Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep190: Lost between the payer and the pharmacy, with Dean Erhardt of D2 Solutions
Transcript
- Speaker 1 0:00 So think about this. I just got diagnosed in many cases with a fairly major, significant disease. I'm getting calls from my physician office, from a pharmacy, from a from a payer. So I'm getting a lot of input here. None of these people really speak the same language, tell me the same thing, are consistent in what they're trying to guide me through. Austin Littrell 0:40 Welcome to Off the Chart, a business of medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, Medical Economics senior editor Richard Payerton sat down with Dean Earhart, president and CEO of D2 Solutions, a consulting and technology company, D2's survey, Patient Access Barriers 2026 found that 21% of patients delayed starting a prescribed medication because of confusion or access problems, and nearly half said that lack of transparency left them anxious and uncertain. Richard and Dean get into why so many prior authorization denials come back with no explanation, why most of those rejections are administrative rather than clinical, what patients still don't know about manufacturer affordability programs, and why Dean believes that upskilling staff around AI is something even small practices can't put off. With all that said, Dean, thank you for joining us. Let's get into the episode. Richard Payerchin 1:44 Thank you for joining us today. Speaker 1 1:46 My pleasure, Richard. So happy to be here, and thanks for the opportunity. Richard Payerchin 1:50 And your company had published a survey recently. We're going to get into that in a second. Before we do, can you introduce yourself and your company? Speaker 1 1:58 Yeah. So, Richard, as you indicated, you know, the president and CEO of D2 Solutions. We are a really a healthcare consulting and technology company. We started in the consulting space in 2008, really focused on helping manufacturers bring new products to market, and taking a look at that more along a continuum versus what we'd seen in the market where people really looked at these things in silos. So, how does distribution impact reimbursement? How does distribution and reimbursement impact the patient services if you are a specialty drug? And so, really taking a look at how those things intertwine and how we can streamline those activities to be able to bring products to market was our first focus. Since then, we've grown significantly into a technology company that supports pharmacy operations as well as a variety of patient services. So, personally, I've been in the industry for in the range of 40 years. So, as you can imagine, you know, longer than one really wants to admit some days, but otherwise, you know, we've really excited about where we're at and where we're taking the industry. Richard Payerchin 3:07 You know what? I'm I'm sure you're going to have some good perspectives to share because working for that amount of time, you've seen things go from paper to electronic. There's a there's a lot of things in healthcare administration we can probably talk about. Yeah, and Speaker 1 3:20 I had the privilege, Richard, of starting out on the on the HMO side. So I originally worked on the payer side, and then I was with one of the large distributors for a number of years. And my last corporate career, I was a corporate position rather. I was with one of the top PBMs. So, so my running joke is, I learned everything I could learn about the payer, the distributor, and the PBM, and once I learned everything, I could only become a consultant, right? Richard Payerchin 3:47 Excellent. I was going to say that, and you know what? Those those all have, I think, some relevance for our audience. We can get into some some more of that, especially relating to drug pricing, which we'll get into, and not just pricing, but most recently, d2 Solutions had published the results of a survey about patient medications and prior authorizations. Can you talk about how that survey came about, and then maybe some of the results? Speaker 1 4:13 Well, we work with a lot of different manufacturers who have products that require prior authorizations, and we have some software that we've developed to solve some of those issues, because what we see in so many instances, Richard, is that a PA is submitted, and it's just submitted on a standard form that's created by a payer. That may be denied, and if it's denied, the entity that is providing that PA, be it a physician office, a hospital pharmacy, a specialty pharmacy, whomever, it doesn't necessarily come back and tell you why it got denied, and so now you've kind of have to guess as to why it gets denied and and what you need to do to be able to get that approved. One of the challenges we have, of course, is the fact that when you take a look at the information coming out from the the AMA. They talk about the challenges with the PAs, and what we see is that there's just no reason, other than structure, really infrastructure challenges, that a PA is delayed 234, days. We talk to manufacturers who have some products that are delayed as long as three or four weeks. Well, if you solve for the problem up front, which is getting the payer the right information, you can cut that time down to virtually nothing because you're submitting the right information up front, and that's really where we're trying to help people focus. Richard Payerchin 5:34 No, I think that's you know exactly on point for our audience and really relatable only because the physician audience that we try to serve-they're the ones who are sending in prior authorizations for their patients. It's really, you know, it's a process that, frankly, I think sometimes the physicians and patients feel maybe sort of an adversarial relationship when there's a denial. Can you talk about that? Speaker 1 5:57 Yeah, I think that's easy to feel that way because again, sometimes those denials come back, and they don't even tell you why it got denied. And then when you talk to somebody at