Transcript Slide 1

Solving Insurance and Healthcare Access Problems | since 1996
Patient Advocate Foundation
The Patient’s Partner
An Overview of Programs and
Service Offerings
Statement of Need
The patients who contact PAF for assistance have many
challenges they are facing including:
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Access to care issues – uninsured or underinsured
Loss of salary or position due to illness
Debt crisis that has resulted from their illness
Economic hardship causing loss of assets and benefits
PAF realizes that many fully insured patients are faced with
unique challenges when utilizing their hard earned benefits
including:
 They can not afford the required pharmaceutical co-payments and
coinsurance
 They are forced to choose between paying for treatment or paying
for their essential costs of living, often resulting in a decision to go
off therapy
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Property of Patient Advocate Foundation (PAF)
Our Mission: To Serve Patients &
Ensure Access to Healthcare Services
Our
Mission
• Patient Advocate Foundation seeks to safeguard
patients through effective mediation assuring access to
care, maintenance of employment and preservation of
their financial stability relative to their diagnosis of life
threatening or debilitating diseases.
Our
Impact
• Since our inception in 1996, PAF has provided direct,
sustained patient assistance to more than 500,000
patients and touched millions more American lives
through the PAF website, online chats and outreach
events.
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Property of Patient Advocate Foundation (PAF)
Many Voices
It is through the experiences relayed
by the patients we serve and the
extensive documentation recorded
by PAF throughout the service
process that we are able to create the
Annual Patient Data Analysis Report
(PDAR)
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Summary of Patient Services:
2010 Patient Data Analysis Report
• Total 2010 Case Count:
82,963
• Total Case Contacts:
934,232
• Webpage Views:
2,766,849
• Total Subscribed Emails:
187,761
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Patient Services Growth:
2009 vs. 2010
49.88% Increase in Patient Case Count
2009
2010
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Analysis of PAF Patients
Ethnicity
Gender
Male 38.13%
Female 61.87%
Source: 2010 Patient Data Analysis Report
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Types of Insurance Coverage
Reported by PAF Patients
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Words from a PAF patient
Mary Lenox
Multiple Myeloma
Chicago, IL
“I cannot tell you how much your
efforts on my behalf mean to me.
Thank you so very much for your
stellar care and steadfast support. I
sing praises with deepest appreciation
to you and the Patient Advocate
Foundation and rejoice in the
abundant gift of your organization to
the lives of so many. May you and
PAF continue to be a beacon of hope
as you provide your unique services
to others.”
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PAF Mission Analysis
Mission Analysis
Medical Debt Crisis Issue Analysis
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Charity Navigator
•Charity Navigator is America's premier
independent charity evaluator and works to
advance a more efficient and responsive
philanthropic marketplace by evaluating the
financial health of over 5,500 of America's
largest charities
•PAF was awarded the top rating of 4 stars
•In FY09/10, $.91 cents of every dollar donated
to PAF went to support a direct patient service
program offered to the public by PAF.
Direct Patient Services
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PAF Direct Patient Services
PAF specializes in mediation, negotiation and education on behalf of
patients to resolve problems in the following areas:
• Resolving debt crisis issues related to diagnosis
• Negotiation of access to pharmaceutical agents, chemotherapy, medical devices,
surgical procedures
• Negotiating pre-authorization approvals and resolutions to coding and billing errors
• Providing assistance in expediting applications for Supplemental Security Income
(SSI) and Social Security Disability Insurance (SSDI)
• Resolving enrollments in insurance issues in the public and private sectors
• Coordinating benefits among agencies, non-profits, and federal and state programs
• Providing assistance in expediting appeals process for insured patients
• Negotiating insurance coverage for clinical trials and emerging therapies
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THE PATIENT'S JOURNEY IS
NEVER ONE STEP
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Cost of Living Assistance related to
illness:
– Rental/mortgage assistance
– Eviction/foreclosure problems
– Food/nutritional needs
– Lodging for treatment
– Transportation
– Utility Assistance
State, Federal & Local programs/Access
to care:
– Medicaid application
– SSDI
– SSI
Access to Care Issues:
– Uninsured
– Availability of Charity care
– Clinical Trials
– County Medical programs
Underinsured
– Appeals Assistance
– Risk pools
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Employment Issues :
