Navigating Health Insurance Coverage for Innovative and Specialty Drugs: Q&A With Maria Kirsch, President of Patients Services at EVERSANA

Maria Kirsch
President, patient services
EVERSANA

EVERSANA recently launched its ACTICS eAccess solution, a platform designed to improve patient access to therapy. Maria Kirsch, president of patient services at EVERSANA, spoke with Pharmaceutical Executive about this new platform and market conditions that led to its creation.

Pharmaceutical Executive: How are current eBV and ePA tools failing to meet the needs of patients?

Maria Kirsch: Medical benefit verification and expertise have long been considered the most complex arena to navigate for patients and health care providers (HCPs), and drug coverage is only one small element of the equation.

The traditional approach to verify this information for patients requires phone calls. Through ACTICS eAccess’ insight into major medical plans, patients and providers can determine patient specific out-of-pocket costs, patient deductibles, and coverage for physician administered drugs, buy and bill as well as ancillary services. Importantly, providers can compare coverage and out-of-pocket costs between pharmacy and medical to identify the best reimbursement pathway for the patient. Finally, next-generation technology expedites the prior authorization submission process, delivering a much higher percentage of accepted submissions by insurance providers.

The old process can be very time-consuming, lasting upwards of 45 minutes to an hour. It can require calls to multiple payers to get insight into medical and pharmacy coverage. Finally, these calls are often required for an individual patient multiple times per year. In the past few years, electronic benefits verification (eBV) tools have evolved to close this gap, but the success rate for an accurate estimate of a patient’s financial responsibility is at best 60%. Why? Most tools today rely on algorithms for estimation. Similarly, with electronic prior authorization (ePA) solutions, some 70% of submissions are rejected with little or no status for patients.

This high rate of inaccuracy has resulted in financial barriers for patients, increased burdens on Patient Assistance Programs and Hubs, and hesitance among HCPs to prescribe therapy. It’s challenging for everyone, and we need to do better.

PE: How does technology like the ACTICS® eAccess platform solve these issues?

Kirsch: At EVERSANA, we have always said since day one that patients are at the center of everything we do. We firmly believe this, and especially on my team that works with patients day in and day out, we needed to do more.

We have invested in both technology and the digital connectivity we have with more than 1,400 payers across the U.S. to solve these challenges.

ACTICS eAccess is that solution that integrates data from more than 90% of covered lives to verify pharmacy and major medical plan coverage nearly immediately, within seconds.

From here, patients (and their physicians) can quickly see out-of-pocket costs, patient deductibles, and coverage for physician-administered drugs, buy and bill as well as ancillary services. Doctors can compare coverage and out-of-pocket costs between pharmacy and medical to identify the best reimbursement pathway for the patient. And on top of it all, our technology expedites the prior authorization submission process, delivering a much higher percentage of accepted submissions by insurance providers.

For patients, it is as simple as entering five fields into a branded website, and within seconds they know what to expect. We have narrowed the funnel to improve access and help more people get on therapy faster.

PE: Will this make it easier for patients and doctors to connect?

Kirsch: Without a doubt, this technology will drastically make life better for doctors and patients by providing a tool they can use at the site of care. Presenting patients with affordable treatment options and necessary out-of-pocket costs during their doctor’s visit not only expedites treatment initiation but creates a level of trust and confidence that cannot be delivered over the phone days after the initial appointment. 

Through this information, both patients and doctors will know what is ahead, and be able to have clearer, more detailed discussions that will result in better outcomes.

PE: Will this help patients find affordable care easier?

Kirsch:Through the ability of ACTIS eAccess to compare out-of-pocket costs between pharmacy and medical, patients will be able to find the best path to care while also seeing the most affordable option. The tool also has the capabilities to help patients learn if they are eligible for a Patient Assistance Program, along with necessary steps to enroll. This obviously comes with other variables including a patient’s perception of a clinician or program, but what ACTICS eAccess has done is open blinds and show both doctors and patients exactly what they need to know to move forward with care.

PE: Can this solution fit into existing patient services programs?

Kirsch:The beauty of what we have built is scalable. We can plug into existing patient support hubs, offer this as a standalone verification tool, integrate the software into patient and HCP-facing websites or add it to an HCP portal. We can do programs of all sizes and the data is unmatched through EVERSANA’s relationships with nearly every insurance payer in the U.S.