Insured Employed Patients Harmed by AFP Intrusions

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.

Background on AFP Programs: Each One Is Different

AFP programs do not call or think of themselves as AFPs. There are a variety of vendors, each of which offers their own unique way to provide services to their SIE clients. Some may seek copay assistance or foundation support for patients, or free drugs through patient assistance programs; some also may offer international drug “discounts” through drug importation. Some may even encourage patients or physicians to switch to other drugs in a class, usually to better align their own ability to generate income off the final drug choice rather than patient needs.

AFP middlemen are making the patient’s path to treatment difficult to near impossible, and treatment physician offices are often the last to know.

• Step 1 – Remove/suspend coverage of specific drugs, enroll patients in AFP programs, with severe consequences for noncompliance. Most AFPs will typically approach their SIE clients as a guide or advocate for the health benefit plan to reduce their spending on pharmacy benefit drugs. The reduction depends on identifying all plan members who are prescribed drugs from a specific AFP suggested list, to be then automatically or mandatorily enrolled in the AFP program. If SIE plan members do not comply with the enrollment into the AFP program or fully provide all requested financial and medical information needed to apply for patient assistance, those patients are informed that they will be responsible for the full cost of their drugs
• Step 2 – Enroll patients wherever possible for cost offsets, reducing SIE and patient costs. If there are discounts or free drug avenues, the AFP will pursue or help the patient pursue such options, a process that can take days, weeks, or even months. Patient assistance programs, concerned that demand from AFP clients may drain charitable resources intended for patients truly in need, are tightening eligibility parameters to minimize or eliminate access for AFP enrolled patients
• Step 3 – Bill for success or drop for lack of success. If an AFP is successfully able to claim discounts or savings related to patient drug costs, they will execute their business model by billing their SIE client a fee for services and continue to do so for the duration of the time that patient receives the drug. If the AFP is unable to present a patient and receive service fees, the patient is often switched back to their full health benefit plan insurance, with the specific drug now covered as it would have been before the diversion to the AFP program. Unfortunately, because the patient has been under the management of an AFP, that patient may have lost access to patient assistance for which they qualified in prior years, leading to painful financial consequences

Patients waited an average of 2+ months and up to 16.8 months to receive their medication.

Impact on Patients Who Are Diverted to an AFP

Results were recently published on a survey done in the last quarter of 2023 of 227 patients who had been diverted to an AFP program.¹

Key takeaways from the patient insights included:

• Patients waited an average of 2+ months and up to 16.8 months to receive their medication
• 24% of patients reported worsening of their condition as a result of the wait for their medication
• 71% of patients reported being confused about the AFP
• 88% of patients reported being stressed when their medication coverage was denied, and they were not sure if they would be able to get their medicine

What Can Practices Do?

Medical providers will not usually become aware that their patient is under the control of an AFP program until notice arrives that the patient does not have coverage for the prescribed drug. That lack of coverage may present to the practice as a notice of a prior authorization process, or even an outright denial of coverage.

One of the easiest opportunities for medical practices will be to raise awareness in physicians and staff to the diverse signs and indications about a possible AFP intrusion that could affect patient access to needed care, adding delays and barriers to treatment and coverage.

Should this occur for a patient with SIE health plan benefits, that could indicate a need to explore deeper:

• Has the patient been told to enroll in a program with a vendor for this specific drug?
• Was this a surprise to the patient? Patients only are diverted into the AFP program for certain drugs on a list developed by the AFP of drugs with the potential for reducing costs to their clients, so patients would find their SIE health benefit insurance to be in force for other medical services and drugs
• Has there been any communication related to paused/denied/status of patient assistance resources to the treating medical practice from or supposedly on behalf of the patient?
• If so, such documents will require close scrutiny as to any information being requested from or pre-filled on behalf of the provider for accuracy and appropriateness
• Has the patient informed the practice of the involvement of an external entity that could be an AFP, and has there been an opportunity to engage or support the patient and/or their SIE health benefit plan regarding the intrusion of an AFP on the patient’s care journey?

Share your thoughts and experiences with me at This email address is being protected from spambots. You need JavaScript enabled to view it.. I would be interested in hearing what you have found, or what more you want to know. I can provide additional resources on this topic if you wish.

Reference

1. Wong W, Yermilov I, Dalglish H, et al. A descriptive survey of patient experiences and access to specialty medicines with alternative funding programs. J Manag Care Spec Pharm. 2024;30:1308-1316.