B (3:28)

Yeah, I would say initially the biggest challenge was coverage by the payers, you know, and you always have to go through that with a new product. So when you know, the first long acting injectable for prep came out, it takes I would say four to six months. There were alternatives, oral prep and one of them had become generic. And of course you have to go through that process. And so initially just getting approval by the insurance companies was the biggest barrier. And at the, when they first came out, they have two different ways you can do this. One is through a pharmacy benefit. So you send a prescription in if it's approved. And once we, it got much easier to get approved. We would then rely on the pharmacy to ship the medication to us. Occasionally a patient could pick it up at a local pharmacy, but then they were tasked with bringing it to us. Once we got the medication on hand, we had to get them scheduled and usually that went pretty well. And then once we did that initial injection, there were follow up injections. And so making sure there's windows with these, like you don't want to go beyond the window or you have to start over. It requires a loading dose which is more frequent than maintenance. So you know, initially that the challenge was when someone didn't show up for their scheduled injection, you know, really having to. The bells and whistles went off, like we have maybe seven days to get them in. Or that prescription, you know, potentially couldn't be used, is sent specifically for that patient. And some people, if they fall out of care, you know, if we can't get them back in, then that medication goes wasted. So it's really a lot of stress and strain for those that just didn't come. The next one was with oral prep. You know, typically people came in every three months to get their refills and we could do the testing. The first long acting injectable was every two months. So they had to make a commitment to come in a little more frequently and get labs more frequently. For some patients, when you're getting more services, you have more co pays. And so we had to make sure they were aware of that. And then we moved into something called buy and bill, which made it easier for us where we could buy the long acting injectable, stock it in our clinic. And it wasn't patient specific, so we weren't sitting there with stocks of this is for Joe Smith and this is for, you know, Ann Jones, and they're the only ones that can use it. But we did take that risk. You know, if it wasn't approved and we gave the injection, we, we had spent a lot of money to buy that medication and we wouldn't get reimbursed. So those were the biggest pain points. Scheduling, of course, and making sure they did show up for those injections on time, frequency of the visits, you know, could be a barrier for some, but it did get them on a better routine. And then just kind of the challenge of making sure we, you know, had going through the process to make sure it was completely authorized before we gave the injection. Otherwise, you know, you could run into some financial issues.

A (7:10)

Talking about these challenges, they're very multifaceted. Right. And one of the things that is obviously very important to this is being able to optimize workflows to then say, okay, how can we make these things easier? Not just for providers, obviously, but also for patients and the folks that actually are getting these treatments. What are some of those steps that your team took to streamline these workflows specifically within your ehr? Emr.

B (7:38)

Yeah. What we realized over that early period is that we needed a team approach to this and we had to have the nursing team and the providers on the ground being very cognizant of the process and, and following it. We leveraged our EMR to be able to coordinate this. We have multiple clinics, so it makes it a little more challenging. But using the EMR and what we call in our EMR actions, we could build that out. We have structured data built in to say where they're at in the process, when it's authorized. Almost like good to go is what we call it. If, if we get it to the point that says, you know, we've been through the prior auth process, we've got it approved, we've actually got confirmation that it's approved, then we give the green light and say, okay, everything's ready to go, schedule the patient, and then we have, you know, case managers, nursing team, patient experience, experts, all those work together utilizing that information in the EMR to get the patient scheduled, you know, when they can come in and then we built a process to do appointments in advance. In other words, when someone came in for that first injection, they needed one in a month, they needed the next one two months after that. And we knew every two months. And so we would build out those appointments ahead of time so the patient was aware. And then really working with our case managers and we also have some additional, what we call, I'll call them patient care coordinators and they would work with the patients to make sure they were not only electronically reminded, but this is so important that we would have messaging through the portal or phone calls to just remind them. And if they for some reason, you know, did not make that appointment, we built a system in place to work towards communicating with the patient. Say hey, we have, you know, five days or seven days, what can we do to get you in kind of thing. So we've, we've leveraged multidisciplinary teams. We have, you know, some centralization of that. But we use our EMR heavily to track and assist and remind and things like that. And that's, that's really been a big help for us.

