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Approaches to Helping the Under-Insured<br />September 2008<br />
Agenda<br />Sharing Perspectives on Helping the Under-Insured:  <br /><ul><li>  A Patient
  A Co-Pay Assistance Non-Profit
  An Insurance Company
  A Physician
  A Pharmacist
  Questions?</li></ul>Page 2<br />
A Patient’s Perspective<br />Page 3<br />Judy Hodges<br />Breast Cancer Patient<br />
A Patient’s Perspective<br />Page 4<br />“I sat in the oncologist’s office and kept saying, I don’t have the money , but I...
A Non-Profit Perspective<br />Page 5<br />Julie Reynes<br />President<br />Patient Access Network Foundation<br />
Why Co-Payment Assistance?<br />Pharmacy cost trends upward exceeded all other components<br /> of medical care from 2007 ...
Why Co-Payment Assistance?<br /><ul><li>  Prescription drugs have the largest co-payments
  Prescription drug costs are estimated to continue increasing in the near term
  Physicians and hospitals have the flexibility to reduce or waive their fees for lower income patients
  If a patient can obtain the thousands of dollars it may cost to access their medications, they will be more likely to ge...
Patient Access Network <br /><ul><li>A 501(c)(3) public charity that launched our initial assistance program in October, 2...
Currently supports 20 disease-state funds for oncology and chronic diseases.
Provides co-pay assistance of from $1500 - $7500 per year for medications.
Received favorable advisory opinion from the Office of the Inspector General (OIG) of the Department of Health and Human S...
Have approved nearly 50,000 patients for cost-sharing assistance.</li></ul>Dedicated to improving access to needed health ...
The Need for Co-pay Assistance from PAN is Increasing<br />Projected<br />2008<br />Demand is increasing by over 30% each ...
An Insurance Company’sPerspective<br />Page 10<br />Gary Owens<br />Physician and Consultant <br />Providing the Insurance...
Biotech Drugs as a Growth Area<br />Biotech Drugs in Development<br />Source: BCBSA Medical Cost Trend Report 2007<br />
Biotech Drugs as a Growth Area<br />Biotech Drug Spending<br />Sources: CMS National Healthcare Expenditure Projection 200...
What Does This Mean to a Plan?<br />In 2007 Specialty Pharmacy spend was approximately 11.4% of total pharmacy spend (and ...
Biotech Drugs and the Health Plan<br />Health plans recognize that new drugs and new uses of existing drugs are creating r...
Disease Specific Examples of Drug Cost<br />15<br />Sources: 2008 Medco Drug Trend Report, Specialty Pharmacy News, Octobe...
The Issues for Plans<br />Page 16<br /><ul><li>  As cost of therapy increase, the cost of providing care also increases
  With purchasers pressure on controlling costs, plans have looked for new ways to involve patients in the management of c...
  However increasing co-payments and moving drugs to co-insurance tiers have brought about access issues for some patients
  Plans increasingly look to external resources to assist members get access to care</li></li></ul><li>Plan Assistance to ...
A Physician’s Perspective<br />Page 18<br />Allan B. Goldstein, MD<br />Physician and Consultant<br />
The Problem of Financial Barriers<br />Page 19<br />Office Visit Co-Pay<br /><ul><li>$30 – 50 out-of-pocket for each offic...
  For weekly visits, $120-200 per month, $1,500-2,600 per yr</li></ul>Oral Medication Co-Pay<br /><ul><li>Higher co-pay fo...
  Yearly costs for biologics may reach $100,000 or more
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  • These are the topics we will cover today. As you see, this presentation will provide data on:the current challenges with the underinsured, healthcare costs in general, how the dynamic insurance environment is impacting the problem and some of PAN’s own data to show how these environmental changes are impacting our bottom line.While this presentation will provide some data, there are still holes in the data that is available around the underinsured and co-payment assistance. PAN has defined as one of our strategic goals to partner with other organizations that have this expertise and interest. If you have contacts at any organizations that might be a good candidate for a partnership, please let Julie know.
  • Pharmacy costs are the largest portion of the out-of pocket expenses that patients must cover. Pharmacy costs are also the fastest growing component of out-of-pocket expenses. Pharmacy costs are expected to increase for several reasons: According to IMS Health’s Global Oncology Forecast, cancer drug costs are expected to increase by 12-14% per year through 2012. Cancer drugs alone account for 17% of the market. According to the Millimian Index, the adoption rate of generic drugs has slowed. Very few high-volume drugs will see their patents expire in the next several years. Lipitor is the next really high-volume drug that will see its patent expire. However, this is not due to occur until 2010. However, this generic drug trend may be mitigated by the increasing push by insurance companies to shift more of the pharmacy burden to the patient. This trend may actually increase the adoption of generics by the consumer. There is also an increase in utilization of specialty type drugs. In addition to the cancer medications, the anti-coagulants and inflammatory medications, like for rheumatoid arthritis and multiple sclerosis, are becoming more widely used.