– Reduced pay or hours
– Job discrimination/harassment
– Loss of salary or position due to
illness
– FMLA
– COBRA
Financial Hardship for Out of pocket
medical costs:
– Cobra premiums
– Deductible assistance
– Out of network fees
– Durable medical equipment
– Medical Supplies
– Co-pay assistance for (medicines,
doctor visits, medical)
– Facilities/services
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PAF Programs and/or
Initiatives
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PAF’s Data Sales Division is
Launched…
In 2010, PAF:
•Resolved 82,963 individualized patient cases nationwide with 30,485 of these
being served through the case management division
•Made 934,232 contacts on behalf of patients with relevant stakeholder in
order to accomplish case resolution
•PAF has captured primary fields of data across approximately 295,000 closed
cases since 2002
•2010 & 2011 data are available immediately for analysis
•PAF has generated a multi-year patient-level database with 260 fields of
confidential about each patient served
•Both private and public insurance systems are represented
•PAF data is unique, “real” time and differ from administrative data
•Allows linkage between patient demographic characteristics,
employment status, medical conditions, insurance coverage, health care
and drug utilization, regional locations, access to clinical trials, and
aspects of personal financial hardship
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Property of Patient Advocate Foundation (PAF)
Data Product Offerings
CUSTOM ANALYTIC REPORT:
PAF will provide a comprehensive, customized report on unique patient populations and
segments of the PAF population as defined by the data customer. This custom analytic
report will report on the specific segments of PAF’s population and will triangulate
information contained in several data variables. This report will also contain brief
descriptors of each exhibit and de-identified case summaries that will further illustrate
and support the access barriers facing unique patient populations. PAF must be cited as
the source of the data.
TARGETED BUSINESS REPORT:
The healthcare market is always changing. PAF’s real-time, relational data base allows
us to provide targeted, real time reports based on the data need or set of questions
provided by our partners.
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Property of Patient Advocate Foundation (PAF)
Disparate Population Outreach
Programs
National Hispanic Latino Outreach Program bilingual case
managers serve Spanish speaking patients nationwide and
conduct 8 hours per week of targeted outreach.
Office locations include: Virginia, California, New York, Texas
2001: 1.24% of PAF patients were Hispanic/Latino
2010: 9.88% of PAF patients were Hispanic/Latino
The National African American Outreach Program educates
specifically on diseases which are high risk for this
population by attending and speaking at local and national
meetings.
2004: 13.92% of PAF patients were African American
2010: 16.91% of PAF patients were African American
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In the words of our
patients
“I am convinced that without your
involvement, I would never have been
given the opportunity to pursue this
transplant. You made me feel so “taken
care of”. I had no idea there were such
subtleties to health insurance policies,
which you know inside and out, thank
goodness! I feel that thanks to you I have
a whole new chance at beating back this
disease. From myself and my family, I’d
like to send you a big THANK YOU!”
Mary Estep
Multiple Myeloma
Chesterfield, VA
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2010 PAF Media Coverage
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Property of Patient Advocate Foundation (PAF)
Our Mission: To Serve Patients
and Out Perform All Others
CPR Mission
• The PAF Co-Pay Relief Program
(CPR) exists to provide direct
financial assistance to insured
patients who cannot afford the copayments and co-insurance
required to access prescribed
pharmaceutical therapies.
Our Mission: To Serve Patients
and Out Perform All Others
• Top Co-Pay Foundation Attributes 1: What is Excellence?
 Ease of Accessing Funding- PAF has three entry points and handles
120,000 expenditure transactions a year
 Availability of Funding- PAF has new funding available each month,
many funds never close
 Patient Advocacy- PAF and NPAF are leaders among patient
advocacy at the national level
• Co-Pay Foundation Rankings: Who is at the Top?
 PAF CPR was the top ranked co-pay program by providers in 2009 for
customer service and ease of program use. 2
 PAF CPR was given top marks by Oncologists in 2010 for customer
service and ease of program use, second only to LLS. 1
1.
2.
Kantar Health, Oncology Market Access, 2010
MattsonJack DaVinci, Oncology Market Access, 2009
Our Mission: To Serve Patients
and Out Perform All Others
• Co-Pay Foundation Market Share 1,2: Who has the
corner?
 There are 71 co-pay funds in the market today
 PAF operates 20 of the 71 funds
 PAF administers 28% of the Co-Pay Market
 PAF administers another 10% of the Co-Pay Market as a
transparent service provider
• Co-Pay Ideal Grant Amount 1: Who meets the need?
