here.

Canadian Health Policy Institute
www.canadianhealthpolicy.com

Friday, August 12, 2011

Hepatitis c-Insurers raising co-pays for expensive drugs


Rather than a set co-pay of $5 to $100 a month, specialty tiers require patients to pay "co-insurance" of typically 25 percent to 33 percent of the total cost. A patient taking the hepatitis C drug Pegasys costing $2,400 a month could face co-insurance of $600 to $800.

Insurers raising co-pays for expensive drugs

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Health insurers are increasingly charging patients sharply higher amounts for the most expensive drugs, often causing sticker shock for the sick people who need them.Health plans that have hiked co-payments say affected patients must pay hundreds of dollars more per month for drugs that can cost thousands, in order to prevent big jumps in premiums for everyone else.

But patients and their advocates say the practice discriminates against people who are unlucky enough to have a disease that is expensive to treat, and forces some to stop taking life-saving medicine. Three reports out this month say the practice can devastate patients financially.Florida has been hit hard, with its large population of seniors and a high proportion of younger patients with HIV, hepatitis, kidney disease and other chronic conditions that are treated with expensive medicines. One estimate says 12 percent of Florida prescriptions — and growing — are affected by the cost hikes.

Randall Rabbitt, a Delray Beach sales manager for an auto warranty firm, felt the co-pay shock. He had been paying $50 a month for Actemra, an intravenous drug for the crippling effects of rheumatoid arthritis, in which the body's immune system attacks his joints.
Then in June, with no notice, the insurer raised his share to $498."I scraped up the money. But I'm not in position to pay $498 a month," Rabbitt said. "That's on top of the $632 a month we pay for the premium. My family can't afford that. I may have to stop taking it."If I'm not on this, I literally have severe neck pain every day, to the point where I can't lift my head. My hips and ankles, I can't walk," Rabbitt said. "It makes all the difference between being able to do something or not. I'd have to go on disability and then what life would I have?"What happened?

The PPO at his job moved the drug into a "specialty tier," a co-pay class typically reserved for pills and IV drugs costing more than $600 a month — such as Rabbitt's Actemra at $1,100 to $2,100 a month.

Rather than a set co-pay of $5 to $100 a month, specialty tiers require patients to pay "co-insurance" of typically 25 percent to 33 percent of the total cost. A patient taking the hepatitis C drug Pegasys costing $2,400 a month could face co-insurance of $600 to $800..... Continue Reading...