Latest / Becker’s Healthcare Podcast / Streamlining Long Acting Injectable PrEP Through Teamwork and Smarter Workflows

Transcript

Streamlining Long Acting Injectable PrEP Through Teamwork and Smarter Workflows · Becker’s Healthcare Podcast

0:00
Hi, everyone. This is Lucas Voss with Becker's
0:02
Healthcare. Thanks so much for tuning in to
0:03
the Becker's Healthcare podcast series. Fantastic to have
0:06
you. Today, we're talking about how provider organizations
0:09
are leveraging EHRs and EMRs to coordinate care
0:13
and navigate insurance requirements for HIV prep patients
0:16
prescribed long acting injectables or
0:19
LAIs.
0:21
Joining me for today's discussion, very excited to
0:23
have him, is doctor Stephen k Barnett, senior
0:25
vice president medical services and chief medical officer
0:28
at Canned Community Health. Doctor Barnett, thanks so
0:31
much for being here today. It's great to
0:32
have you.
0:33
Thank you. And I'm so glad to be
0:35
here and talk about something this
0:37
we've been working on for the last few
0:39
years and,
0:41
really excited about sharing our experience with you
0:43
guys. Yeah. Really excited to hear about it
0:46
too. To kick us off, though, before we
0:47
get started and hop into our conversation, I'd
0:49
love to start off with just a quick
0:51
introduction, a little bit about yourself and and
0:53
your work in health care.
0:55
Well, good. I'm currently the chief medical
0:58
officer at Can Community Health. So, you know,
1:01
my in my role,
1:03
I
1:04
kinda manage all the providers and a lot
1:07
of the clinical pieces in our clinics,
1:09
including nursing,
1:11
clinical research,
1:12
behavioral health, and so forth.
1:15
I came to Can about eight years ago.
1:18
I had been in group and private practice,
1:21
in a very underserved
1:23
community in South Carolina. That's where I did
1:25
the first I hate to admit it, but
1:26
I've been practicing for
1:28
soon to be thirty years. I'm getting old.
1:31
But started in this small rural town, which
1:34
was very one of the poorest counties in
1:36
South Carolina
1:38
and did full scope primary care on family
1:40
medicine.
1:42
But in a situation like that, we had
1:44
four doctors for about a population of 40,000.
1:47
Didn't have
1:48
a lot of specialty,
1:50
care available in the community.
1:53
Back in those days, the HIV epidemic was
1:56
in its early stages, and
1:58
I did have to rely on, you know,
2:00
infectious disease to help me with my patients.
2:04
And then over the years, as the treatment
2:07
got more,
2:09
refined and and just amazing these days, we
2:12
didn't have prevention back then,
2:14
just treatment.
2:16
Learned learned about HIV, became an HIV specialist
2:19
so I could care for those people in
2:21
that community without
2:23
specialists around.
2:24
And then came to Cannes,
2:26
started as a provider in our first clinic
2:29
outside of Florida and South Carolina,
2:31
became a regional medical director for South Carolina,
2:35
Virginia, and New Jersey, and then they asked
2:37
me to be the the chief medical officer.
2:39
So that's where I've been for about the
2:41
last four years in that role.
2:44
Well, it's so great to have you again.
2:45
I wanna start us off with sort of
2:47
level setting the conversation a little bit. You
2:49
mentioned a couple of important things here in
2:51
your intro as well. When we talk about
2:53
long acting injectable prep,
2:56
there's a lot of complexity
2:58
around it. You know, obviously, we talk about
3:01
scheduling and getting
3:03
getting it to patients, it's itself.
3:05
But also,
3:07
when we talk about insurance navigation.
3:09
Right? We talk about dose timing. There's so
3:12
many factors that influence this space.
3:15
Before
3:16
optimizing
3:17
your
3:18
EHR work flows, what were some of those
3:21
biggest pain points that you've encountered
3:24
in coordinating
3:25
care for these patients?
3:28
Yeah. I would say, initially, the biggest challenge
3:31
was coverage by the payers. You know? And
3:33
you always have to go through that with
3:35
a new product. So when, you know, the
3:38
first long acting injectable for prep came out,
3:41
it takes, I would say,
3:43
four to six months. There were alternatives,
3:46
oral
3:48
prep,
3:49
and one of them had become generic.
