How Product Acquisition Impacts Patient Support Service Offerings: Buy and Bill vs. Specialty Pharmacy
At Archbow, our manufacturer clients often ask, “What patient and provider service offerings do I need to build an industry-leading patient support program?”
The answer to that question can be complex and depends upon several factors. One key factor can be product acquisition and how it impacts the services and solutions needed to best support patients and other stakeholders involved in their treatment, including Healthcare Professionals (HCPs) and caregivers. Since patient support programs are typically designed and implemented for specialty products, these products are most often distributed via buy and bill and specialty pharmacy pathways.
It’s essential to begin with a clear definition of these acquisition methods and what they mean:
Buy and bill is how an HCP purchases the medication from a specialty distributor. After treating the patient, the HCP will submit a claim form to bill the patient’s insurer for reimbursement. Coverage typically adjudicates through a patient’s medical benefits, and the HCP will bill the patient for their cost-share portion of the medication and any administration-related fees.
Specialty pharmacy, on the other hand, is when an HCP sends a prescription to the specialty pharmacy that carries the medication and that pharmacy directly bills the patient’s insurer for the medication. Coverage may be adjudicated through either the patient’s medical or pharmacy benefit, depending on the insurance plan, the type of medication, how it is administered, and other factors. The specialty pharmacy will bill the patient for their responsibility for the medication cost. (Note that the HCP may still bill the patient for office visit-related fees and/or product administration-related fees.)
There are varied nuances between the point of prescription and initiation of treatment, depending on how the medication is obtained. Since there are different players, reimbursement pathways, and considerations determining whether a medication falls under “buy and bill” or “specialty pharmacy,” the patient support offerings that are most important for HCPs and patients will also vary.
The most significant difference is that a manufacturer’s service offerings for a buy and bill product are typically geared toward supporting the HCP’s access, acquisition, and reimbursement for the medication. On the other hand, service offerings for medications obtained through a Specialty Pharmacy are typically centered on providing direct assistance to the patient through coordination with the pharmacy, patient education, and caregiver support.
Specific services that are important to consider for a buy and bill medication include the following:
Site of care coordination – determining all sites of care that could acquire the product and coordinating between the prescribing and treating facilities, if applicable
Distribution pathways – helping the HCP understand where and how they can acquire the medication and how the patient’s coverage, out-of-pocket responsibilities, and access may differ for each
Billing and coding guidance – educating HCPs on how to bill for the medication, understanding claim form requirements by payer, and informing the applicable drug and procedural codes
Claims support – providing claims review services to ensure claims include all required information before they are submitted to an insurer, as well as claims appeal services to assist HCPs in the instance that a claim has been underpaid or denied
Sample or voucher programs – providing patients and HCPs with access to medication while the HCP works through product acquisition
Medical copay program solutions – building a copay program that will provide reimbursement to the HCP or patient after treatment
Patient Support service offerings for a product obtained through a Specialty Pharmacy may need to include the following:
Specialty Pharmacy coordination – determining mandated specialty pharmacies, white-bagging coordination (as needed), reimbursement support, and working with the specialty pharmacy to ensure they receive the prescription and can ultimately fulfill the product, partnering to remove barriers to access along the way
Quick Start and/or Bridge programs – programs that are geared toward helping a patient initiate and stay on medication expeditiously while working to obtain coverage through the patient’s insurer on the back end
Patient education – providing tools, materials, and resources to help patients initiate and stay on therapy. Since most specialty pharmacy medications require a patient to self-administer (orally, via self-injectable, etc.)
Caregiver support – additional educational tools and resources intended specifically for caregivers who may be leading, assisting, or participating in product administration and/or other aspects of a patient’s treatment journey
Pharmacy copay program solution – building a copay program that will be applied before patient treatment so the patient doesn’t have a large out-of-pocket cost-share responsibility
If you are preparing to launch a patient support program and need strategic guidance on building your program, which services should be included, and how to best communicate with your patient and HCP customers, Archbow can help. We have deep expertise in designing and customizing patient support programs and distribution strategies based on critical factors related to your product, therapeutic area, and patient population. Contact us today to get started.
Archbow Consulting helps pharmaceutical and biotech companies in the USA and Europe design, build, and optimize product distribution and patient access strategies. Archbow was founded by industry veterans to meet a need in the marketplace for consulting options that offer diverse real-world experience, can leverage deep connections across the industry, and can also provide actionable strategic guidance. We invite you to learn more about our team, services, and client’s success, and connect with us via email, LinkedIn, Twitter, or subscribe to this blog which you can do below.