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Why is Medication Difficult?

By Anne Dieffenbacher

Positive patient outcomes face plenty of obstacles. Consider medication: The pressure to make medicines more accessible and affordable influences prescribers’ decisions when they choose a medication therapy for their patients.

Anne Dieffenbacher
“In the value-based healthcare reality, the new focus will be on quality of care, not quantity.” – Anne Dieffenbacher, senior vice president of Strategy and Solutions for TMS Health

But it doesn’t end there: Additional hurdles from payers, such as defined step edits or prior authorizations, can add barriers to both the physician office and patient in getting the desired therapy. If the office does not know the process to get the insurance approvals for the patient, they often discover coverage issues at the pharmacy counter.  This forces the patient to either pay out of pocket, or refuse the prescription.

Alternatively, the pharmacist may call the physician to discuss alternative therapies or drugs that are covered by the patient’s plan. But the result may not provide the best outcome for patient. They may then investigate how to get the patient the desired therapy, but the process is time-consuming, which delays delivery of the medication.

Many drug manufacturers have implemented a variety of programs to help get patients on their products, and even lower the patient’s out of pocket costs. A few examples:

  • Reimbursement support programs, or “HUBS,” can help patients and providers navigate the complex payer networks and fight on behalf of the patient for reimbursement for the desired therapy. These services can support verification of coverage, quantify out of pocket cost, support prior authorizations or step edits, and handle appeals
  • Many drugs also have discount cards, copay assistance or free product for those who qualify.

These programs can help patients get the drugs they need, and keep their out of pocket costs as low as possible.

Getting the Medication is Only Half The Battle

Taking the medication as prescribed is critical to healthy outcomes. Sadly, many people don’t understand their disease state, or the prescriptions their providers give them. Moreover, they may not take their meds appropriately or change behaviors that can lead to a healthier lifestyle. 

Healthcare providers and payers are increasingly concerned with medication adherence. That’s because of the growing evidence that non-adherence continues to rise, which is associated with poor health outcomes and higher costs of care. A 2015 study in The Journal of Aging Research reviewed self-reported medication adherence in patients. The study “assessed socio-demographic determinants of adherence. Sixty percent [of patients]had low adherence to medications.” A 2005 article from the New England Journal of Medicine estimated that the cost of non-adherence to drug therapy amounts to $100 billion to $290 billion annually in the United States.

In the value-based healthcare reality, the new focus will be on quality of care, not quantity, which reinforces the importance of improving medication adherence. This change makes it all the more critical that drug manufacturers focus on the access and adherence to their medications so that prescribers can place patients on the best medication or therapy regimen.

These support programs must support access to high quality medications, provide patient education, manage fears and expectations, and provide adherence reminders. We know that a therapeutic plan that includes the right medication can improve a patient’s health or – at the least — slow the progression of chronic conditions. Done right and regularly, we can usually count on these regimens to produce long-term benefits. But none of this can happen if we don’t help patients get the medication, and assure they take it as prescribed.