solving insurance and healthcare access problems | since 1996 patient advocate foundation the...

Solving Insurance and Healthcare Access Problems | since 1996

Patient Advocate FoundationPatient Advocate FoundationThe Patient’s PartnerThe Patient’s Partner

An Overview of Programs and Service Offerings

The patients who contact PAF for assistance have many challenges they are facing including:

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

Statement of Need

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Property of Patient Advocate Foundation (PAF)

Our Mission: To Serve Patients & Ensure Access to Healthcare Services

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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)

13 April, 2011 Property of Patient Advocate Foundation (PAF)

Many Voices

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• Total 2010 Case Count: 82,963

• Total Case Contacts: 934,232

• Webpage Views:2,766,849

• Total Subscribed Emails: 187,761


Summary of Patient Services:2010 Patient Data Analysis Report


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49.88% Increase in Patient Case Count

Patient Services Growth:Patient Services Growth:2009 vs. 20102009 vs. 2010

2009 2010

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Gender

Source: 2010 Patient Data Analysis Report

Male 38.13%Male 38.13%

Female 61.87%Female 61.87%

Ethnicity


Analysis of PAF Patients

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Types of Insurance Coverage Reported by PAF

Patients

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Mary Lenox Multiple MyelomaChicago, IL


Words from a PAF patient

“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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Mission Analysis

Medical Debt Crisis Issue Analysis


PAF Mission Analysis

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 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

PAF Direct Patient Services

THE PATIENT'S JOURNEY IS NEVER ONE STEP

THE PATIENT'S JOURNEY IS NEVER ONE STEP

• 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

• 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

http://en.wikipedia.org/wiki/File:US_CDC_logo.svg

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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

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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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, Texas2001: 1.24% of PAF patients were Hispanic/Latino2010: 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 American2010: 16.91% of PAF patients were African American

Disparate Population Outreach Programs

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In the words of our patients

Mary EstepMultiple MyelomaChesterfield, VA

2010 PAF Media Coverage

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http://www.washingtonpost.com/

http://www.sacramentopress.com/section/frontpage

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. Kantar Health, Oncology Market Access, 2010

2. MattsonJack DaVinci, Oncology Market Access, 2009


• 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, 20102. MattsonJack DaVinci, Oncology Market Access, 2009


• 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 co-payment assistance program

• Developed personal relationships with thousands of healthcare providers and pharmacies

CPR Impacting Lives and Fulfilling Our Mission

• CPR was established in April 2004, under OIG opinion, #04-15. Our program is the 2nd oldest CPR program in the nation

• CPR offers assistance to– Government Beneficiaries including those covered by:

• Medicare – All co-payments made by PAF count towards a patients True Out-Of-Pocket expense (TrOOP) from the first dollar expended

• Medicaid• Tricare/VA Benefits

– Commercially insured beneficiaries

• 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 Program Governance and Compliance

• 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

• 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 currently offers assistance in 20 disease funds including:

CPR Open Disease Funds

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 Co-payment 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

CPR Program Goals: CPR Program Goals: Experience and ExpertiseExperience and Expertise

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)

How to Access CPR

https://www.copays.org/

https://www.cprproviders.patientadvocate.org/

Patient, Provider andPatient, Provider andPharmacy Portal FeaturesPharmacy 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 Auto import required documents through eFax if fax is the preferred submission method

• Bar code recognition for faxed documents 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)

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:

Highly available Secure Quick and Efficient (burden of application is approximately 5-7 minutes) Patient look up features available - assists with expediting reapplication

process

The Registration process takes approximately 3 minutes to complete and is onlynecessary 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)

Provider Portal and Pharmacy Provider Portal and Pharmacy Portal Application ProcessPortal Application Process

https://www.cprproviders.patientadvocate.org/

• 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!

Approval ProcessApproval Process

• 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 FeaturesCPR 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

CPR Program FeaturesCPR Program Features

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“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.”


Co-Pay Relief Patient Testimonial

Rose Marie KimmelOsteoporosis

Wilmington, DE

National Patient Advocate Foundation is a national non-profit organization dedicated to providing

the patient voice in improving access to, and reimbursement for, high-

quality healthcare through regulatory and legislative reform at the state and

federal levels.

NPAF – 725 15th Street, NW, 10th Floor – Washington, DC 20005 – www.npaf.org

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http://www.npaf.org/

State Government Affairs

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

NPAF Patients’ Voice Network

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http://www.npaf.org/

National Underinsured National Underinsured Resource DirectoryResource Directory


http://patientadvocate.org/help4u.php37

National Underinsured Resource

Directory Pull Out Cards

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www.insureustoday.org


contact us at 866-207-8023

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• 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


Patient Educational Opportunities Educational OpportunitiesPAF PublicationsPAF Publications

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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


PAF Websites

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421 Butler Farm Road Hampton, VA 23666

Phone: 1-800-532-5274

Fax: (757) 873-8999

Internet: www.patientadvocate.org

E-Mail: [email protected]

421 Butler Farm Road Hampton, VA 23666

Phone: 1-866-512-3861

Fax: (757) 952-0118

Internet: www.copays.org

E-Mail: [email protected]


Contact Us

solving insurance and healthcare access problems | since 1996 patient advocate foundation the...

Documents

patient case count2009201013

direct patient service

behalf of patients

insured patients

unique challenges

debt crisis issues

pharmaceutical agents

issues uninsured