 Most patients need $3,800-$4,500 in co-payment support
 Current PAF awards range from $1,250-$5,000 depending
upon disease fund, based on treatment protocol costs that
are reviewed annually
1. Kantar Health, Oncology Market Access, 2010
2. MattsonJack DaVinci, Oncology Market Access, 2009
CPR Impacting Lives and
Fulfilling Our Mission
• Successfully completed 7 years of operation in April 2011
• Served more than 45,800 patients
• Allocated more than $120M in patient assistance; mobilizing
$480M in insurance reimbursement to providers
• Built capacity to successfully and efficiently process in excess
of 120,000 expenditures annually
• Brought to bear years of expertise and best practices to serve
as a transparent service provider to administer another copayment assistance program
• Developed personal relationships with thousands of
healthcare providers and pharmacies
CPR Program Governance
and Compliance
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CPR was established in April 2004, under OIG opinion, #04-15. Our
program is the 2nd oldest CPR program in the nation
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CPR offers assistance to
– Government Beneficiaries including those covered by:
• Medicare – All co-payments made by PAF count towards a patients True Out-OfPocket expense (TrOOP) from the first dollar expended
• Medicaid
• Tricare/VA Benefits
– Commercially insured beneficiaries
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PAF’s CPR was granted an Evergreen Clause in 2008 as part of a
modification to our opinion issued by the OIG which allows PAF, under
the protection of the OIG, to open additional disease states beyond
those specifically approved by the OIG in their opinion without having to
seek approval from the OIG so long as the new silos are established
and administered in accordance with the guidance provided in the 2004
OIG opinion. PAF is the only co-pay program with an Evergreen
Clause.
CPR Open Disease Funds
CPR currently offers assistance in 20 disease funds including:
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Breast Cancer
Lung Cancer
Prostate Cancer
Cutaneous T-Cell Lymphoma
Chemotherapy Induced
Anemia
Chemotherapy Induced
Neutropenia
Kidney Cancer
Sarcoma
Colon Cancer
Lymphoma
Head and Neck Cancer
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Malignant Brain Tumors
Pancreatic Cancer
Multiple Myeloma
Myelodysplastic Syndrome
(MDS)
Osteoporosis
Hepatitis C
Pain
Rheumatoid Arthritis
Diabetes
Autoimmune Disorders
(ITP, UC, Crohn’s, PA)
CPR Program Goals:
Experience and Expertise
PAF’s CPR program prides itself on being a high touch, full
service patient oriented program. All policies and
procedures have been designed with three goals in mind:
– To leverage our years of high touch patient and provider service
expertise and state of the art technology to expedite the process
of patient access to prescribed pharmaceutical therapies while
insuring the process is as fiscally efficient as possible
– To provide Co-pay patients support through the PAF Case
Management team when their needs go beyond direct Copayment support. This program feature positions PAF uniquely
in the Co-pay vertical.
– To maintain compliance with the OIG Opinion as it provides
protection to PAF and each donor to the CPR program
How to Access CPR
Three Points of Program Entry
 Toll Free by Phone~ 866-512-3861
 Patient Portal~ https://www.copays.org
 Provider Portal~
https://www.cprproviders.patientadvocate.org
 Pharmacy Portal~
(Pending launch on 8/1/2011)
Patient, Provider and
Pharmacy Portal Features
Expedited application process enabled by enhanced technologies including:
• Electronic Signature capability
 Patients and providers can electronically sign the application and
physician verification forms
• Document import capabilities
 Upload required documents at the time of initial application
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Auto import required documents through eFax if fax is the preferred
submission method
• Bar code recognition for faxed documents
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Auto import required documents through eFax if fax is the preferred
submission method
• System automatically attaches documents to an
application when uploaded or faxed
(Pending launch on 8/1/2011)
Provider Portal and Pharmacy
Portal Application Process
Providers and Pharmacies have an option to apply electronically through a
secured, web-based application portal, designed specifically for providers and
pharmacies making application for assistance on behalf of their patients. Benefits
of utilizing the Provider Portal and the Pharmacy Portal include:
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Highly available
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Secure
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Quick and Efficient (burden of application is approximately 5-7 minutes)
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Patient look up features available - assists with expediting reapplication
process
The Registration process takes approximately 3 minutes to complete and is only
necessary the first time you use the portal! Once registered, Providers and
Pharmacies can utilize the application portal 24 hours a day!
The provider portal can be accessed at:
https://www.cprproviders.patientadvocate.org
The pharmacy portal can be accessed at:
(Pending launch on 8/1/2011)
Approval Process
• When completed applications and required documents are received
into the system, they are reviewed on a first come, first serve
basis by an Application Specialist using the custom database
which determines the eligibility
• Eligibility is based on the following criteria:
– Existence of insurance coverage for pharmaceuticals
– Qualifying diagnosis verified by physician
– Financial need: 500% of FPL
– Adjusted for COLA by geographical location
• Approval typically takes 24-48 hours once all required documents
are received
• Patients and their providers are notified by phone and by letter of
their one year approval into the CPR program!