  • Although everyone is getting squeezed from multiple directions, we believe that if patients can get their medications paid for, that the rest of the cost burden can be managed by patients or may be waived by the physician or the hospital.So, we think that co-payment assistance is one piece of the healthcare puzzle that makes the difference between patients living and dying.
  • Now we will switch gears a bit and discuss the Patient Access Network or PAN. PAN has been around for nearly 3 years. We have funds in 20 disease states equally split between chronic and oncology funds. These include Crohn’s disease, cystic fibrosis, MS and RA on the chronic side and breast cancer, NHL and Multiple Myeloma on the oncology side. We are especially wanting to expand our disease states in the oncology area into brain, ovarian and prostate cancers.The yearly caps for our disease funds range from $1500 – 7500 per year. Most of the oncology funds have the higher caps. The average used by our patients is around $3300. PAN received our OIG opinion last December. We take compliance very seriously. We have firewalled our Lash operations in Charlotte, NC from the rest of the Lash Group and the Amerisource Bergen Company to eliminate any perception of a conflict of interest. We have hired a PAN executive director and we have moved our headquarters to the Washington DC area. Also, we are getting ready to bring a compliance capability on board to continue to monitor the OIG opinion.We are pleased to note that PAN has helped nearly 50,000 patients since our start in 2004.
  • Transcript of "PowerPoint Presentation"

    1. 1. Approaches to Helping the Under-Insured<br />September 2008<br />
    2. 2. Agenda<br />Sharing Perspectives on Helping the Under-Insured: <br /><ul><li> A Patient
    3. 3. A Co-Pay Assistance Non-Profit
    4. 4. An Insurance Company
    5. 5. A Physician
    6. 6. A Pharmacist
    7. 7. Questions?</li></ul>Page 2<br />
    8. 8. A Patient’s Perspective<br />Page 3<br />Judy Hodges<br />Breast Cancer Patient<br />
    9. 9. A Patient’s Perspective<br />Page 4<br />“I sat in the oncologist’s office and kept saying, I don’t have the money , but I’m not going to die because I can’t pay for this. I am not going to die because I am underinsured.”<br /> Judy Hodges, PAN Patient <br />
    10. 10. A Non-Profit Perspective<br />Page 5<br />Julie Reynes<br />President<br />Patient Access Network Foundation<br />
    11. 11. Why Co-Payment Assistance?<br />Pharmacy cost trends upward exceeded all other components<br /> of medical care from 2007 - 2008.<br />Source: 2008 Milliman Medical Index<br />Page 6<br />
    12. 12. Why Co-Payment Assistance?<br /><ul><li> Prescription drugs have the largest co-payments
    13. 13. Prescription drug costs are estimated to continue increasing in the near term
    14. 14. Physicians and hospitals have the flexibility to reduce or waive their fees for lower income patients
    15. 15. If a patient can obtain the thousands of dollars it may cost to access their medications, they will be more likely to get treatment</li></ul>‘We found that reductions in drug copayments increased medical adherence.’ Michael E. Chernew, Health Affairs, Jan-Feb 2008<br />Source: 2008 Milliman Medical Index<br />Page 7<br />
    16. 16. Patient Access Network <br /><ul><li>A 501(c)(3) public charity that launched our initial assistance program in October, 2004.
    17. 17. Currently supports 20 disease-state funds for oncology and chronic diseases.
    18. 18. Provides co-pay assistance of from $1500 - $7500 per year for medications.
    19. 19. Received favorable advisory opinion from the Office of the Inspector General (OIG) of the Department of Health and Human Services in December 2007.
