New middlemen and middlewomen are making the patient’s path to treatment difficult to nearly impossible, and treatment physician offices are often the last to know. When a patient’s health insurance comes through a self-insured entity’s (SIE) health benefit plan, there is a growing likelihood that a middleman vendor has convinced the SIE to hire them to save on specialty pharmacy costs.
These vendors often label themselves with positive-sounding descriptives, such as prescription/specialty drug advocates, pharmacy consulting companies, or even a plan participant-focused cost-saving service. The medical and patient support communities started referring to these middlemen collectively as specialty carve-out vendors, and in recent years, alternative funding program (AFP) vendors. However, it is difficult to track the prevalence of these programs, let alone the impact their activities have on patients and cancer centers, because their interactions tend to fall directly on the patient. Medical practitioners are not their target, and the difference in describing these middleman programs makes it harder to connect the dots between real-world activities affecting patients and the generalized warnings about AFPs, including several editorials over the past 4 years in Oncology Practice Management.
A recent study has documented the impact on patients, their access to care, and their fears, frustration, and confusion brought on by the intrusion of AFPs into the patient's medical journey. This study will help the medical community better understand how much AFPs might be behind growing rates of prior authorizations, coverage denials, and numbers of SIE-insured patients suddenly presenting as uninsured for certain drugs. Learning that an AFP is behind a patient's sudden financial and access-to-care concerns will help practice staff and physicians address the source more effectively.