3:51
And, of course,
3:53
you have to go through that process. And
3:55
so, initially, just getting approval by the insurance
3:59
companies was the biggest barrier.
4:01
And at the when they first came out
4:03
is they they have two different ways you
4:05
can do this. One is through a pharmacy
4:07
benefit.
4:08
So you send a prescription in if it's
4:11
approved, and once we it got much easier
4:14
to get approved,
4:16
we would then rely on the pharmacy to
4:18
ship the medication
4:20
to us.
4:22
Occasionally, a patient could pick it up at
4:24
a local pharmacy,
4:25
but then they were tasked with bringing it
4:27
to us.
4:28
Once we got the medication on hand,
4:31
we had to get them scheduled.
4:34
And usually, that went pretty well. And then
4:36
once we did that initial
4:38
injection, there were follow-up injections. And so
4:42
making sure there's windows with these, like, you
4:45
don't want to go beyond the window where
4:47
you have to start over. It requires a
4:50
loading dose,
4:51
which is more frequent than maintenance.
4:54
So,
4:54
you know, initially,
4:57
that the challenge was when someone didn't show
4:59
up for their scheduled injection,
5:02
you know, really have the
5:04
the the bells and whistles went off like
5:06
we have maybe seven days
5:08
to get them in or that prescription,
5:11
you know, potentially couldn't be used
5:14
is
5:15
sent specifically for that patient. And some people,
5:17
if they fall out of care,
5:19
you know, if we can't get them back
5:20
in, then that medication goes wasted.
5:23
So it's really a lot of stress and
5:25
strain for those that
5:28
just didn't come. The next one was with
5:31
oral prep. You know, typically, people came in
5:34
every three months to get their refills, and
5:36
we could do the testing.
5:38
The first long acting injectable was every two
5:40
months. So they had to make a commitment
5:43
to come in a little more frequently and
5:44
get, you know, labs more frequently
5:48
for some
5:49
some patients. You know, when you're getting more
5:51
services, you have more co pays.
5:54
And so we had to make sure they
5:56
were aware of that.
5:58
And then we moved into something called buy
6:00
and bill, which made it easier for us
6:02
where
6:03
we could buy the
6:05
the long acting injectable
6:08
stock in our clinic, and it wasn't patient
6:11
specific. So we weren't sitting there with stocks
6:14
of this is for Joe Smith, and this
6:16
is for, you know,
6:19
Anne Jones.
6:20
Mhmm. And they're the only ones that can
6:22
use it.
6:23
But we did take that risk. You know,
6:25
if
6:26
it wasn't approved and we gave the injection,
6:29
we had spent a lot of money to
6:31
buy that medication, and we wouldn't get reimbursed.
6:34
So those were the biggest pain points, scheduling,
6:38
of course,
6:39
and making sure they did show up for
6:42
those injections on time. Frequency
6:45
of the visits, you know, could be a
6:47
barrier for some,
6:49
but it did get them on a better
6:50
routine.
6:51
And then just kind of the
6:54
challenge of making sure we,
6:56
you know, had the going through the
6:59
process to make sure it was completely authorized
7:03
before we gave the injection.
7:06
Otherwise,
7:06
you know, you could run into some financial
7:08
issues.
7:10
Talking about these challenges, they're very multifaceted.
7:13
Right? And and one of the things that
7:15
is obviously very important to this is being
7:17
able to optimize
7:19
workflows to then say, okay. How can we
7:21
make these things easier, not just for providers,
7:24
obviously, but also for for patients and the
7:27
folks that actually are getting these treatments?
7:29
What are some of those steps that your
7:32
team took to streamline these workflows specifically within
7:35
your EHR or EMR?
7:38
Yeah. The you know, what we
7:41
realized over that early period is that we
7:44
needed a team approach to this, and we
7:46
had to have,
7:48
you know,
7:49
the nursing team and the providers on the
7:52
ground being very cognizant of the process
7:55
and following it. We leveraged our EMR
7:58
to be able to coordinate this.
8:01
We have multiple clinics, so it makes it
8:04
a little more challenging.