the payer, I mean, look that that skill set can be all over the board. So you may talk to somebody who says yes, provide this, and it'll get approved. And then it still gets denied. And the next time you call somebody, it becomes well, no, that's not really what we needed. We needed something else. And so the the rules of the road are not always clear, the documentation that's required is not always clear, and so part of this process is for us at least is defining it up front. So what we did, Richard, is we actually developed a software where we're looking specifically at a given product payer combination, and so a given product may have different requirements if you're submitting to payer one versus payer two versus payer three. So, what we've done is taken a look at those individual requirements to make sure that when you're submitting, you're submitting in accordance with those exact specifications. The other thing we've done is we've created a model where we can identify for you when you're out of range or when you're missing information. So, you know, using myself as an example, I might write down St. Louis, Missouri, which I live in Metro St. Louis, and my zip code. But my zip code doesn't match St. Louis because I live in a suburb of St. Louis, not in the city of St. Louis, and so by catching those type of errors and correcting for those up front, you eliminate a lot of what happens at the payer side, which you get thrown out for those type of errors. But the vast majority of them are really administrative in nature, not clinical in nature. Richard Payerchin 7:38 You know what I I like the tech talk, but and I'm glad you brought it back to the clinical, though, because I wanted to maybe talk about the clinical side, the patient side. The survey found that 21% of patients delayed starting a prescribed medication due to confusion or access issues. Do those access issues and confusion stem around prior authorizations, or are there other factors? Speaker 1 8:01 Why the for the survey that we looked at, it was largely around prior authorizations, Richard, and that confusion really for the patient. There's a lot of issues, right? The first issue is they simply don't know what's going on. So think about this: I just got diagnosed in many cases with a fairly major, significant disease. I'm getting calls from my physician office, from a pharmacy, from a from a payer. So I'm getting a lot of input here. None of these people really speak the same language, tell me the same thing, are consistent in what they're trying to guide me through. So what we're really working through is how do we connect with that patient in real time at the physician office, and then guide them through this process so that it becomes smooth across the entire spectrum. So they know, hey, we need to talk to you at the physician office because we need to have three other questions answered, right? So they know, hey, your prior auth has been submitted to payorx but it's going to take at least 48 hours for us to get information back. I mean, many cases these patients don't even know where to call when they have questions, so they might call their physician office. But we know physician offices largely are understaffed and are just busy as heck, right? And so now they're trying to call back that that patient, and there may be 6789, phone calls back and forth before they connect. What we're really trying to solve for is how do we solve for that via a digital component, right? So we can auto schedule that call with the physician office, so we can enable that patient to maybe ask 20 questions before they ever get there, right? So, what is the status of my medication? When can I expect it? Do I need to pick it up at retail? Is it going to get delivered to my home? What is my cost going to be? All of those things that a patient doesn't know, we're trying to solve for earlier in the process, so that patient can really understand. Oh, and by the way, I just found out I'm going to have a. $200 co-insurance, and I can't afford that. Did you know that there's a copay program or an affordability program available? You know, I think in the survey we talk about how what a large percentage of patients don't even realize those type of services are out there. Richard Payerchin 10:16 You know, it's a great segue. I think to a point I wanted to ask about because we always like to be solutions focused as well, and especially, you know, before we we started chatting, I was telling Sarah a little bit our you know our audience primarily is physicians, a lot a lot in primary care, and a lot, you know, we still cater to physicians who remain in independent practice. With all due respect, there are times when a software solution or a computing platform for those docs who may not have a lot of money to invest because they are in a smaller office. How can they smooth out that process so that the patient feels more informed? Speaker 1 10:53 Well, well, I think if you're talking about the investment side, there's got to be a balance between how much time am I saving in labor versus how much am I spending in technology? Right. The other side of the coin is that labor tends to be highly variable, depending on if somebody's on vacation or you know many times somebody might leave a job and all of a sudden I don't have a reimbursement case manager anymore because the best person in my office just took another job down the road, and so there's a lot of unseen costs. I think that physician offices don't necessarily recognize that really do drive a lot of this activity. Right. The other thing is you've just got to make it easier to use. Right. So there shouldn't be a long training process, training program, etc. I mean, what we see is that if we can get a physician office on a on a platform and get them on the phone for 15 minutes, we can have them trained on how to use the system. It's got to be very intuitive and very easy to use, and that makes it easy for their staff. But it also starts cutting down on their staff time, which ultimately cuts down on their overall