Patient Advocacy and Patient-Centered Care

What negative things can happen to patients regarding medications?

• Insurance companies now remove drugs from formularies at any time during the year

  • Formulary lists are reviewed prior to subscriber joining plans

  • Typically, about 50% of all insurance companies remove drugs throughout the year

  • Medicare Part D – Must give 60 days notice

• Patients may make different decisions about drug therapy

  • Do not take medication

  • Split doses

  • Consider OTC, alternative remedies

How do you build advocacy?

• Communication on medical issues

  • With patients

  • With providers

  • With payors

• Clinical skills

  • Drug information expert

  • Patient counseling and education

  • Provider education and information source

• Address gaps in the transitions of care

• Address gaps in health literacy

• Use knowledge of health insurance, formularies to navigate costs

Finding lower cost alternatives

• Prescribers are aware of the high burden of drug costs

• Review formulary for patient’s plan

  • Find lower tier options

  • Discuss lower cost alternatives

  • Communicate with prescriber

How do drug discount cards work?

• These are price-negotiation tools, not insurance

  • Leverage discounts with PBMs and pharmacies

  • Use instead of insurance

Companies partner with PBMs and negotiate prices

Patient searches for a medication and prices are compared

- Pharmacy processes like insurance

- Patient pays the price out of pocket.

SingleCare

• Unique - does not contract with PBMs

• Contracts directly with pharmacies

• Cannot be combined with insurance

• Accepted by major chains and many pharmacies

• To date - positive response from patients

• Free of charge

AWP - Average wholesale price

• Example MSRP for a car

• Not what pharmacies pay

• Typically inflated above real acquisition cost

MAC - Maximum allowable cost

Ceiling price set by PBMs for generics (secret)

NADAC - National Average Drug Acquisition Cost

CMS calculated estimate of what pharmacies pay for drugs

Who is the payer for discount cards and why?

The patient is the payer.

• There is no third party payer

• PBMs adjudicate discount card claims

• Discount card fees = Spread pricing

• PBM fee (spread) revenue reduces pharmacy profits

• Discount card revenue reduces PBM profits

What does PBM spread pricing apply to?

- only generic medications

MAC lag vs. acquisition cost

• PBMS update MAC slowly and pharmacies absorb cost increases

NADAC vs. reality

• NADAC reflects average acquisition

• Individual pharmacies may pay more than NADAC

WAC irrelevance

• WAC is not used in reimbursement, despite being higher

Issues with patient assistance programs

• Last for 6-12 months, cases canceled after 1-2 unanswered phone calls to patient

• Verifying patient availability to receive delivery

• Short dated products potentially funneled through PAPs

How are companies more proactive with patient assistance programs?

• Staff contacts pharmacies for updated information

• Notifies pharmacy about availability and copay changes

• Patients to self-enroll

• Allowing some off label use for oncology drugs

Co-Pay accumulators

• PBMs eliminate opportunity for copays to count towards deductibles in PAPs

• If an accumulator is available (~17% of health plans) it reduces the out of pocket costs significantly for patients

• If practice is prohibited, will likely be a reduction in specialty drug prescriptions

Establishing an advocate program

Staff member – regular team member who also hold advocate designation

• Champions patient preferences

• Make sure all team members are accountable in assuring patients are fully informed

Excellent way to “promote” a technician

•       Good performer

•       Someone who is looking for a challenge

•       Perhaps you can give this person an increase or ask your DM if an increase is possible after this person has proven the benefit of having an advocate 

What can a patient advocate champion do in a pharmacy?

• Researches clinical data to complete and maintain prior authorizations

• Obtains prior authorization

• Performs test claims to determine copayments or copays

• Understand insurance plans including formularies, copayments

• Researches drug discount cards

• Helps patient navigate the health care system- prior authorizations, claim denials, etc.

