INDIANAPOLIS—Eric Farmer ’07 remembers being frustrated.
It was around 2014, and Farmer, an HIV Clinical Pharmacist at Indiana University Health Methodist Hospital, was working at one of the largest providers of HIV care in Indiana, yet he was spending most of his time filling out paperwork.
The Affordable Care Act was in the midst of being implemented, and many of Farmer’s patients were having issues with their health insurance marketplace plans covering the HIV medications he prescribed. So, Farmer was looking for an “in” at the Indiana Department of Insurance in hopes of influencing the process on a larger scale.
Then, an email from a former Butler University professor popped into his inbox.
Carriann Smith, professor of pharmacy practice, was working on a project —with the Department of Insurance—on marketplace health insurance plans. Would Farmer be interested in helping?
“It was unbelievable timing,” says Farmer, who graduated from Butler with a degree in Pharmacy in 2007. “I was desperately looking for a way to improve the process when it comes to deciding what drugs insurance companies cover on marketplace plans. We were having issues with plans covering some of the HIV medications and not others, and I wanted to influence the process on a much bigger scale than just my institution.”
Now, about four years later, the partnership between Butler and the Department of Insurance, which has involved about 25 Butler undergrads, five Butler alumni, and 11 Butler faculty, is doing just that—influencing the process. The tool they created, which insurance companies in Indiana fully implemented last year, specifies what medications insurance companies should cover for 17 diseases that are health priorities in the state.
One purpose of health insurance plans available on the marketplace, Smith says, was to provide a level playing field, and to make sure individuals with certain diseases were not discriminated against by insurance companies in terms of the level of coverage provided.
However, prior to this tool, insurance companies were deciding which medications to cover for each disease. There was limited external clinical perspective or dialogue with experts about why certain medications would or would not be covered, Smith says.
“Our tool takes into account all of the latest research, the published literature, and uses the clinical experience and expertise of our faculty, as well as external experts,” Smith says. “The goal is to bridge the gap between the regulators, the insurance companies, and the clinicians, and get everybody on the same page. We look at the evidence and, based on that evidence, say ‘Is that side effect of that medication really true, or is a prior authorization really needed, or, from a clinical perspective, this really should be covered.’ Medicine is not always black and white, and this now allows for more of a dialogue.”
The Department of Insurance now shares the tool with insurance companies in Indiana, who in turn use it while finalizing their marketplace insurance plans for the year. Plans are then submitted to the Department of Insurance for approval. The tool is used by the insurance companies when deciding which medications to cover for the 17 diseases it looks at.
By providing this expertise, and in turn, this tool, to insurance companies, Butler is adding a clinical perspective to the medication decision-making process when it comes to designing insurance plans. Most insurance companies have limited clinical expertise on staff when thinking through which drugs should be covered. As a result, the clinical perspective is not always taken into consideration or discussed. This process adds that clinical expertise, which in turn could result in a more thorough development of insurance plans.
“Our goal is not necessarily to make more drugs covered, but to make sure the key products are covered,” Smith says. “We need to weigh the benefits and potential side effects for patients. So our job as clinicians is to carefully consider the literature and evaluate whether or not a treatment is best.”
Keeping up with the latest literature and research has been the main focus of Drew Johnson, a P3 Pharmacy major, who has been involved in the project since 2018. Johnson reviews all of the generic products that come to market and makes sure the tools for bipolar, depression, and MS reflect the most current medications.
To do that, Johnson collaborates with clinical pharmacy specialists, reads up on drug industry newsletters, sifts through literature in the latest databases, and, occasionally, whips out his notes from the clinical experts who recently taught his classes at Butler to see if there is a particular drug in the pipeline that he should be aware of.
“Without having an external clinician looking at these plans, it is possible for the insurance company to look past the clinical perspective,” Johnson says. “Our involvement helps to ensure that quality insurance programs are sold throughout the state of Indiana to all individuals.”
That was essentially why the Department of Insurance reached out to Butler in the first place.
Jenifer Groth, spokesperson for the Department of Insurance, says the Department reached out to Butler in an effort to leverage the pharmacy program’s expertise, as the Department worked to determine if insurance carriers were covering an adequate amount of prescription drugs.
Which all leads back to Eric Farmer and all that paperwork.
As the Affordable Care Act was being implemented, Farmer was noticing that many of his patients with marketplace plans were having trouble getting coverage for the HIV medications he was prescribing.
“Keep in mind, when it comes to HIV, these pills are expensive,” he says. “To control HIV, the first line regimen is usually $2,500 to $3,000, and it only gets more expensive from there.”
The problem was, Farmer was seeing that most of his patients with marketplace plans were getting denied those first line regimens. The insurance companies were asking for prior authorizations for those drugs. Sometimes, insurance companies would not only ask for a prior authorization, but they would instead recommend trying a different drug—usually one from the 1990s, or one that was no longer on the market in the U.S.
“HIV is a field that moves super fast and many insurance companies weren’t keeping up,” Farmer says. “I would spend the majority of my day filling out paperwork, and I am lucky that I was able to. Imagine a small primary care doctor in rural Indiana—if he or she gets a prior authorization back from an insurance company, they likely won’t have the time or person power to fill out that paperwork. Instead, they will just ask the insurance company what will they cover, and just prescribe whatever the insurance company says they will cover. As a result, that patient is not getting the best care.”
Now, Farmer is working on the HIV tool to help guide insurance companies. One aspect of Farmer’s work is determining what medications should be covered, and which should require prior authorizations and which shouldn’t—all from a clinical perspective.
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