Overcoming Hidden Obstacles in the Script-to-Therapy Journey

Growing up, my dad often shared the parable of a man searching for his keys under a streetlamp. A passerby offers to help and asks if he dropped his keys where he’s looking. No, the man replies, he dropped them in the darkness but is looking where there's light because he can actually see there.

My dad loved telling me that parable because a) like all dads everywhere he really loved parables, and b) I was always losing my stuff as a kid. Now that I’m older (and still sadly constantly losing my keys), I think about that proverb quite a bit: I see it often in the way that we as a healthcare industry try to help doctors and patients start and stay on the right treatment: we focus on what’s visible and measurable, but the real challenges often lie in the shadows.

The hidden challenges in provider-administered drugs

It’s just plain hard, sometimes obscenely so, for doctors and patients to overcome all the dumb non-clinical obstacles that get in the way of treatment. This is even harder for provider-administered drugs. Manufacturers rightly focus on reducing the time and blockers to treatment, but frequently target the most visible and measurable fixes.

This makes sense: these teams historically had few compliant levers to improve the process. One such lever is benefit verification (BV) support, where speed is key. That meant going from three days to two days to one day to hours to potentially instantly. No doubt, this is a worthy goal; an instant response for the provider could make the medical side of the benefit resemble the instantaneous pharmacy benefit.

But zooming out, that reduction in time from BV request-for-help to BV answer represents just a small piece of a much bigger puzzle. Most of the time-consuming parts of the script-to-therapy journey live in different parts of the process.

Understanding the full workflow

Let’s break down the script-to-therapy journey for a healthcare organization (HCO):

1. Script order: After seeing a patient, a doctor writes a prescription (‘script’) for a drug.
2. Get into BV queue: That prescription gets routed to a queue that a staff member needs to work.
3. Run BV: Once it hits the top of their queue, staff will “run the BV” by calling the payer directly, consulting an internal reference, checking the payer’s website/policy, or going to a pharmaceutical hub website to submit the information, and then waiting for a response.
4. Get into PA queue: Once they’ve got an answer, it goes back into another queue of patients who have been “verified” and are ready to have prior authorization (PA) run.
5. Create Prior Authorization (PA): Once it hits the top of that queue, the same person (or sometimes a different user) will create the PA by collecting the information, filling out the PA form, and submitting it to the insurance company.
6. PA response: From there, they wait. And wait. And sometimes wait some more for that PA response…
7. Manage PAs: Take action on any PAs that require more information.
8. Scheduling: Finally, when a response comes back from the insurance company (cross your fingers for an approval!) the HCO can schedule the patient to get the infusion/injection in-office.

samacare-access-diagram © SamaCare

This process takes ~20 days on average (though we’ve seen data for some classes of therapy where it’s more like 40-60 days!). As the chart below shows, the time is taken up by almost everything else besides the actual time to run the BV, including the “shoulder” activities of waiting for it to go from exiting one process to hitting the top of the queue for the next.

Shrinking the “shoulder” times

While reducing the raw BV processing time is beneficial — and measurable! — it doesn’t significantly impact the overall process. To make a meaningful difference, manufacturers must consider the entire process holistically and find ways to shrink the “shoulder” times where the prescription is sitting in a queue:

• After the doctor has written the prescription.
• In translating the BV to a PA.
• In the time a payer takes to adjudicate a PA.
• In acting to address a contested PA.
• In acting to schedule a patient after the PA has been completed.

Integrating support into existing workflows

But how do we shrink that “shoulder” time? One rule-of-thumb: if the provider or their team have to constantly get out of their existing workflow and “pull” support from the manufacturer, it will not work. That just adds one more queue and handoff for the administrative team to manage. Instead, manufacturers have to find ways to help providers inside their existing workflow. By doing so, the manufacturer can help address the problem proactively — not just reducing the shoulder times but eliminating them altogether. That’s hard, because these solutions are not fully “in the light”; but they are solutions that address where the problems actually lie.

Syam Palakurthy is the Founder and CEO of SamaCare