Navigating the Complexity of Healthcare: Insights into Alternative Funding Programs

Understanding the Complexity of Health Care The American healthcare system is a complex entity comprising several systems such as Medicare, Medicaid, TRICARE, private insurance, and numerous state and local healthcare programs. Additionally, patients have access to charity care programs and patient assistance programs. For example, pharmaceutical manufacturers sponsor patient assistance programs (PAPs) that offer financial aid or free product to low-income individuals to supplement any existing prescription drug coverage. Therefore, when politicians propose quick solutions to lower the cost of medicine, introduce a single-payer system like ‘Medicare-for-All’, or bring about an immediate free-market revolution to health care, it's not entirely accurate. There are no simple reforms or singular solutions that will affect all the layers and complexities of providing greater access to health care at lower costs. Healthcare reform necessitates several changes that will take time and require both the public and private sectors to adapt. The only certainty about American health care is that it's incredibly complex.

The Need for a Comprehensive Approach

The current health care environment calls for a comprehensive approach that includes more private-sector competition, health insurance flexibility, greater price transparency, and numerous other reforms. For instance, what are Alternative Funding Programs (AFPs) and how do they provide medical coverage to patients? Businesses are striving to stay competitive in an economy rocked by historic inflation, unprecedented supply-chain shortages, high interest rates, and low-cost foreign competition. AFPs could assist small businesses in their efforts to remain operational and prosper. AFPs help companies reduce their health care costs by 'offloading' the health expenses of certain specialty medications. They achieve this by leveraging the pharmaceutical industry’s charitable giving – the patient assistant programs. In simple terms, AFPs help employers lower their pharmacy benefit costs. Alternative Payment Programs advocate for patients by navigating the complex healthcare landscape of PAPS to find solutions where employer-sponsored health plans fall short.

Addressing the Underinsured

Millions of Americans are underinsured – they might have some form of group health plan coverage, but that coverage doesn’t adequately cover their medical costs – the specialty medicines they need. Specialty drugs are high-cost prescription medications used by patients with serious, complex illnesses – for instance, patients with cancer, arthritis or MS. AFPs fill the insurance gap for the underinsured patient – an insurance gap that if not addressed leaves patients vulnerable to both serious illnesses and financial ruin. AFPs can assist patients lacking traditional insurance; specifically, patients who are in self-funded plans that do not provide coverage for high-cost prescription medications needed to treat chronic conditions – i.e., specialty medicines. AFPs serve patients who can’t afford treatment, and patients who lack the financial means to pay for the medication out-of-pocket.

The Impact of AFPs

AFPs are increasingly impacting our healthcare systems, and their business model is intriguing. The pharmaceutical industry points to how AFPs are designed to take advantage of manufacturer-sponsored PAPs, primarily for high-cost specialty medications. AFPs work by carving out specialty medicines and then using patients’ insurance status to enroll them in a manufacturer PAP. The results are health plans and employers benefit from these services by saving money on prescriptions. In a recent conversation with Paydhealth’s David A. Galardi (Chief Commercial Office), he described his company’s vocation with an actual client’s circumstance: ‘In a large school district, an employee under a group health plan needed three costly specialty medications. Without intervention, the district would have faced nearly $650,000 in annual costs. PaydHealth stepped in, reviewed the case, identified forms of assistance the individual was eligible for, and helped secure free assistance for the employee within 72 hours. This not only preserved access to the prescribed therapy but also saved the public sector employer from bearing the high costs while ensuring the patient received the necessary treatment.’ AFPs, like Paydhealth, could be part of the health care fix patients deserve – addressing real problems in the healthcare space.

Bottom Line

Specialty medications account for 51% of total pharmacy spending though they are used by less than 2% of the population. Policymakers should be looking at solutions to get the right medicine to the right patient at the right time – and at the right cost. Let’s have that public discussion so patients see greater access to the medicines and treatments they need. The complexity of the healthcare system calls for innovative solutions like AFPs. What are your thoughts on this matter? Share this article with your friends and sign up for the Daily Briefing, which is everyday at 6pm.