How Annual Benefit Changes Can Negatively Impact Patient Adherence

We’re in the midst of benefits reverification season- a time when physicians and specialty pharmacies tackle the time-consuming task of confirming patient coverage changes, obtaining new prior authorizations (PAs), and re-enrolling patients in financial assistance programs. Aside from the administrative challenge providers face in navigating this process efficiently, these annual benefit changes have the potential to negatively impact patient adherence to care. 

A Flurry of Change

When employers make changes to their benefit plans each year, it triggers an overload of paperwork, phone calls, and coordination between insurers, providers, and patients. Even if the employer doesn’t switch health plans or insurers, the plan’s co-pay, coinsurance, or deductible amounts might be different, medications may be dropped from formularies, coverages could be reduced or cut altogether, and patient assistance programs (PAPs) might require re-enrollment. The fact that some prescriptions may be covered under a medical benefit and some covered under a prescription benefit often further confuses the patients trying to navigate this properly. 

At the very least, all plan deductibles will automatically reset with the new calendar year, resulting in out-of-pocket costs that patients may not be prepared for, or able to afford.

Providers bear the brunt of the work to confirm how these annual benefit changes will impact their patients as they are required to submit any required paperwork, and ensure they’ll be reimbursed appropriately. Patients can face difficulties too—especially when it comes to their health outcomes.

The Many Obstacles Patients Face 

Healthcare access and affordability are known to influence a patient’s adherence to therapy, and adherence is a strong determinant of health outcomes. It’s an interrelated web—and one that can be negatively impacted each year when health benefit changes take effect and providers undertake the labor-intensive tasks of reverification and re-enrollment.

One of the greatest risks is the onslaught of paperwork processing causing delays that threaten continuity of care, which is especially troublesome for patients with complex diagnoses and life-threatening conditions. Obtaining new prior authorization approvals can prove to be  a significant hurdle during reverification season, particularly for the many providers that still handle some or all of the PA process manually. In fact, one in four patients experienced a PA-related delay in receiving treatment in 2020. 

Likewise, annual changes in benefits can create affordability issues that impair a patient’s health outcomes. With the average annual cost of specialty medications exceeding $84,000 per patient in 2020, the affordability risk is especially high for patients receiving specialty therapies.  If a particular therapeutic is no longer covered, requires a higher co-pay, or a high deductible plan has now been reset, patients may find they can’t afford their current treatment regimen once the new year begins. 

When a therapy is no longer affordable, patients make difficult choices that can cause their health to suffer. They may take their medications less often than prescribed to stretch out the prescription, as one in three patients report doing. Or worse, they may opt not to pick up or refill the prescription at all. Once the out-of-pocket costs for a treatment reach $500 or more, the abandonment rate rises to 41%.

When serious health conditions are involved, missing a treatment or failing to take the prescribed medication can have grave health consequences. Yet the alternative is no better, as some patients resort to foregoing other necessities to pay for their medications and other treatments. 

PAPs that offer free or reduced cost medications or co-pay cards can help patients overcome affordability hurdles. Yet many insurers and manufacturers require patients to re-enroll in those programs at the start of each year. If the patient or provider isn’t aware of the requirement, or there are delays in getting the application submitted and approved, patients may face bills they simply can’t afford to pay. When that happens, it’s common for patients to cancel treatments, delay procedures, and leave prescriptions unfilled. 

Practical, Patient-Centric Solutions

Smoothing the transition to a new benefit year can minimize treatment disruptions for patients, reduce their affordability obstacles and concerns, eliminate undue stress and anxiety, and ensure they can adhere to the treatment plans that are vital to their health and quality of life. 

Providers often staff up at this time of year to ensure they have the resources to handle the reverification process efficiently. They notify patients early and often about the potential for benefit changes, ask questions to determine if and how patient benefits may be affected, and emphasize the importance of reverifying benefits to ensure continued care. They also establish and train staff on standard procedures for handling situations where patients are due for treatment, but their benefits haven’t been reverified or their PAs haven’t been processed yet.  

Despite these efforts, annual benefit changes still have the potential to negatively impact patient outcomes, especially when the reverification process is handled manually. It becomes time-consuming, inefficient, and error-prone—raising the risk of delays and inaccuracies that can threaten access, affordability, adherence, and ultimately health outcomes.

That is why leading specialty pharmaceutical manufacturers are increasingly adopting hub services technology. The right hub can process both Rx and medical benefit verifications, streamlining benefit verification and PAP enrollment---not only during the annual benefit change season, but year-round. 

Hub technology connects manufacturers, providers, and patients in ways that automate workflows, improve accuracy, and speed the benefits process from end to end. With the right technology in place, providers can ensure their patients have access to much-needed therapies they can afford, without disruption, so they are more likely to stay on their treatment plans, increasing the odds they’ll experience positive health outcomes. 

Contact CareMetx to learn how hub services technology can streamline your benefits processes during annual reverification season and year-round.