In the last segment of a three-part series, Tracy Foster, President of Lash Group; and Stacie Heller, Vice President, Health Policy of Xcenda review online health systems and the role technology will play in the future of the industry.
There are four key stakeholders benefitting from technology advancements, and realizing increasing opportunities to integrate and streamline information sharing:
1. Patients – support program enrollment & ongoing communication
2. Providers – data sharing, analysis & communication
3. Payers – data sharing & processing
4. Manufacturers – data sharing, analysis and communication
Today, 25 states have online systems, but in the near future, patients will be able to have real-time online eligibility determination for Medicaid, CHIP and health insurance exchanges in all 50 states. For most states, this will be a comprehensive transformation of systems and processes, and many will use federal funding to build new systems to support public, subsidy, private eligibility and application. It's important to note that the focus will be on real-time insurance eligibility and enrollment, including determination of eligibility for subsidy assistance, and on "smart phone" systems (self-service approach), but states must also provide an assisted approach. Coverage and copayment details for individual specialty products are not part of the current system development and are likely many years away.
The framework for system requirements will support new levels of information sharing and integration. High level integration of process and information flow with all partners – federal and state – will help ensure seamless coordination between Medicaid, CHIP, Exchange & public Health & Human Services programs, CBOs, etc. Key features include a modular, flexible and scalable approach to systems development, with open architecture and shared computing resources. In addition, the framework will be accessible and adaptable by other states, and will align with and advance Medicaid Information Technology Architecture (MITA).
"...the challenging reimbursement environment has stimulated the use of technology."
From the patient perspective, the framework will make healthcare data more accessible. Consumers will essentially own their own data, and can take it with them, and significant self-attestation will be allowed. States will also have new data sources for real-time eligibility determination. The federal hub will include IRS data (current to 18 months), social security data (current to six plus months), and Homeland Security info (three plus months). States are planning to add additional data sources to improve access to job / income loss changes in a real-time environment – and many states are planning to focus on this data first. In addition, all information will be accessible via smart phone, which is important as a substantial portion of the underprivileged population have a smart phone.
From a provider perspective, the challenging reimbursement environment has stimulated the use of technology. Providers are currently facing a multitude of reimbursement challenges and administrative complexities, including:
• Decreasing reimbursement and uncertainty of future reimbursement
• Increased patient out-of-pocket costs and greater impact of uncompensated care
• Lack of reimbursement for managing self-administered therapies
• Increased utilization management and case management by payers (i.e., prior authorizations, treatment guidelines / pathways)
Due to these issues, providers are moving towards increased utilization of health information technology resources, including electronic medical records (EMRs), drug inventory cabinets, data analytics tools, and e-prescribing. In fact, 570 million prescriptions were routed electronically in 2011, representing a 75 percent increase from 2010. E-prescribing also results in better adherence on the patient side – first fill pick up is ten percent higher using e-prescribing.
"...570 million prescriptions were routed electronically in 2011, representing a 75 percent increase from 2010."
While these technology advances represent great advances in patient access to care, there are many intensive tasks ahead to fully implement a functional system. As a result, manufacturers may have additional opportunities for access to data about product use, trends and treatment patterns, patient adherence and response, and overall access to care that will be helpful in development of a product's value story within its therapeutic area. The ability to better understand how physicians are prescribing and how patients are responding can be very helpful when shoring up coverage dynamics and access strategies.
Looking ahead: the evolution of patient services
As healthcare reform comes into focus, we're seeing an increased emphasis on the underinsured, enhanced services to support new coverage sources, and evolving strategies around patient affordability. Manufacturers will be impacted by these areas of emphasis, and as a result, will need to develop additional services, like copay assistance, to support the underinsured. We're also seeing more integrated services to address patient outcomes and product value, and service models to address changing payer payment models. Finally, we're seeing streamlined enrollment, more communication channels and mechanisms that leverage technology, additional processes and policies to support providers, and policies to support patient access.
Though the ACA has posed many challenges, it's causing many new trends to evolve and take shape as we move into a new era of healthcare reform. The need for patient support services remains and our work in this area is far from complete. The environment is only getting more complex, and as a result, manufacturers need to ensure they are prepared for the various scenarios that will arise as expanded access provisions go into effect in 2014.
About the authors:
Vice President, Xcenda
Stacie Heller brings twenty years of experience to her role as Vice President of Xcenda's Health Policy consulting practice. Based in Washington DC, Heller leads a team of consultants from across the country who develop reimbursement launch strategies and guide clients through complex decisions related to coverage, coding, compendia, health policy / healthcare reform implementation, and the design of patient and provider support services.
Heller has in-depth knowledge of healthcare reform implementation, including guidelines on Accountable Care Organizations. As the editor of Health Policy Weekly, a complimentary e-publication, Heller keeps clients and stakeholders informed on the latest legislative and regulatory updates. Heller and her team track and analyze congressional and regulatory health policy and provide manufacturers and other stakeholders with ongoing strategic guidance, proactive updates, analysis and policy briefs related to issues affecting the healthcare industry.
Heller's expertise encompasses a wide range of public payers and includes developing reimbursement strategies for new products and addressing reimbursement obstacles for existing therapies. Previously, Heller directed the operational management of the reimbursement-based patient assistance programs for HIV / AIDS therapies at the Lash Group. Before joining the Specialty Group, Heller monitored physician-related reimbursement issues for the American Society of Internal Medicine, now part of the American College of Physicians (ACP). Heller received a B.A. in public policy from Pennsylvania State University.
Tracy Foster, MBA
President, Lash Group
As President of Lash Group, Tracy Ott Foster contributes her expertise, strategy and experience to a company known for its unique patient and provider support programs. For over 20 years, Lash Group has designed, developed and implemented innovative programs within the pharmaceutical, biotech and medical device industries, creating solutions that help patients begin therapy in a timely manner while maximizing their ongoing continuity of care.
Under Foster's executive leadership, Lash Group provides industry-leading access services from reimbursement strategy and support to copay and patient assistance solutions, and adherence and other clinical case management support services. Through these personalized and scalable support services, Lash Group enhances speed-to-therapy, promotes increased adherence and delivers actionable data to their partners. As part of AmerisourceBergen Consulting Services, Lash Group works to serve manufacturers with reimbursement services, patient advocacy programs, health outcomes and pharmacoeconomic consulting, advisory boards and payer-related analytics.
A respected speaker and insightful author of numerous trade articles, Foster's influence on the pharmaceutical industry has spanned over 15 years. Her regular nationwide speaking engagements provide insights and strategic guidance on pertinent industry issues including product support programs, patient access, reimbursement policy and trends. Strategic planning, thought leadership and specialty pharmaceuticals continue to be passions for Foster, whose dedication and enthusiasm earned her accolades from the Charlotte Business Journal with a Top 25 Women in Business Achievement Award as well as a 40 under 40 Award.
How will the new US healthcare environment affect pharma, payers and patients over the next few years?