cost work. Physician's Practice 12:08 Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60 seconds, we deliver proven real-world tactics you can plug into your practice today. Whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom; they come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to feature it. Shoot me an email at kreynolds@mjhlifesciences.com with your topic, a quick outline, or even a smartphone clip, we'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next P2 Management Minute. Richard Payerchin 13:01 That interaction between staff and tech, and patients, and our our physicians, because they're not necessarily programmers. They're in the business of you know healing people, which is good. And so I'm always fascinated by by that sort of dynamic of both providing the clinical care as well as managing the office. And I think you raise a great point, which is a segue to a question I'll I'll kind of wing it, because in a broader sense, if we're talking about one medical office, and you mentioned about the physician, for example, weighing the costs and benefits of technology, that time savings that it brings, it's going to come with a cost, but it's going to also hopefully provide some savings. Let me, let me, and where I'm going with this is sort of bigger picture. Do you think then technology is going to be a panacea for the really shortage of physicians and healthcare workers that we have? Speaker 1 13:53 I think it has to be, Richard. Because if you take a look at your point, is a great point, right? If you take a look at what the numbers tell us physician shortages, nursing shortages, and this just general healthcare workers. We're going to have a dramatic shortage by 2030, and they're going forward. And if technology doesn't address this, we're going to have a significant amount of people, including myself, that are getting older. And as we know, as people get older, they need more services. How are they going to get those services if there's not people there to deal with that? That is going to come with technology. Now, the good news, I think, you know, we talk about how the older people maybe aren't adapting as much to technology, but that's going to change dramatically in the next five years. And the reason for that is simple, because the people that are coming into retirement now, the people from call it 58 to 64, we're really we have really been exposed to technology for the last 30 years. We've worked most of our corporate careers on laptops and to a large degree on cell phones and smartphones and iPads. So we're not as cautious, let's call it, of technology and technology solutions as I think the people in the generation above us. So I think that adaptability will be significant. Plus, as we see with digital therapeutics and other digital products, they're going to be more involved in simply delivering healthcare services, and what is the value of that? I mean, we work as an example with a product that's a migraine product that is a technology you wear on your arm. Well, now guess what? I can, I can be cured, so to speak, but I can be be resolved of a significant amount of my migraine products problems, rather, with a product that has no chance for a side effect because I don't intake the product. As more and more of those technologies become available, I think more patients are going to get more comfortable with. Yes, I can talk to an AI agent, but I also can use digital therapeutics, wearables, and other items to enhance my overall healthcare experience. Richard Payerchin 16:08 You know what I think? It's a great tie-in both with that that clinical treatment side as well as technology and and personnel. Let me shift gears maybe slightly because one of the things that really caught my eye and and I wanted to make sure I ask about in your 2026 outlook, because we were talking a moment ago here about a shortage of healthcare workers. One of your ideas about a solution to the healthcare workforce shortage is to upskill existing employees. Can you talk about that concept? How's that going to work, and especially how you can apply it in a smaller practice. Speaker 1 16:42 Well, the reality, Richard, is that with the advent of AI and the speed at which we're seeing technology move forward, we're all going to have to get smarter. We we just don't have a choice. It's either you're going to get smarter or you know you're going to get left behind. It's kind of you know I like to use the horse and buggy analogy, right? I could still be riding my horse, but that car is going to pass me at 60 miles an hour. Well, if AI is going to pass me at 60 miles an hour, I better learn how to use it, and I better learn how to get comfortable. And I think it's worthwhile. And I know you're talking about independent physician offices that are somewhat financially constrained, if not significantly financially constrained. But I do think they've really got to take a look at what do I need to invest in, and it doesn't necessarily mean millions of dollars, but maybe it's a couple of classes twice a year for my my employees to upskill their skills around AI and around other technologies that are simply going to move forward, whether I like it or not, and if I don't enable them to be a part of that, to be able to utilize those those that skill set, then actually it's going to get more expensive for me over time because the technology is going to be up here and my skill set is going to be down here. So if I don't keep that skill set moving forward, that's going to bump into a problem, and I think that problem's not that far away. Richard Payerchin 18:03 You know what? In again, another great segue here because you're teeing me up when you talk about a problem that's not that far away. Because one of the things, and in fact, if you look on medicaleconomics.com, one of our current cover stories, really, it was written by a colleague, but it's talking about the age of. I don't want to ramble here. We go from you know the sort of the the rollout of ChatGPT in 2022 to now. We're already in the