    20. 20. Have approved nearly 50,000 patients for cost-sharing assistance.</li></ul>Dedicated to improving access to needed health services for insured patients who cannot afford the out-of-pocket costs associated with their treatment.<br />Page 8<br />
    21. 21. The Need for Co-pay Assistance from PAN is Increasing<br />Projected<br />2008<br />Demand is increasing by over 30% each year, while revenues remain stable<br />Source: Patient Access Network Data, 2004 - 2007<br />Page 9<br />
    22. 22. An Insurance Company’sPerspective<br />Page 10<br />Gary Owens<br />Physician and Consultant <br />Providing the Insurance Company’s Perspective<br />
    23. 23. Biotech Drugs as a Growth Area<br />Biotech Drugs in Development<br />Source: BCBSA Medical Cost Trend Report 2007<br />
    24. 24. Biotech Drugs as a Growth Area<br />Biotech Drug Spending<br />Sources: CMS National Healthcare Expenditure Projection 2003-2013<br />
    25. 25. What Does This Mean to a Plan?<br />In 2007 Specialty Pharmacy spend was approximately 11.4% of total pharmacy spend (and was over 1/3 of the total trend driver)<br />The year over year specialty trend was 12.3% <br />Unit cost was responsible for 8.4% with utilization making up the other 3.9%<br />Top three categories of specialty drug spending:<br />Autoimmune diseases (Rheumatoid arthritis, Psoriasis, Lupus)<br />Cancer<br />Multiple sclerosis<br />13<br />
    26. 26. Biotech Drugs and the Health Plan<br />Health plans recognize that new drugs and new uses of existing drugs are creating revolutionary treatment advances.<br />Coverage of drugs is essential and important for any health benefit plan.<br />Purchasers are looking to plans to manage costs or pass excess cost on to the consumer<br />Balancing the need of the purchaser with the needs of the consumer is difficult<br />Not creating access problems for members is important.<br />But so is keeping the plans affordable.<br />
    27. 27. Disease Specific Examples of Drug Cost<br />15<br />Sources: 2008 Medco Drug Trend Report, Specialty Pharmacy News, October 2006<br />
    28. 28. The Issues for Plans<br />Page 16<br /><ul><li> As cost of therapy increase, the cost of providing care also increases
    29. 29. With purchasers pressure on controlling costs, plans have looked for new ways to involve patients in the management of costs.
    30. 30. However increasing co-payments and moving drugs to co-insurance tiers have brought about access issues for some patients
    31. 31. Plans increasingly look to external resources to assist members get access to care</li></li></ul><li>Plan Assistance to Members<br />Plans provide case managers to work with patients<br />These case managers can do any or all of the following:<br />Educate members about the medication and the need for compliance<br />Help the patient access benefits in the most cost effective way<br />Help the patient discuss treatment options with their physicians and perhaps find less costly, yet clinically effective treatments<br />Help the patients locate sources of financial assistance<br />Inform physicians of plan benefits and options for members.<br />Remember, we are all in this together and the goal of patients, physicians and plans is to provide access to high quality, yet affordable care. <br />17<br />
    32. 32. A Physician’s Perspective<br />Page 18<br />Allan B. Goldstein, MD<br />Physician and Consultant<br />
    33. 33. The Problem of Financial Barriers<br />Page 19<br />Office Visit Co-Pay<br /><ul><li>$30 – 50 out-of-pocket for each office visit
    34. 34. For weekly visits, $120-200 per month, $1,500-2,600 per yr</li></ul>Oral Medication Co-Pay<br /><ul><li>Higher co-pay for brand (tier 2) and non-preferred (tier 3) meds</li></ul>Parenteral Biologics<br /><ul><li>Increasingly subject to 20% co-insurance (tier 4)
    35. 35. Yearly costs for biologics may reach $100,000 or more
    36. 36. Co-insurance may be $20,000+ per year</li></li></ul><li>Medicare Prescription Drug Coverage (Part D)<br />Page 20<br /><ul><li> Premium: $0-100+ per month
    37. 37. Deductible: $275 per year
    38. 38. Coinsurance: $559 (25% of first $2,510)
    39. 39. “Donut Hole”: $3,216 (no coverage $2,510 to $5,726)
    40. 40. Total Out-of-Pocket $4,050 excludes monthly premium
    41. 41. “Catastrophic” Coverage: patient pays 5% of any expenses over $5,726</li></ul>Total Out-of-Pocket = Lots!<br />
    42. 42. The Scope of the Problem <br />Page 21<br />Some Specialties Impacted:<br />Endocrinology<br />Gastroenterology<br />Hematology<br />Neurology<br />Oncology<br />Pediatrics<br />Pulmonology<br />Rheumatology<br />
    43. 43. The Scope of the Problem<br />Page 22<br />Some Diagnoses Impacted:<br />Anemia<br />Breast Cancer<br />Colorectal Cancer<br />Cutaneous T-Cell Lymphoma<br />Lung Cancer<br />Multiple Myeloma<br />Myelodysplastic Syndrome<br />Non-Hodgkin’s Lymphoma<br />Pancreatic Cancer<br />Rheumatoid Arthritis<br />Psoriatic Arthritis<br />Ankylosing Spondylitis<br />Crohn’s Disease<br />Cystic Fibrosis<br />Multiple Sclerosis<br />Gaucher’s disease<br />Growth Hormone Deficiency<br />
    44. 44. Physician Responses<br />Page 23<br /><ul><li> Absorb the co-pay