• Assists the patient with finding applicable financial resources - patient assistance programs, foundation grant support

• Serves as a liaison between patient, providers, third party plans

• Strong relationships with patients - educate patients throughout the process - follow up calls, explain the need for prior authorization, explain assistance programs

• Make sure the patient is as informed as possible so they can make decisions about their health care

• Advocate does NOT make decisions about health care, prepares patients to make them

Prior authorizations

• Increased gatekeeping for high-priced specialty medications, new medications

• Prior authorizations can lead to delays or rejection of important therapy.

• Improved process through electronic submission of forms.

• Opportunity for pharmacist and technicians to handle documentation

• More clinics asking pharmacists to assume this workload.

• New careers - Prior Authorization Specialists

Realities of social and economic situations

• Aging baby boomers

• Access to health information

•Payer's demands

• Patient demand

Medical realities

• Easily recognized conditions with well-accepted care plans are unusual

• More often - healthcare involves less certainty, "best" course of treatment often involved choosing between two or more beneficial options

• Patient care is fragmented in U.S. - generalists, specialists, hospitals, health systems, nursing homes, home care, etc

2001 Report from Institute of Medicine - Crossing the Quality Chasm

o Care must be "safe, effective, patient-centered, timely, efficient, and equitable"

o Typical response was painting walls, improved signage

Affordable Care Act - cites patient-centered care but some lack of clarity on what this means to implement shared-decision making

o Shared decision making - core of patient-centered care

o Communication between patients and providers, eliciting patient preferences, integrate informed patient preferences into an individualized care plan

The planetree model

• The Planetree International Model is a patient-centered care framework that emphasizes humanistic, holistic, and partnership-based healthcare.

• Founded in 1978 by Angelica Thieriot after her own hospitalization experience

• Focus: Treating patients as whole persons, not just diseases

• Widely adopted in hospitals, ambulatory care, and long-term care settings

10 components of the planetree model

• Human Interaction and Relationship-Centered Care

• Architectural and interior design

• Food and nutrition

• Patient and family education

• Family, Friend and Volunteer involvement

• Access to Information

• Spirituality and Cultural Diversity

• Human touch

• Healing arts

• Complementary/ alternative therapy

• Healthy communities

• Healing Environments

Core Principles of Planetree model

- human interactions

- family and patient engagement

- information and education

- healing environment

- collaborative care

- leadership and culture

Components of the Planetree Model Mind, Body, and Spirit

• Patients have direct communication

• physical space

• no partitions

• Kitchenette

• Patients

• Visits

• Designated "care partners"

• Variety of educational materials

• Patients and charts

• Progress notes

• Self-medication program

• Specialists

The Planetree Community

• >100 hospitals

• Medical Centers and Continuing Care Communities

• 16 Countries

• Wide Range of Healthcare Organizations

Planetree Model Pros

o Strong alignment with modern healthcare

o Improves patient trust and engagement

o Enhances interprofessional collaboration

o Measurable impact

o Direct application to pharmacy practice

Planetree Model Cons

o Resource intensive

o Time constraints

o Measurement challenges

o Cultural resistance

o Potential tension with efficiency

The eight picker principles of person-centered care

o Fast access to reliable health advice

o Effective treatment delivered by trusted professionals

o Continuity of care and smooth transitions

o Involvement and support for family and carers

o Clear information, communication, and support for self-care

o Involvement in decisions and respect for preferences

o Emotional support, empathy, and respect

o Attention to physical and environmental needs

Picker principles

The Picker Institute Principles of Person-Centered Care are a widely adopted framework that defines what matters most to patients during healthcare experiences.

• Developed through patient research in the 1980s-1990s

• Focus: Designing care around patient needs, preferences, and values

• Used globally to guide:

• Quality improvement

• Patient experience measurement (e.g., surveys like HCAHPS)

The Institute of Medicine defines patient-centered care as:

“Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.” 

CPESN of Northeast New York- Minimum Service Sets

- CMRs

- Med sync programs

- Immunizations

- Med recs

- Personal medication record