The Lynx Group

Patient Assistance Programs

October 2013, Vol 4, No 8

Hollywood, FL—“Patient assistance is not an option but a very important part of the fabric of our healthcare system,” said Patrick McKercher, RPh, PhD, President of the Patient Access Network Foundation, at the 3rd Annual Conference of the Association for Value-Based Cancer Care. “While some predict that when the donut hole squeezes shut there will be no need for patient assistance programs, this could not be further from the truth.”

Patient assistance takes a variety of forms, mostly (1) “the free goods” provided by pharmaceutical manufacturers, (2) coupons and vouchers, which provide approximately $6 billion worth of aid, and (3) manufacturer’s copay cards.

The 5 major charitable foundations that provide most of the assistance include the Patient Access Network, the Chronic Disease Fund, HealthWell Foundation, Patient Services, and the Patient Advocate Foundation. The estimated total aid provided through these 5 entities alone is $600 million. Another half dozen or so 501c3 organizations also provide funds, bringing the total patient assistance budget to about $1 billion, Dr McKercher estimated.

The need for patient assistance can also be appreciated by visualizing a typical workday at the Patient Access Network, he said. “We will handle 1000 phone calls in a given day. When people call us, they’re calling for a single purpose: they are looking for help.”

“We’ll pay the cost share on about 1000 claims each business day. We’ll approve about 500 patient grants, worth about $1 million in expenditures,” he said. “And we are relatively small….To indicate how the need is growing, consider that 4 years ago our patient load was about 13,000. We finished 2012 with 59,000 patients on our books, and we’ll end 2013 with over 100,000 patients.”

“This is a rapidly growing, demanding business,” he noted. “The magnitude of what we do, and the number of patients that we touch, is probably quite a bit more significant than what the average person thinks.”

Will the ACA Lower the Demand on Patient Assistance Programs?
Patient assistance programs exist for the estimated 50 million Americans who are uninsured or otherwise outside the “entitlement safety net. Many have been paying insurance premiums their whole lives but are underinsured when cancer strikes.” Altogether, many Americans are essentially “above the indigent and below the affordability thresholds,” Dr McKercher said.

The Affordable Care Act (ACA) is not expected to reduce these numbers or lessen the demand for patient assistance, according to Dr McKercher.

Figure: Healthcare Reform Creates New Needs for the Underinsured: >30 Million New Insured to Enter the Market by 2016.
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“I'm expecting 2 things,” he said. “While there may be a smaller obligation or smaller liability on the part of the patients, because there are patient premium supports and some subsidies built into the system, there will be a much larger patient population exposed to probably larger copay obligations” (Figure).

He noted that several “preexisting accelerators” will ensure that the need for patient assistance remains unabated, such as the shift to more expensive oral cancer medications, the expanded market in specialty pharmacy, with high out-of-pocket costs; the impact of the new insurance exchange market; and challenges and regulations that will slow the implementation of government out-of-pocket subsidies.

Moving into the era of the ACA, charitable foundations will feel some restrictions, Dr McKercher predicted. For example, foundations cannot give preferential treatment to any single treatment, healthcare system, or provider and cannot disclose the source of funding to the provider or the patient.

He hopes that a positive change, because of increasing need, will be the establishment of standards for patient assistance programs. Duration of aid would be a good place to start, he said.

“It’s cruel to give somebody assistance for 6 months, but have it be exhausted halfway through the patient’s therapy,” Dr McKercher said. His own program seeks to provide aid for the entire treatment duration (or for 12 months), and preferentially uses its funds for treatment renewals. “The only thing that holds us back from guaranteeing renewals is whether or not the funding is going to be there,” he added.

With the persistence of economic barriers, Dr McKercher predicted that a significant population of Americans could, at least theoretically, get “boxed out” of access to progressive therapies. Numerous studies have documented that about 25% of lower income Medicare beneficiaries abandon therapy because of costs. Under the ACA, the need for cost-sharing will only become greater, as will the continued need for patient assistance programs, Dr McKercher emphasized.

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