David Williams: This is David E. Williams , co-founder of MedPharma Partners and author of the Health Business Blog. I’m speaking today with Scott Dulitz, VP and General Manager of AccessMED and Rick Ford, Director of Reimbursement Consulting. AccessMED is a patient access and drug reimbursement company owned by US Oncology.
Recently you held a patient access summit. How did it go?
Scott Dulitz: Yes, we held our first patient access summit here in Kansas City. AccessMED has been providing reimbursement support and patient assistant services to pharmaceutical manufacturers for 15 years. We felt the time was right to have a forum like this to provide pharmaceutical manufacturers and biotechnology companies with a good understanding of the market landscape as it applies to patient access.
We talked about the Affordable Care Act and implications for patient access. A key theme is that while patients will have more options as we move toward 2014, it’s unclear how those options translate into access. More patients may have insurance, but what type of insurance are they going to have?
We already see direct cost sharing assistance from pharmaceutical manufacturers for commercially insured patients. Due to the economic crisis we’re seeing more patients drop their Medicare supplemental coverage, which can put them at risk for 20 percent out-of-pocket cost share. On the commercial side we’re seeing more private payers mimicking what Medicare is doing from an ASP reimbursement perspective. That’s putting more pressure both on providers and patients.
Williams: Please explain Medicare’s ASP based reimbursement model and how commercial payers are mimicking it.
Dulitz: Prior to the MMA reform in 2003 most community-based oncology providers would ‘buy and bill.’ They would buy the product direct from manufacturers, administer it in the office, and bill the payer. In addition to their administration fees, oncologist would also receive a margin on top of the drug price that they paid the manufacturers. As we have moved to the average selling price (ASP) reimbursement model under Medicare, community based providers now receive ASP plus 6 percent.
This shift in reimbursement has caused a decrease in margin for providers. Large commercial payers are following suit. Many are moving to a similar model, which is putting a lot of pressure on providers in that buy and bill marketplace.
Williams: When that happens, is there a potential backlash in which some office-based patients get turfed over to a hospital setting and wind up costing payers more?
Dulitz: Yes, you’re absolutely right David. A lot of community-based practices have substantial credit pressure. There’s a lot of credit risk right now in that marketplace to the point where patients that are coming in that have Medicare coverage or Medicaid coverage are being referred out of those community based settings and into a hospital based setting. If we look at the oncology model specifically, that’s often making these elderly, sick patients travel long distances to obtain access to care.
Williams: How are pharma companies trying to help physician offices and patients navigate through these turbulent waters?
Dulitz: There’s substantial need for cost sharing assistance for these patients. For a number of years pharmaceutical manufacturers have been providing free drugs to the indigent uninsured but it’s time to take a step back and redefine ‘uninsured.’
There are a number of patients with insurance today that are significantly underinsured to the point where we may look at expanding patient assistance programs (PAPs) to offer some form of free drug assistance. On the commercial payer side what we see is manufacturers providing direct cost sharing assistance.
For example, Genentech was one of the companies at the conference. If you look at their product Avastin, they’re providing direct cost sharing assistance with co-pays and deductibles to commercially insured patients that are prescribed Avastin.
Williams: What role do affected specialists such as oncologists need to play over this time? I understand there’s assistance coming from the pharmaceutical companies but do such practices need to start doing things differently or adding different kinds of staff or approaching patients in different ways?
Dulitz: We had Dr. Marc Neubauer, a practicing oncologist in Kansas City weigh in with a provider perspective. One of the questions that we posed to Dr. Neubauer is whether the role of the financial counselors and social workers within his practice will change as health reform rolls out.
Dr. Neubauer said the changes are already there. His office has made changes to processes so that financial counseling discussions take place with patients prior to treatment. He also said it’s incumbent upon those financial counselors to be very familiar with the various services being provided by pharmaceutical manufacturers and also 501(c)(3) cost sharing assistance/co-pay assistance foundations that are available out in the marketplace.
Williams: What role do you see evidence based medicine and comparative effectiveness research to play as cost starts to factor into the insured oncology market for the first time?
Dulitz: We didn’t spend a lot of time on this topic during the conference, but there is a lot of discussion within the oncology space about comparative effectiveness. There is a concern from a branded products manufacturer standpoint about whether it is really comparative effectiveness or cost effectiveness.
There is an emphasis by manufacturers upfront to ensure that as they design their clinical studies they also look toward reimbursement implications.
Williams: Tell me more about AccessMED. What the services do you provide and how does it fit under the US Oncology umbrella?
Dulitz: We’ve been in business for 15 years. Four years ago we were purchased by US Oncology. It was a really good marriage. AccessMED was predominantly a patient assistance and reimbursement support services provider within the oncology marketplace. However lots of the lessons we’ve learned through providing patient assistance and reimbursement support assistance in oncology have translated over to other specialty therapeutic areas.
Beyond traditional call center services that we offer we also have a consulting arm. Much of the discussion today has focused on the cost of drugs and the ability for patients to afford their share of that cost. However another area that we touched on at the patient access summit was about the critical administrative tasks or barriers that are being put in place.
REMS (Risk Evaluation and Mitigation Strategies) have now become prevalent for products reaching the marketplace, in fact so prevalent that they’re looking at REMS for the entire opioid therapeutic class. Access encompasses many different things. Cost is one of the pieces of the equation but mitigation strategies are another.
Rick Ford: One of the important things to understand about REMS is not only does it encumber the process of providing that drug to the patient, but in all likelihood it also limits the willingness of physicians to prescribe those medications because of the overhead associated with that. So making those REMS programs smooth and efficient is a key strategy in patient access.
Williams: This has been very educational for me. Any other comments that you want to share?
Dulitz: This is our first attempt at a patient access summit. A lot of the feedback that we’ve received from the manufacturers coming out of it was very positive. The need for education and awareness around patient access is only going to increase.
As health care reform rolls out there are going to be more options for patients, but we need to see how options translate into access.
Williams: I’ve been speaking today with Scott Dulitz who is the Vice President and General Manager and Rick Ford, Director of Reimbursement Consulting at AccessMED. Thank you for your time today.