Quite often the headlines capture skyrocketing costs of medications. While those headlines are filled with many debatable positions, starting with whether the issue is drug pricing or the drug pricing ecosystem fraught with misaligned incentives, there is a major issue that is ignored. According to IQVIA’s U.S. 2020 Medical Spending and Affordability report, non-drug, patient healthcare costs for medical services associated with office visits, diagnostic tests, and hospital outpatient and inpatient services, reached $260 billion in 2019, rising at a 4.6% CAGR over the past five years. This growth in patient costs is in addition to the growth in out of pocket drug costs that exceeded $82 billion in 2019. These statistics highlight that the real issue is beyond drug pricing and it in fact, the total cost of healthcare placed upon the patient. Specifically, the sequalae of the costs, barriers, and organized chaos a patient faces in accessing care compounded by a low literacy in navigating a complex healthcare maze – places them at risk for financial toxicity with poor clinical outcomes.
Reflecting on my experience with specialty pharmacy patients, brought me back to the patient treatment journey – a journey that starts well before a medication is prescribed. The moment a patient engages in their healthcare ecosystem, multiple hurdles are introduced to them including navigating a complex health benefit design coverage structure, out-of-pockets healthcare costs (coinsurance, deductibles etc.) and gaining fluency in how to access care within their ecosystem. Additionally, while big data and interoperability is available at certain vantage points, what would seem reasonable and necessary to ensure continuity of care such as accessing and sharing patient healthcare information, continues to be elusive for patients and their respective providers. Gaps throughout the healthcare maze continue to fuel rising costs to the system and ultimately the patient. With horizontal and vertical integration, support for patients should be better aligned however, we find that often patient confusion, limited access points, and authorization hurdles become the predominant theme.
Financial toxicity or hardship is an important part of the patient journey influencing decisions that result in negative clinical outcomes and poor quality of life. While it may seem hyperbole to say financial toxicity can result in mortality, it is fair to say that if financial burden results in avoidance of healthcare services or treatment, causality is not unreasonable. Unfortunately, patients are making these tough decisions to stop treatment, avoid treatment and/or not access care throughout their treatment journey and at points where financial costs with risks are disproportionately weighting the decision.
As innovative treatments offer hope, cure, and new quality of life for patients, a real obstacle to initiating, completing, delaying care, or follow-up care is in fact, financial toxicity. Opportunities to address these hurdles can begin with foundation grants, manufacturer assistance programs, and hardship assistance programs. However, if strategies do not include effective mechanisms for advocacy programs, enhanced innovative contracting, effective and undisruptive supply chain integration, and Patient Reported Outcome Measures (PROMs) enriched clinical protocols, then missed care intervention opportunities, treatment attrition, and financial toxicity, all become a certain consequences. Additionally, policy threats that introduce barriers such as impact to best price rule, can result in grave consequences to vital patient assistance programs’ existence.
Addressing financial toxicity is a complex issue that requires a clear understanding of the breakdowns within our value chain. Strategies that include development of innovative contracting across new stakeholders in value chain, comprehensive assistance programs leveraging real world data to facilitate actionable impact while gathering feedback, and incorporating PROMs to identify interventions or coordination opportunities, is a start. Optimization of amplified care navigation protocols for coordinated management of episodes of care, that can provide off-ramps for transitions of care and support throughout the patient journey, is critical. As these pieces of the puzzle come together, there is a continued need to leverage the discussion on total cost of healthcare and those corresponding outcomes. For expert solutions to enhance strategies focused on addressing the challenges of the patient treatment journey in the specialty market, contact Sapere Health.
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