4 Ways to Support Patients Navigating Annual Benefits Changes

Formulary updates, new or revised health insurance plans, prior authorization expirations and patient deductible resets all tend to happen more often in the first few months of the year. That’s when provider and pharmacy teams can really shine as patient champions, removing barriers to medication and treatments and promoting better health.

Miranda Delatore, MSN, RN, NEA-BCVP of Network Operations

December 15th, 2022

Medical rowboat prior authorization healthcare paperwork — Illustration by Keith Negley

While the first months of a new year might be slow in some lines of work, it’s a very busy time for many healthcare workers — from medical offices to pharmacies to insurance and pharma companies.

Every year on Jan. 1, a significant piece of healthcare resets. A perfect storm of change gathers in the skies above healthcare workers.

During this time, patients need the help of their providers — including pharmacists, nurses, physician assistants, office managers and many others — more than ever to stay on treatment.

The wave of changes care team members can expect includes:

Many employer, government and institutional health insurance plans, like those at pension systems, reset.
Health insurance companies release their updated formularies, which are annual lists of the prescription drugs they will cover and at what level.
Prior authorizations require renewal during this time of the year. Prior auths are required by insurance companies to ensure medications, treatments and procedures are medically necessary; for cost reasons; to avoid drug misuse; and for cosmetic medications.
At the beginning of the new plan year, patient deductibles and out-of-pocket maximums reset.

Which medications made the list? Which did not? Find out in our 2022 Drug Formulary Updates article.

How can providers and pharmacists best support patients when benefits changes occur?

The rush of health benefit adjustments in the first few months of the year calls for an “all hands on deck” approach across healthcare. Care team coordination becomes paramount to avoid disruptions in treatment.

From the people who have been down this path before, here are a few tips to make January, February and March go as smoothly as possible.

Tip No. 1: Get ahead

Patients who have been taking prescriptions or receiving treatments for one or more chronic conditions may have new insurance coverage come Jan. 1. Their plan may or may not cover those medications, devices or other treatments at the same level, and affordability challenges could arise.

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To support them, make a habit of asking in December — before any changes occur — what might be coming. Are they going to a new employer soon? Joining a partner’s health plan? Or perhaps their employer is planning insurance or other administrative changes?

In the last 12 months, 66% of patients experienced a delay in receiving their medications, and administrative access challenges contributed to more than three-fourths of those missed fills.CoverMyMeds Patient Survey, 2022 Providers have the power to help. By starting electronic prior auth requests as soon as they prescribe a medication, patients can get their prescriptions nearly two weeks sooner, on average, compared to requests started later at the pharmacy.Metro Health Case Study, 2017

With the right information at the right time, care team members can have a plan to bridge gaps or delays in coverage as new prior auth requests arrive. That way, patients can receive the healthcare they need without interruption.

Tip No. 2: Let technology help so you can take care of patients

Informing a patient that their insurance plan no longer covers a medication they’re taking is difficult. That communication is critical and potentially life-altering for a person — and is equally stressful for providers and pharmacists, too.

These difficult conversations take time and increase the workload on the care team. The 2022 Medication Access Report found providers feel the effects of staff shortages and increased workload that goes with them: 42% said they were burned out, and 69% said they felt depressed.Medscape National Physician Burnout & Suicide Report, 2021 Burnout goes well beyond physicians — almost 20% of all healthcare workers quit their jobs between February 2020 and December 2021.Voices from the Front Lines of Health Care: Part II, Morning Consult, 2021

For pharmacists, a rapid increase in duties during the COVID-19 pandemic has contributed to increased strain that continues today. According to the 2022 Medication Access Report, three-fourths of pharmacists regularly gave immunizations, 37% had newly taken on helping patients solve medication affordability challenges, 42% called patients to follow up, and 44% managed a prescription home delivery program.CoverMyMeds Pharmacist Survey, 2021 More than half, 51%, don’t feel they have adequate time in the day to complete their work.CoverMyMeds Pharmacist Survey, 2022

In the battle against those stressors, what may seem like small workflow changes can make a big impact. In-workflow technology solutions that automate repetitive tasks and offer the ability to surface benefits information without jumping to another program can make a difference in a day when every minute counts.

Tip No. 3: Get rid of manual processes

Benefits verification and prior auth requests consume significant staff resources all year. On average, practices complete 41 prior auth requests per physician, per week, and 88% of physicians describe the burden associated with these requests as high or extremely high.American Medical Association annual survey 2021

That’s especially true when volumes spike in the first three months of the year. Completing these and other administrative tasks electronically can save a lot of time and money — $16.3 billion in potential savings annually for the medical and dental industries combined.2020 CAHQ Index

The early part of the year may mean a flurry of benefits verification and prior auth requests, but providers can take heart knowing they’re helping patients.

Manual processes involve phone calls and faxes between pharmacists and providers’ offices as they work on prior auth requests, with 80% of pharmacists relying on fax.CoverMyMeds Pharmacist Survey, 2022 Pharmacists say checking the status of a request as the feature they'd most like to add to their current system. Those operating with such a solution saw a 14% increase in paid claims, on average.CoverMyMeds Pharmacist Survey, 2021

Tip No. 4: Embrace pharmacists’ special affordability powers

Pharmacists especially find themselves having the conversation about changing health coverage, which can take patients by surprise.

In our latest survey of pharmacists to inform the upcoming 2023 Medication Access Report, 77% said they felt it was their responsibility to make sure patients received their medications in a timely manner, and 44% said they bear the greatest responsibility among care team members to ensure patients are paying the lowest price for their prescriptions.CoverMyMeds Pharmacist Survey, 2022
Updating patients on their coverage status is a chance to help with affordability solutions such as cash discount cards, copay cards or patient assistance programs. Pharmacists are at the center of that conversation — with 84% saying they provided patients with these and other affordability options.

Care team members have an opportunity to help improve health outcomes every time they help a patient overcome a medication access challenge.

While the early months of each year may present a sometimes-stressful flurry of benefits verification and PA request-related tasks, healthcare providers and pharmacists can take heart knowing they’re helping patients and their families on their journey toward better health.

For more on how healthcare team members can and do support patients experiencing medication access challenges, read the 2022 Medication Access Report.