How Policy Impacts Patient Support

By Ana Stojanovska; Corey Ford, MHA |

The changing landscape of healthcare coverage and access and the effect on patient assistance programs.

Seismic shifts in the healthcare policy landscape can play a considerable role in altering the need and demand for patient support services offered by manufacturer programs. Since the inauguration of President Donald Trump, congressional Republicans have launched significant undertakings to reform the laws that govern America’s complex healthcare system. Despite the push, efforts to repeal and replace the Affordable Care Act (ACA) have fallen short.

With a full repeal no longer a viable option, congressional leaders have sought other legislative remedies and the Administration has exercised its regulatory authority to weaken the ACA. For example, the Administration eliminated cost-sharing subsidies that insurers rely on within the health insurance exchange market. These subsidies help pay for the out-of-pocket expenses for some of the lowest-income individuals in the market. Similarly, loosened ACA standards allow access to short-term insurance plans that may deny coverage to individuals with pre-existing conditions and facilitate an exodus of healthier individuals from the existing exchange market—consequently resulting in a sicker risk pool in the exchange market. Most significantly, in December 2017, Congress repealed the individual mandate, which required most Americans to have a basic level of healthcare coverage or face a penalty. While the full impact of these changes will not take place until 2019, the Congressional Budget Office estimates that three million people will be uninsured by 2019.1

The impact of policy changes.

These changes likely will force insurance carriers to raise premiums, explore market exits and maintain high out-of-pocket costs to patients.

The repeal of the individual mandate will likely lead to younger, healthier individuals foregoing health insurance completely, particularly in the exchanges. Similarly, the regulatory moves will mean that younger, healthier individuals may also get insurance outside of the exchanges via short-term insurance plans with less comprehensive coverage. The mishmash of the individual mandate repeal and the regulatory changes portends a much sicker risk pool in the health insurance exchange market.

For pharmaceutical manufacturers, this shifting landscape likely signals increased demands for financial assistance and core service offerings for patients who find themselves uninsured or underinsured due to high OOP expenses or policy exclusions. As sicker patients grapple with higher costs and limited coverage options, manufacturers may face costly impacts to their business.

"As sicker patients grapple with higher costs and limited coverage options, manufacturers may face costly impacts to their business."

Preparing for the impact on patient support.

How can manufacturers prepare for the changes borne from a shifting healthcare landscape? Patient support programs can prepare to meet increased needs from patients facing uncertainty in their care by:

  • Preparing staff for patient pain points: In a poll of attendees at an Xcenda education session during the most recent CBI Patient Assistance Program (PAP) Conference, more than half noted that appropriate product and financial assistance is the most critical aspect needed to meet the challenges of a shifting landscape. Preparing staff who will need to address the pain points that patients will experience throughout their journey will be integral to providing a positive experience for vulnerable individuals. For example, as payers continue to pass costs onto patients, their out-of-pocket burdens are likely to increase. Both hub services and field teams can help providers understand financial assistance options for prospective patients.

    As the front-line point of contact for patients and providers, dedicated support program staff can help enroll patients and navigate financial assistance and denied claims. The upfront education is potentially more complex than it has been in the past, but may help prevent patient assistance denials in the long term.
  • Updating patient projections on a regular basis. Nearly half of Xcenda PAP presentation attendees noted that they updated their projections on a consistent basis—an instrumental way to stay abreast of increasing demands as more individuals react to the changes in their healthcare insurance. Without regular internal check-ins on patient projections, programs may be at risk for an influx of demand and inadequate resources to support free product or other patient assistance efforts. Manufacturers should also continue to maintain a pulse on the competitive landscape to determine how they can evolve their services to reflect the needs in the market.
  • Incorporating electronic benefit verification: Greater market uncertainty around insurance coverage and patient access necessitates coordination—particularly in determining a patient’s level of benefits and coverage. This underscores the imperative for accurate and complete benefit verification before assistance is provided by the program. Enrolling into the program to initiate benefit verification can clarify the patient’s insurance coverage, cost-sharing or prior authorization (PA) requirements. Integrating electronic benefit verification systems with existing workflows will drive a more seamless experience for all parties and aid in initiating therapy quickly. While benefit verification is an essential feature of any assistance program, the increasing number of individuals requiring assistance will drive the need for programs to be more efficient and accurate, and electronic benefit verification can solve for this pain point by harnessing and evaluating large data sets automatically.

    Additionally, the need for patient care coordinator education at the outset is only heightened further due to the uncertainty following political and policy shifts, and targeted field reimbursement support can drive greater use of hubs for benefit verifications to accurately gauge coverage, product access and PAs.

Staying on top of healthcare legislation and regulatory developments.

The continually evolving policy landscape shifts could reduce or exacerbate the number of individuals who are at risk of losing health insurance. Manufacturers should monitor for updates that could potentially impact their business so they can maintain timely access to care for the patients who rely on their therapies. Staying abreast of these legislative and regulatory changes will allow manufacturers to optimize their programs accordingly.

1Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2018 to 2028.  Congressional Budget Office. 30 May 2018. Accessed 2 August 2018. Available online at

About the Authors

Ana Stojanovska

Vice President, Commercial Consulting
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Corey Ford

Corey Ford, MHA

Director, Reimbursement & Policy Insights
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