age of AI scribes. Speaker 1 18:34 Yes. Richard Payerchin 18:34 When when you're out there, kind of just talking with pharmacists, with physicians, with healthcare systems, you know it. I don't want to assume that AI scribes are a given, but given that they already are starting to make some inroads, what comes next? What do you think is on the horizon? What have you been hearing? Speaker 1 18:53 Well, I think there's a lot of technologies that are going to really help physicians going forward. So, and I think technologies that enable physicians to expand their reach. So, give you a great example, Richard. I talked to a company just a few weeks ago that has a virtual technology that enables a physician, let's say at the at the Mayo Clinic, to be in front of a patient in you know rural Idaho in in a virtual format. So, you know, I'm sitting here. My my virtual entity is looking as if I'm real in the room with the patient, and I can have that patient consult right there, even though I'm 1000 miles away. So I think those technologies are coming and coming quickly, and yeah. But but going back to your AI scribes, the AI scrabs are going to get smarter, right? I know we talked a lot today about, you know, are there hallucinations? Are there mistakes? But I I was visiting with somebody not so long ago. In fact, it was just last week when he said, "Yeah, but look at it this way, because they're converting their entire call center to an AI call center. Now they will have the ability to have, you know, people. We'll talk to individual patients on occasion, but as he said, if I could actually measure the number of mistakes people make, the number of mistakes my AI makes will be significantly less. And so, even though you know people may be a little cautious at this point about using an AI agent for certain elements, I think we're 12 to 24 months away from people saying, you know what, I've had enough experience with that now that I'm comfortable with it, and we've seen examples. And so I read about an example actually in Japan, where they're using small robots to go into the children's ward and ask children about how they feel. So this is for small children, like seven years old and under, and what they're finding is that the patients will actually talk to the robot and tell them what they're feeling and what hurts more than they'll talk to the doctor. So I think there's other things here that are going to be very interesting as we go forward. Richard Payerchin 20:56 You know what I was going to say? We've talked a lot about technology, and certainly it's important. I wanted to go back to your your 2026 outlook, though, because you had talked about an age of volatility and the forecast of being stormy with a chance of crazy. There's politics. We've you know touched on some technology, supply chain issues, regulatory storms. Four months into the year, which do you which of those has become the most important, and what do you think is going to emerge for the rest of the year? Speaker 1 21:26 Well, I think there's a lot of change in the industry and change in the regulatory industry, and I think change in the payer side is going to be one of the things that we're going to see pretty dramatically, Richard. And I mean, with PBM reform and some of the noise around that, we're seeing some of the PBMs now come out and try to revamp the contracts that they're having with certain manufacturers. So, is that going to have a significant impact on access to certain drugs come 2027? I mean, we've seen where the PBMs have had more significant lists of products that are just in their non-covered bucket, and that's going to continue to, I think, expand. And then the other question, of course, is: Are we going to see a real serious adoption? And I believe we are of biosimilar products. But are we also going to see a race to the bottom in terms of price? And is that going to effectively be like we saw, you know, generic injectables a few years ago, where it was a race to the bottom of the price, and then all of a sudden wasn't available because nobody could afford to make it. So I think there's a lot of volatility. I like to use that word a lot. A lot of volatility here that we haven't really been able to predict where the bottom is, but we're going to see a lot of that over the next couple of years. Richard Payerchin 22:40 I was going to say you gave me some homework here too, because I I I can't in any way, shape, or form pretend to be real familiar with biosimilars and what's going to happen with that. But now you've really you got the wheels turning for me here to find out, because and as I was telling Sarah, one of the things that comes up every commercial you see on TV for for a new drug has the what? Ask your doctor about. Ask your doctor. Ask your doctor, and it's our audience that gets those questions. So they're going to have to keep up to speed on that stuff too. Speaker 1 23:12 Well, and where where we're going with some of this, Richard, is we actually are involved with manufacturers who are putting commercials on that say go to this website or go to this QR code, and in that situation, we're actually enrolling patients into programs in real time at that point in time. So yes, and then and then we can connect to you know schedule a visit with their physician, and so we can do that via technology. We find about 30% of the patients out there don't have a primary care, so we can connect them, if appropriate, to a telemedicine doctor. But what we're seeing is there's a real need to not just say call your doctor, but enroll in a program. And now we can provide you educational materials. We can provide you a 10 question questionnaire to figure out is this product really something you should consider, or is it not? And so I think there's a lot of upfront activity here that we're working on with various different groups that can be incorporated to ease some of that burden on the physician, so that they're not getting questions on things that absolutely don't make any sense, but they're getting questions on things that