Improving Patient Access for 2025 By Alisa Redmon

Learning from the Past for a Better Future: Improving Patient Access in 2025

By Alisa Redmon

As we approach a new year, the familiar refrain of “new year, new me” resurfaces. Whether it’s setting goals, creating inspiration boards, or crafting a bucket list, we’re all reflecting on the past year to shape a better future. For individuals with chronic conditions, this reflection often includes their health journey—how many flares they endured, or whether insurance or formulary changes disrupted their care.

For those of us in healthcare, particularly biologic coordinators, this season of reflection offers an opportunity to reevaluate how we can better serve our patients. In 2025, our shared goal should be ensuring patient access and improving outcomes.

What We’ve Learned: Insights from 2023

The 2023 Biologic Coordinator Career Survey Report provided valuable insights into what drives job satisfaction and challenges in this field:

• Top Motivation:

  • 60% of respondents emphasized that patient care and outcomes were the most important to their job satisfaction.

  • 33% cited their motivation as “beating payors to gain approvals,” while 28% focused on improving patient outcomes.

• Key Barriers:

  • Insurance requirements were cited as the top challenge by 35% of respondents.

  • High copays followed closely, with 31% identifying it as a significant issue.

This data reflects a harsh reality: access issues directly impact not only patients but also the job satisfaction of those advocating for their care.

Breaking Down the Barriers

Insurance Requirements: The “Does Not Meet Criteria” Denial Letter

For many, the fight for patient access starts with insurance hurdles. At the center of these barriers are Pharmacy Benefit Managers (PBMs).

PBMs were originally created to help insurers manage drug costs, but over time, they’ve gained significant control. They set formularies, establish step-therapy protocols, and determine which medications patients can access. Their decisions, often guided by committees formed by insurers, can directly impact patient outcomes.

While PBMs are subject to state and federal regulations, the degree of oversight varies widely, leading to inconsistencies and inequities in patient access.

The High Cost of Copays

Copays are another significant barrier for patients, and once again, PBMs play a pivotal role. Acting as intermediaries between insurers and pharmaceutical manufacturers, PBMs negotiate pricing and reimbursements. Unfortunately, the pricing models they employ often lead to inflated costs for patients.

Here’s how it works:

• PBMs charge insurance plans more for a drug than they reimburse to pharmacies.

• The PBMs keep the difference as profit, leaving patients with higher copays.

The result? Patients bear the financial burden of a system that prioritizes profits over access.

Taking It Personal: The Fight for Our Patients

One social media post sums up the frustration patients face:
“Who’s covering the therapy I’m going to need from dealing with [anonymous PBM here]?”

This post is a stark reminder of why biologic coordinators do what they do. Reflecting on the past year, we think of our most memorable cases—the victories and the challenges. These stories fuel our fight to overcome barriers and ensure patients receive the care they deserve.

Looking Ahead: 2025 Goals

As we enter the new year, it’s time to turn reflection into action. Our goal for 2025 is clear: Mitigate barriers to access and enhance patient outcomes. Here’s how we can start:

1. Reflect on 2024:

   • Identify the most common barriers that affected patient access and outcomes.

   • Evaluate which processes worked and which need improvement.

2. Tackle Insurance Barriers:

   • Stay informed about state and federal regulations affecting PBMs.

   • Advocate for greater transparency and accountability in formulary decisions.

3. Address Copay Challenges:

   • Help patients navigate co-pay assistance programs.

   • Push for pricing models that prioritize affordability and access.

4. Keep Patients at the Center:

   • Remember the faces and stories behind the data.

   • Stay motivated by the impact your work has on real lives.

Conclusion: A Future Focused on Patient Impact

The challenges in healthcare access are vast, but so are the opportunities for improvement. As we step into 2025, let’s commit to learning from the past and driving change. By addressing insurance requirements, reducing financial burdens, and advocating for systemic reform, we can help patients achieve better outcomes and brighter futures.

Our goal for 2025 is simple yet powerful: Ensure access. Enhance outcomes. Make an impact. Let’s work together to make it happen.