Supporting Patient Access to Biologics Through Communication, Adherence, and Persistence

Many types of biologics have been approved by the US Food and Drug Administration, including monoclonal antibodies (eg, adalimumab [Humira]), therapeutic proteins (eg, filgrastim [Neupogen]), and vaccines (eg, agents used for tetanus and influenza). In 2018, sales of biologics totaled approximately $125 billion, reflecting an increase of 50% from 2014 figures.1 Biologics coordinators play a central role in overcoming challenges to patient access to these agents by navigating benefits, communicating with insurance companies, and advocating for individual patients.

“I have been in dermatology for over 17 years, and the vast majority of that time has been spent working with patients who are receiving biologics and systemic therapies,” explained Daisy Noyola, CMA, Biologics Coordinator, Mindful Dermatology,

Dallas, TX. “When I first started working with patients on biologics, we did not have many options; that has changed tremendously.”

ADDRESSING CHALLENGES TO TREATMENT

Biologics coordinators face several challenges as they work to ensure that patients receive timely access to therapy. For example, patients do not always inform their providers that there have been changes in benefits or insurance carriers. According to Ms Noyola, most patients do not fully understand their insurance coverage.

“I do not expect our patients to necessarily understand their entire benefit breakdown or know their benefit investigation,” she explained. “However, I do expect them to communicate that they have had some insurance change or even loss for that matter.” Ms Noyola said that she tells her patients, “I can’t help you if you don’t help me. I basically need you to be a participant in your own care.”

Another challenge involves dealing with insurance companies that want to take charge of therapeutic decision-making for patients. For example, some companies may require step therapy or a particular treatment for all patients rather than considering each patient’s individual situation.

Many providers are mindful of their patients’ clinical needs and can narrow down the best treatment options for them.

“We are not necessarily looking at the best option from an insurance perspective, but rather from a treatment perspective,” said Ms Noyola. “Unfortunately, the insurance companies don’t necessarily view it that way.”

Because prescribers often prefer one drug over another, the healthcare team must push back against insurers that want to dictate which drug should be prescribed for patients.

“I am pretty stubborn,” said Ms Noyola. “I am the one that typically does all of the appeals and letters of medical necessity. Sometimes it leads to treatment delays. Fortunately, most manufacturers have a bridge (or “quick start”) program that allows commercially insured patients to begin treatment while we are waiting for approval.”

Ms Noyola explained that payer access restrictions require the office to advocate for the patient and to send updated information supporting the patient’s need for a particular medication. She estimated that 70% of submitted appeals result in the insurance company overturning its decision, and hopefully, the drug being approved by health plans.

Peer-to-peer discussions are held regularly with representatives of the insurance plan to allow providers to explain their clinical rationale for prescribing a certain therapy and provide supporting documentation, if needed.

The cost-sharing responsibilities associated with biologics are often substantial. Ms Noyola explained that she informs patients about the costs of therapy at the beginning of the process.

“When you receive that explanation of benefits statement, some patients get sticker shock,” she said. “We let them know that these are costly medications. However, there is usually some form of financial assistance available, whether it is through the drug manufacturer or a not-for-profit foundation.”

Promoting adherence to therapy

After patients receive their biologic medications, adherence can also be a major issue.

“My experience regarding adherence with dermatology patients who are self-administering their medications at home is that when their disease is out of sight, their medication is out of mind,” said Ms Noyola. “Patients frequently skip doses, increase the interval between doses, or completely forget about their medications for months. However, these patients frequently experience painful and debilitating flares as a result of nonadherence.”

In-office administration of biologics helps dermatology practices reinforce the importance of medication adherence.

“When we are able to administer treatments in the office every time we see the patient, that is a moment for us to coach them, to bring them back in, and make them feel empowered,” she said. “You’re doing the right thing. You’re doing great. We’re seeing results, and you are exactly where you should be.”

Ms Noyola noted that it is important for biologics coordinators to consider one patient at a time and to treat all patients with the care that they would want for themselves or a loved one.

“I think that it is too easy to give up, and that is not what we are here for,” she said. “We are here to do the right thing for the patients and to empower them. An empowered patient can do quite a bit for themselves. Having the right advocate behind them means a lot.”

Reference

  1. IQVIA Institute for Human Data Science. Medicine use and spending in the U.S.: a review of 2018 and outlook to 2023. May 2019. www.iqvia.com/-/media/iqvia/pdfs/institute-reports/medicine-use-and-spending-in-the-us---a-review-of-2018-outlook-to-2023.pdf. Accessed April 20, 2020.

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