there has at least been some level of pre-screening to say let's have a valid conversation here. Richard Payerchin 24:26 You know what? I'm glad you touched on that. And one of the things I I did have written down to ask about was sort of the dynamic that takes place with direct to patient models and primary care because I feel like in some ways our audience is probably hopeful that patients maybe use some of those services to get access to care, but on the other hand, sometimes, frankly, a direct-to-patient model, in a sense, becomes a competitor for a primary care physician, and in a sense, is maybe stealing one of their customers. I just didn't know how. Have you been talking with many physicians about how how how to. That or perhaps downplay that. Speaker 1 25:02 Yeah, probably not as many richers as I should, but I think the real catch 22 here is going to be the patient's going to be the driver. And so again, I think as we see an emergence of people who are more comfortable with technology, and clearly COVID made people more comfortable with talking to a doctor on the phone than previously, we're going to see the the patient who's going to be the driver of that, and so it's not going to be as much as the teledoc is stealing my doctor, my patient rather, as much as the patient, whether it be because they don't have a primary care, because of timing, because they want to do it after they get off work tonight, whatever the case might be, they want to go down that route because they find it as a more convenient vehicle. So, we talk about putting the patient in as they're the CEO of their healthcare experience, and I think part of that is they're going to determine how they want to receive that healthcare information. Richard Payerchin 25:54 You know, a few moments ago, something you mentioned caught my ear. I hope I heard it correctly. I think you had said somewhere in the neighborhood of 30% or so of patients may not even have a primary care physician, whether that be by access, by location, or simply just haven't had need for it. But that's one thing that I know our audiences-they will scream. That's why we need to invest in primary care. Yes. Richard Payerchin 26:20 What would you like to see for primary care investment? Speaker 1 26:23 Well, that's a that's a really good question, but I think part of that to your point is also location, location, location, right? And and we are are seeing more and more you know healthcare deserts where they they don't have a doctor in the geographic area, they may not have a pharmacy or a pharmacist in the geographic area, so I think one of the questions becomes: How do we capture patients from those desert areas, and then how do they interact with the primary care? And does that primary care individual, who may be the closest individual, and they're still 75 miles away, you know, create a day a week or a half a day a week or a day every two weeks when they effectively are a telehealth provider, then then they can you know facilitate healthcare for those people that that are in that desert. So I just think we've got to rethink how we're doing some of these things based on the geography of what's going on in the marketplace as a whole, and again just the patients in general. If they don't want to go in and physically see a doctor because it's just inconvenient for them, as much as we might want to say, look, it's in your best interest to see a doctor, and look, I'm a firm believer in that. But if people get in their mind that I can't take three hours off from my work to go see a doctor because I'm, you know, get paid an hourly salary and I'm barely getting by, then we have to show the flexibility to be able to service that patient. Richard Payerchin 27:46 It's a great survey. What did I not ask about the survey that you'd like our audience to know? Speaker 1 27:51 You know, I just think healthcare access in general are is getting is getting more and more challenging for a lot of individuals, and and we've got to really take a look at how do we make it easier on the patient to be able to access the services that they need, and so I think you know the survey maybe notwithstanding, it's really about it tells a story. And what story does it tell? It tells a story that patients can't always easily access healthcare, and even when they do, it's it's large, it's confusing, and look, you and I are in the middle of it all the time, and we can maybe guide our way through it. But for the person that goes into a physician office and all of a sudden gets referred to a specialist, and now finds out I've got a disease that costs $250,000 a year, what do I do? And so I think the the one takeaway I want people to really think about is how do we make that transition easy enough on a patient and understandable enough on a patient so they they can get guided to the best possible care without just walking away because they're confused. Richard Payerchin 28:54 I'm Richard Payerchin, reporting for Medical Economics. My guest today has been Dean Earhart, founder and CEO of D2 Solutions. We've covered a lot of ground. It's been a great conversation. I hope we get a chance to talk again sometime. Speaker 1 29:06 Richard, it's been absolutely my pleasure. Thank you so much. Austin Littrell 29:20 Once again, that was a conversation between Medical Economics senior editor Richard Payerchin and Dean Earhart, president and CEO of D2 Solutions. My name is Austin Latrell, and on behalf of the whole Medical Economics and Physicians Practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, and solutions for your practice, you can find us by searching "off the chart" wherever you get your podcasts. Also, if you like the best stories that medical economics and physicians practice, delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the chart, a business and medicine podcast is. Produced by Chris Mazzolini and Keith Reynolds, and produced by Austin Latrell. Medical economics and physicians' practice are both members of the MJH Life Sciences family. Thank you. Transcribed by https://otter.ai