8:06
But using the EMR and
8:08
what we call in our EMR actions, we
8:10
could build that out. We have structured data
8:14
built in to say where they're at in
8:16
the process
8:17
when it's authorized.
8:19
Yeah. Almost like good to go is what
8:22
we call it. If if we get it
8:24
to the point that says,
8:26
you know, we've been through the prior auth
8:28
process.
8:29
We've got it approved. We've actually got confirmation
8:32
that it's
8:34
approved. Then we give the green light and
8:35
say, okay.
8:36
Everything's ready to go. Schedule the patient. And
8:39
then we have,
8:41
you know, case managers,
8:43
nursing team,
8:45
patient experience experts, all those work together
8:48
utilizing that information in the EMR to get
8:51
the patient scheduled,
8:52
you know, when they can come in. And
8:54
then we built a process to do appointments
8:57
in advance. In other words, when someone came
9:00
in for that first injection, they needed one
9:03
in a month.
9:04
They needed the next one two months after
9:06
that, and we knew every two months.
9:09
And so we would build out those appointments
9:12
ahead of time
9:13
so the patient was aware. And then really
9:16
working with our case managers, And we also
9:18
have some additional what we call
9:21
they're they're
9:22
I'll call them patient care coordinators,
9:24
and they would
9:26
work with that with the patients to make
9:28
sure they were, you know, not only electronically
9:31
reminded,
9:32
but this is so important that we would
9:34
have, you know, messaging through the portal
9:38
or phone calls to just remind them. And
9:41
if they,
9:42
for some reason,
9:43
you know, did not make that appointment,
9:46
we built a system in place to work
9:49
towards communicating with the patient. Say, hey. We
9:52
have, you know, five days or seven days.
9:54
What can we do to get you in
9:56
kind of thing? So we've we've leveraged multidisciplinary
10:00
teams. We have,
10:01
you know, some centralization
10:03
of that,
10:04
but we use our EMR heavily to
10:07
track and assist and remind and things like
10:10
that. And that's that's really been a big
10:12
help for us.
10:14
You mentioned prior auth, which is an important
10:17
step
10:18
in all of this.
10:20
How
10:21
much of a game changer
10:23
was it to have this in electronic form?
10:25
Right? EPA electronic prior authorization.
10:28
And then we also talk about enhanced medication
10:30
administration records or MARs.
10:32
How did that change day to day operations?
10:36
Yeah. I would say most importantly was
10:39
the electronic
10:41
prior auth. And
10:42
each you know, we now
10:45
have two long acting injectables
10:47
in from two separate companies, and they have
10:49
built out
10:51
systems where we can
10:53
enter that into their system,
10:56
and then they do the benefits analysis.
10:59
We do have to check behind that,
11:01
but we have people that do that.
11:04
So the actual manufacturer
11:07
has Teams built,
11:09
and it's all electronic
11:10
that we can submit. And then it comes
11:13
back because it's not only is it approved
11:15
or not, we have to look at some
11:17
payers will approve it through the pharmacy,
11:20
some through
11:22
the met what we call medical benefit, which
11:24
is where we stock it and we buy
11:26
it
11:27
and administer it. And then some will do
11:29
both. The newest LAI has both the oral
11:33
loading
11:34
tablets, and then there's
11:37
the injection.
11:38
And sometimes it's interesting.
11:40
We have to know for both both the
11:42
oral and the injectable, and they can they
11:45
can differ.
11:46
So but that makes it pretty smooth to
11:49
get that initial.
11:50
Hey. It's not covered at this time. That's
11:53
pretty clear
11:54
cut. Or it's covered, and here's the ways
11:56
you can prescribe it or administer it.
11:59
So that's been helpful. We have found, though,
12:03
insurances change, and it's hard to keep up.
12:06
So we typically
12:08
try to follow that up with a actual
12:10
call to the payer, the insurance company,
12:13
and confirm it once once we've got that
12:16
information, and they will typically give us an
12:19
approval
12:20
number.
12:21
And once we get that, we can absolutely
12:24
proceed. You know, there have been,
12:26
luckily rare, but there have been times where
12:29
the system tells us it's approved. We get
12:31
the medication,
12:33
and then we
12:34
submit the claim. And they go, hey. Wait
12:36
a second. It wasn't approved.