CPR Program Features
• Donations released in total into the donor selected silo
immediately upon receipt
• CPR will accept all qualified new and renewal
applications on a first come, first serve basis with no
limit imposed each month on the number of approvals
issued
• CPR will accept and process all expenditures on a first
come, first serve basis until such time that the available
funds in the entire silo are exhausted
• Grant award is not reserved, nor guaranteed, for the
patient
CPR Program Features
• The CPR program is not drug specific as is required by
the OIG Opinion
• The treating physician is the primary source for
determining eligible covered therapies for each patient in
the program based on his/her treatment protocol
• CPR has a look back period of 12 months from the date
of the patients’ approval
• CPR allows 2 months once their award year has ended,
for Date of Services pending insurance
• Patients may reapply once their award year has ended,
if they are still in need of continued assistance
Co-Pay Relief Patient Testimonial
“I am writing this letter to thank Patient
Advocate Foundation for the help I have
received to obtain funds for my
medication. My co-pay for the three month
supply would be $500.00. I then called Dr.
Schwartz’s office and explained my
situation. It was then that I was told about
“Patient Advocate Foundation Co-Pay
Relief Program.” I was approved for
assistance within weeks. Also, all the
counselors I’ve spoken to at Patient
Advocate Foundation are always so
helpful, considerate and understanding to
my needs and my medical condition. It has
been a real pleasure to work with such an
organization.”
Rose Marie Kimmel
Osteoporosis
Wilmington, DE
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Property of Patient Advocate Foundation (PAF)
National Patient Advocate
Foundation is a national non-profit
organization dedicated to providing
the patient voice in improving access
to, and reimbursement for, highquality healthcare through regulatory
and legislative reform at the state and
federal levels.
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NPAF – 725 15th Street, NW, 10th Floor – Washington, DC 20005 – www.npaf.org
State Government Affairs
NPAF Patients’ Voice Network
The Patients’ Voice Network is comprised of patients,
caregivers, physicians, nurses, attorneys, patient advocates, and
patient services professionals. The purpose of this Network is:
• Educating elected officials at both the state and federal levels about policy and
legislative reform that improves, restores, and/or maintains access to care.
• Educating the public on free patient services available from Patient Advocate
Foundation
Advocacy Activities
• Action Alerts, Community Outreach, Patient Advocate Proclamations, Annual Patient
Congress, and Town Hall Meetings.
• Sign on to volunteer at NPAF.org
NPAF – 725 15th Street, NW, 10th Floor – Washington, DC 20005 – www.npaf.org
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National Underinsured
Resource Directory
http://patientadvocate.org/help4u.php
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National Underinsured Resource
Directory Pull Out Cards
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www.insureustoday.org
contact us at 866-207-8023
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Patient Educational Opportunities
PAF Publications
• insureUStoday.org
• National Underinsured Resource Directory: An Interactive Tool
• Managed Care Answer Guide
• Your Guide to the Appeals Process
• The National Financial Resources Guidebook for Patients: A State-by- State Directory
• First My Illness, Now Job Discrimination
• Your Guide to the Disability Process
• Promoting a Healthier African American Community
• Promoting a Healthier American Indian & Alaskan Native Community
• “A Greater Understanding” Pamphlet Series of 19 Pamphlets
• Lighting the Way: A Practical Guide to Clinical Trials
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PAF Websites
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www.patientadvocate.org – PAF Public Website
www.copays.org - Co-Pay Relief (CPR)
www.colorectalcareline.org - Colorectal CareLine (CCL)
www.cinv.patientadvocate.org - Chemotherapy-Induced Nausea and
Vomiting Careline (CINV)
www.pafcares.org - PAF Cares aka Virginia Cares Uninsured Program
(VCUP)
www.promiseofhope.net - A Promise of Hope Affair (POH)
pc.patientadvocate.org - Patient Congress (PC)
nls.patientadvocate.org - National Legal Symposium (NLS)
www.npaf.org - National Patient Advocate Foundation (NPAF)
www.insureustoday.org – InsureUStoday
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Contact Us
421 Butler Farm Road
Hampton, VA 23666
421 Butler Farm Road
Hampton, VA 23666
Phone: 1-800-532-5274
Phone: 1-866-512-3861
Fax:
Fax:
(757) 873-8999
(757) 952-0118
Internet: www.patientadvocate.org
Internet: www.copays.org
E-Mail: [email protected]
E-Mail: [email protected]
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