Eliminating Hurdles to Life Saving Medication

Wednesday, April 11, 2018

The moment you’re exposed to the HIV virus, a clock starts ticking. You have  72-hours to begin taking medication that greatly reduces your risk of contracting the virus, and the sooner you start taking it, the more effective it is.

If you go to Whitman-Walker Health in Washington, D.C. and report an exposure, it triggers their “red carpet service.” This means you don’t wait for an appointment; you see a nurse and an insurance navigator immediately, and leave with a prescription for a Post-Exposure Prophylaxis medication (PEP) that you can walk over and fill at the in-house pharmacy. But with effective treatment conditional on speed, this is where  things can come to a halt.When the pharmacist keys in the prescription, for some health plans, PEP comes up as a mail-order drug, which usually means that you fill out a slip, go home, and wait — much longer than 72 hours — for your medication to arrive by mail. This is because insurance companies were able to negotiate the best price for PEP as a mail-order drug. While it seems crazy that a time-sensitive medication would ever be considered for mail-order service, PEP has more than one use, and when it’s being taken regularly and on a schedule for other purposes, receiving it by mail may be reasonable. But it does nothing to help people who have a short window to prevent the contraction of HIV.

Again and again over the last few years, this problem came up at Whitman-Walker: a patient was fast tracked through the clinic only to hit a stumbling block at the pharmacy counter. “Whitman-Walker sees an average of twenty-five people every month who need PEP for HIV exposure. Getting them the medication they need is critical not only to their health, but also to controlling the spread of HIV broadly,” said Dr. Sarah Henn, Senior Director for Healthcare Operations and Medical Services.

Over the last several years, pharmacists, technicians, and insurance advocates at Whitman-Walker have spent countless hours on the phone with insurance companies explaining why patients can’t wait for the drugs to arrive by mail and seeking an exception. “Sometimes, with hours of advocacy, we could get companies to make an exception,” said Erin Loubier, Senior Director for Health and Legal Integration and Payment Innovation at Whitman-Walker. “But it would come down to the wire. It was really dangerous for our patients, and incredibly burdensome for our staff.”

Pharmacists at Whitman-Walker reported the problem to the health center’s operations committee, which looks at how patients move through care at the health center and solves problems like this one. After interviewing pharmacy staff and insurance navigators, the health center’s legal services and policy teams drafted a letter to the two insurance companies with these barriers explaining in medical detail why patients couldn’t wait for this medication to arrive by mail, and asking the companies to change their policies and allow PEP to be filled immediately at the pharmacy without wait or additional cost-sharing.

Within a week, Whitman-Walker heard back from both companies. The first one removed all utilization restrictions, including the mail order requirement for PEP prescriptions. The second company implemented an automatic override, allowing a 30-day supply for PEP medication to be filled if a pharmacist called to request one.

“This is the kind of systemic problem we only know about because we are part of the care team embedded in the health center,” said Ms. Loubier. “It was our pharmacists raising an operational problem that allowed us to see this roadblock to fast and effective care for these patients. Our legal services team works tirelessly to respond to individual needs of patients, but we also help identify trends in individual needs to use policy solutions to remove barriers like this one so our team can provide the best possible care.”

Whitman-Walker is not done yet. For the second insurance company, getting patients this medication still hinges on a staff member making a call, which remains burdensome and, most importantly, can slow down and even prevent the medications being administered on time. They are working to eliminate any utilization requirements — including this one — for PEP medications. Guillaume Bagal, the Policy Associate at Whitman-Walker who is handling the follow up with the insurance company, knows the stakes. “Removing this last barrier is what will ensure that anyone anywhere who needs this medication can walk into a pharmacy with a prescription and leave with PEP in hand without delay,” he said. “And that’s our goal, to give everyone the very best chance to prevent the contraction of HIV.”

Story by Kate Marple and Erin Dexter
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