Data intelligence unlocks doors for patients who can’t afford their medications.
Unless patients can afford the medications they need, we don’t have a healthcare system that works — and with more than half the U.S. population living with chronic diseases,¹ our system is being put to the test. Large patient populations are cycling in and out of hospitals as they start and stop treatment plans they can’t always afford, adding pressure to an already-strained healthcare ecosystem.
The costs for chronic and specialty medications are often cost-prohibitive for patients, making co-pay and affordability programs more important than ever. Yet many biopharmaceutical companies are struggling to fund them, as external threats such as accumulator models and the ever-increasing cost of high-deductible health plans (HDHPs) make them less viable.
So, what can we do about it? Four things.
Through machine learning that leverages proprietary data, RxCrossroads by McKesson has identified four principal affordability barriers and is tackling them with highly intelligent and targeted affordability program strategies. Here’s how.
1. Addressing Prior Authorization Cost Implications
As the number of available medications to treat chronic diseases grows, an increase in the volume of prior authorizations (PA) is an inevitable response payers are using to control spending. This places additional burden on patients as prior authorization creates delays to starting therapy or results in denials. Supporting patients with coverage alternatives is key to addressing this. Through an exclusive integration between RxCrossroads’ LoyaltyScript® co-pay program and CoverMyMeds’ PA Reach℠ prior authorization technology, patients have a closed-loop solution to address the prior authorization cost barrier.
If a prior authorization is rejected, patients can enroll in the LoyaltyScript® program and submit co-pay claims, so they aren’t stuck without the treatment they need while they go through the appeals process. Meanwhile, the co-pay claim data triggers a notification to a PA support specialist who attempts to resolve the PA issue. If the PA denial is overturned, RxCrossroads will notify 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
High-deductible healthcare plans have become a fixture in our system, and the use of accumulators in HDHPs to prohibit co-pay programs from applying to patients’ deductibles only exacerbates difficulties for patients. Co-pay programs are often the only thing getting patients through their out-of-pocket expenses until their coverage kicks in. If a patient’s co-pay expenses are prevented from chipping in to the deductible, paying it off becomes an uphill battle. 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 creates the opposite of the desired outcome. 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 — creating further strain on the healthcare system. It’s imperative that we address this.
RxCrossroads is solving this with unique solutions, including the Accumulator Predictor Tool™, which identifies brands and patients most likely to be impacted by accumulators, and DeductAssistTM, which helps patients overcome financial hurdles to minimize the accumulator impact.
By identifying and supporting these patients, RxCrossroads can find alternative payment options and offer adherence support. This also helps biopharma companies maximize their access and adherence budgets.
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 leverages proprietary machine-learning algorithms and integration with RelayHealth’s pharmacy technology to minimize questionable cash-card behavior. This real-time platform integration applies a proprietary exclusion logic to stop cash-card use if a patient is without commercial insurance coverage, preventing the misuse of cash cards to pay for government-funded drugs and driving significant savings for co-pay program sponsors.
4. Combating Co-Pay Program Abuse
Despite increased state and federal scrutiny, co-pay assistance programs are particularly vulnerable to anomalous activity. Fraudulent claims typically occur at the pharmacy and vary in scale. They impose significant costs on the healthcare system and have been on the rise in recent years. RxCrossroads leverages a team of data scientists and proprietary machine learning to protect co-pay programs from anomalous pharmacy activity. That team analyzes new trends and creates actionable algorithms to identify these anomalous data patterns and score them appropriately for risk. This technology allows RxCrossroads to implement targeted co-pay-protection strategies that increase program efficiency and efficacy for biopharma 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 patient access, affordability and adherence solutions, RxCrossroads by McKesson is dedicated to combating and solving these issues. Providers want their patients on medications that are right for them, and patients need to be able to afford those medications to have better outcomes. To address affordability issues, biopharma companies should seek data-proven solutions and consultation to more effectively target and fund co-pay programs for patients. If we can’t achieve this, 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.
1.Centers for Disease Control and Prevention (CDC), 2019
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