A (10:14)

You mentioned prior auth, which is an important step in all of this. How much of a game changer was it to have this in electronic form? Right. Epa, electronic prior authorization. And then we also talk about enhanced medication administration records or mars. How did that change day to day operations?

B (10:36)

Yeah, I would say most importantly was the electronic prior auth and each, you know, we now have two long acting injectables and from two separate companies and they have built out systems where we can enter that into their system and then they do the benefits analysis. We do have to check behind that, but we have people that do that. So the actual manufacturer has teams built and it's all electronic that we can submit and then it comes back because it's not only is it approved or not, we have to look at. Some payers will approve it through the pharmacy, some through the met, what we call medical benefit, which is where we stock it and we buy it and administer it and then some will do both. The newest LAI has both the oral loading tablets and then there's the injection. And sometimes it's interesting, we have to know for both, both the oral and the injectable and they can, they can differ. So but that makes it pretty smooth to get that initial, hey, it's not covered at this time. The that's pretty clear cut or is covered and here's the ways you can prescribe it or administer it. So that's Been helpful. We have found though insurances change and it's hard to keep up. So we typically try to follow that up with a actual call to the payer, the insurance company and confirm it. Once we've got that information and they will typically give us an approval number and once we get that, we can absolutely proceed. You know, there have been luckily rare, but there have been times where the system tells us this, approve, we get the medication and then we submit the claim and they go, hey, wait a second, it wasn't approved. So we make sure we go that extra step and get that authorization number. I will say that if you're doing it through the pharmacy, pharmacies are built to do this for you. They tell you, hey, it's approved or not. And if it's not approved, they help us with prior authorizations which is, it's not approved, you're going to have to go through more steps. And then there's a, there's a platform out there called cover my meds. Often it'll get shifted over to that and that allows us to electronically submit the data they need to get a decision.

A (13:15)

You've touched on a very important point earlier in our conversation which is the human element to this and the team element to this, which I think is very crucial. And I was just wondering if we can come back to that and if you could share just a little bit more about how collaboration across those teams supported this optimization that we just touched on and what kind of impact you've seen it had on the organization.

B (13:41)

Yeah, And I, and I will tell you, we learned through going through this process and having some difficulties and some failures. Right. And it's evolved. We started when the first long acting injectable, it was for treatment came out. So we, we had to, we had to go through this process. We actually published a white paper on our experience and our in how we're now doing it. But it took going through that and our hope is that, you know, others can learn from our lived experience, which was not always pretty, to be able to optimize this and not have to go through those pain points that we went through. But basically, you know, the best way I can describe it is kind of walk you through. Patient decides they want to go on a long acting injectable that's usually there with the provider and then the provider needs to get the nursing team involved to start the process and then they, you know, we basically will use those manufacturer platforms and we have to fill out a form electronically to get it submitted to run the Benefits analysis, and then we get that information back. We actually now have, I'll call it a centralized team. We actually have outsourced a little bit of it, and once we get it to that point, they do their stuff, but then they have to come back and say, hey, they need more information. So that's got to go to the nursing team and the provider, and they have to provide more information. So it's a back and forth thing until we get the full approval. And so coordinating that, again, what we've leveraged is a way to do that with some structured data in our emr, because we're actually, you know, we're big on looking at what we do and, you know, using things like Power BI to analyze how this is working. And so that structured data allows us to analyze our process and continue to refine it. But that communication within the EMR is kind of the mainstay of how we can do this, you know, with. We actually have about 30 clinics in six states, and if each clinic is trying to master this by themselves, it's much more complex. So we kind of have that centralized process that in each clinic we have users of that process. And we've been able to take a lot of time, but we've been able to train them to communicate and utilize the information to get it back to the patient.

A (16:29)

Such a fascinating process. And at the end of the day, again, everybody benefits in terms of the provider, but then also the patient, obviously, which is crucial. Dr. Barnett, it's so fantastic to have you. Thank you so much for taking some time for us today.

B (16:43)

Thank you. And again, I appreciate the opportunity and reach out at any time if I can be of help.

A (16:50)

It's great to have you. And you can tune into more podcasts from Becker's Healthcare by visiting our podcast page at beckershospitalreview. Com.