    45. 45. Collect the co-pay up front
    46. 46. Refer to hospital or clinic
    47. 47. Stop providing infusion services in the office
    48. 48. Employ sub-optimal treatment regimen
    49. 49. Hire staff to conduct financial evaluation
    50. 50. Identify and counsel patients unable to meet out-of-pocket requirements</li></li></ul><li>Consequences for Patients<br />Page 24<br /><ul><li> Disruption of the patient/physician relationship
    51. 51. Increased travel and inconvenience
    52. 52. Financial stress or distress
    53. 53. Failure to take medications
    54. 54. Sub-optimal treatment
    55. 55. Clinical deterioration and/or disease process progression</li></ul>The underinsurance challenges may negatively impact the patient’s health.<br />
    56. 56. A Pharmacist’s Perspective<br />Page 25<br />Edith Rosato, PharmD<br />Senior Vice President, Pharmacy Affairs <br />and National Association of Chain Drug Stores<br /> Foundation<br />
    57. 57. National Spending on Healthcare<br />Cost increases for hospital outpatient services and prescription drugs continue to outpace those for inpatient and physician services.<br />Annual Per Capita Percentage Change in Health Care Spending, by Category of Service, 2001-2006<br />Source: Bradley C. Strunk, Paul B. Ginsburg, and John P. Cookson. "Tracking Health Care Costs: Declining Growth Trend Pauses In 2004." Health Affairs Web Exclusive, June 21, 2005; and Ginsburg, Paul B., Bradley C. Strunk, Michelle I. Banker, and John P. Cookson. "Tracking Health Care Costs: Continued Stability But At High Rates In 2005." Health Affairs Web Exclusive, Oct. 3, 2006. <br />
    58. 58. The Underinsured: Coping With Rising Prescription Drug Costs<br />Represent 25M in 2007 and rising <br />72M or 41% of working-age adults have problems paying medical bills<br />29% unable to pay for basic necessities<br />39% use savings<br />30% take on credit card debt<br />46% skimp on medications<br />33% compared to 19% of adequately insured used ER<br />The uninsured population compounds this issue<br />Sources: The Commonwealth Fund, Biennial Health Insurance Surveys, August 2008<br />
    59. 59. The Current State of Medication Adherence in the U.S.<br />Estimated annual costs to the healthcare system: $177B<br />Only 50% of patients take medications as prescribed<br />Reasons for non-compliance:<br />Cost<br />Forgetfulness<br />Denial of the illness<br />Misunderstanding of the directions<br />Lack of understanding of the disease<br />Lack of symptoms<br />Impact of chronic disease: <br />130M patients (45% of population); 7-10 deaths annually<br />$1.3 Trillion annual drag on economy <br />Represents 91% of all prescriptions filled<br />The Result is a <br />Significant Public Health Crisis<br />Sources: National Council on Patient Information and Education, “Enhancing Prescription Medicine Adherence: A National Action Plan”. August 2007<br />
    60. 60. Community Pharmacy Response<br />Many chains have introduced prescription savings<br /> programs to assist the uninsured or underinsured<br />Covers prescription brand and generic drugs, preventative and lifestyle drugs, vision, dental and hearing…even pet meds<br />
    61. 61. Other Discounted Drug Programs and Financial Assistance Programs<br />HealthCare Club of America <br />
    62. 62. Retail Clinics<br />Health and wellness destination<br />Offers affordable healthcare<br />One-stop shopping convenience<br />
    63. 63. Government Programs<br />Health Resource Services Administration 340B Program<br />Safety Net Clinics<br />Medicare Part D: Covering the “donut hole” patients<br />SCHIP: America’s Promise Alliance and All Kids Covered <br />
    64. 64. Healthcare Reform Debate: Opportunity to Advocate for Patients<br />High quality, affordable and accessible healthcare coverage should be the goal of any reform proposal<br />Cost-sharing, such as patient co-pays, should be set at affordable levels and not prevent patients from seeking appropriate medical care<br />Patients should have access to the most cost-effective medication to treat their condition<br />Lower cost, equally effective generic medications should be encouraged <br />Preventative services such as medication therapy management should be encouraged <br />
    65. 65. Role of the Pharmacist<br />Convenient, highly accessible community based health resource for patients <br />Pharmacists are knowledgeable about available programs for uninsured and underinsured patients<br />Encourage patients to utilize and interact with their pharmacists<br />
    66. 66. Conclusions<br />Page 35<br /><ul><li> Patients are making life or death decisions based on their ability to pay for healthcare
    67. 67. Each healthcare component is trying to help in its own way
    68. 68. Medication costs are a large component of the challenge.
    69. 69. Each healthcare component has constraints imposed by the government, stockholders, funding, etc.
    70. 70. Many challenges remain
    71. 71. Healthcare reform is likely to create new challenges</li></ul>Questions?<br />
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