12:38
So we make sure we go that extra
12:40
step and get that authorization
12:42
number.
12:43
I will say that if you're doing it
12:44
through the pharmacy, pharmacies are built
12:47
to
12:49
do this for you. They tell you,
12:51
hey. It's approved or not. And if it's
12:53
not approved,
12:54
they help us with prior authorizations,
12:56
which is it's not approved. You're gonna have
12:59
to go through more steps.
13:01
And then there's a there's a
13:04
platform out there called CoverMyMeds.
13:06
Often, it'll get shifted over to that, and
13:09
that allows us to electronically
13:11
submit the data they need to get a
13:13
decision.
13:15
You've touched on a very important point earlier
13:17
in our conversation, which is the the human
13:20
element to this and the team element to
13:23
this, which I think is very crucial.
13:25
And I was just wondering if we can
13:26
come back to that and if you could
13:27
share just a little bit more about how
13:29
collaboration
13:30
across those teams, right,
13:32
supported
13:33
this optimization that we just touched on and
13:36
and what kind of impact it's it you've
13:38
seen it had on on the organization.
13:41
Yeah. And I and I will tell you,
13:43
we learned
13:45
through going through this process and having some
13:48
difficulties and some failures. Right? And as AVA,
13:52
we started when the first long acting injectable,
13:55
it was for treatment, came out.
13:57
So we we had to we had to
13:59
go through this process. We actually,
14:02
published a white paper on our experience and
14:06
our
14:06
and how we're now doing it. But it
14:09
took going through that, and our hope is
14:11
that, you know, others can
14:14
learn from our lived experience, which
14:17
was not always pretty
14:19
to be able to optimize this and not
14:22
have to go through those pain points that
14:24
we went through. But, basically,
14:26
you know, the best way I can describe
14:28
it is kinda walk you through patient
14:32
decides they
14:33
want to go on a long acting injectable.
14:35
That's usually
14:37
there with the provider,
14:38
and then the provider needs to get the
14:41
nursing team involved
14:43
to start the process.
14:44
And then they
14:46
you know, we basically
14:48
will use those
14:49
manufacturer platforms, and we have to fill out
14:52
a form electronically
14:54
to get it submitted to run the benefits
14:57
analysis, and then we get that information back.
15:00
We actually now have I'll I'll call it
15:02
a centralized team. We actually have outsourced a
15:05
little bit of it. And once we get
15:07
it to that point,
15:09
they do their stuff, but then they have
15:11
to come back and say, hey. They need
15:12
more information. So that's gotta go to the
15:14
nursing team and the provider,
15:17
and they have
15:18
to provide more information.
15:20
So it's a it's a back and forth
15:22
thing until we get the full approval.
15:25
And so coordinating that, again, what we've leveraged
15:29
is
15:30
a way to do that with some structured
15:32
data in our EMR,
15:34
because we're actually you know, we're big on
15:37
looking at what we do and, you know,
15:40
using things like Power BI to analyze
15:43
how this is working.
15:45
And so that structured data allows us to
15:47
analyze our process and continue to refine it.
15:50
But that communication
15:51
within the EMR
15:53
is kind of the mainstay of how we
15:56
can do this, you know, with we actually
15:58
have about 30 clinics in six states.
16:02
And if each clinic
16:04
is trying to
16:05
master this by themselves,
16:08
it is much more complex. So we kinda
16:10
have that centralized
16:12
process
16:13
that
16:14
in each clinic, we have
16:16
users of that process. And we've been able
16:18
to it's taken a lot of time, but
16:20
we've been able to train them
16:22
to
16:23
communicate and and utilize the information to get
16:26
it back to the patient.
16:29
Such a fascinating process. And at the end
16:31
of the day, again, everybody benefits in terms
16:34
of the provider, but then also the patient,
16:35
obviously, which is crucial.
16:37
Doctor Barnett, it's so fantastic to have you.
16:40
Thank you so much for taking some time
16:41
for us today.
16:43
Thank you. And I I again, I appreciate
16:45
the opportunity, and reach out at any time
16:48
if I can be of help. It's great
16:50
to have you, and you could tune into
16:52
more podcasts from Becker's Healthcare by visiting our
16:54
podcast page at beggers hospital review
16:57
dot com.