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Hi, everyone. This is Lucas Voss with Becker's

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Healthcare. Thanks so much for tuning in to

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the Becker's Healthcare podcast series. Fantastic to have

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you. Today, we're talking about how provider organizations

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are leveraging EHRs and EMRs to coordinate care

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and navigate insurance requirements for HIV prep patients

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prescribed long acting injectables or

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LAIs.

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Joining me for today's discussion, very excited to

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have him, is doctor Stephen k Barnett, senior

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vice president medical services and chief medical officer

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at Canned Community Health. Doctor Barnett, thanks so

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much for being here today. It's great to

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have you.

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Thank you. And I'm so glad to be

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here and talk about something this

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we've been working on for the last few

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years and,

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really excited about sharing our experience with you

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guys. Yeah. Really excited to hear about it

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too. To kick us off, though, before we

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get started and hop into our conversation, I'd

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love to start off with just a quick

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introduction, a little bit about yourself and and

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your work in health care.

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Well, good. I'm currently the chief medical

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officer at Can Community Health. So, you know,

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my in my role,

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I

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kinda manage all the providers and a lot

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of the clinical pieces in our clinics,

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including nursing,

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clinical research,

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behavioral health, and so forth.

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I came to Can about eight years ago.

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I had been in group and private practice,

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in a very underserved

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community in South Carolina. That's where I did

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the first I hate to admit it, but

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I've been practicing for

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soon to be thirty years. I'm getting old.

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But started in this small rural town, which

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was very one of the poorest counties in

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South Carolina

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and did full scope primary care on family

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medicine.

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But in a situation like that, we had

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four doctors for about a population of 40,000.

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Didn't have

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a lot of specialty,

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care available in the community.

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Back in those days, the HIV epidemic was

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in its early stages, and

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I did have to rely on, you know,

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infectious disease to help me with my patients.

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And then over the years, as the treatment

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got more,

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refined and and just amazing these days, we

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didn't have prevention back then,

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just treatment.

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Learned learned about HIV, became an HIV specialist

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so I could care for those people in

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that community without

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specialists around.

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And then came to Cannes,

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started as a provider in our first clinic

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outside of Florida and South Carolina,

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became a regional medical director for South Carolina,

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Virginia, and New Jersey, and then they asked

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me to be the the chief medical officer.

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So that's where I've been for about the

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last four years in that role.

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Well, it's so great to have you again.

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I wanna start us off with sort of

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level setting the conversation a little bit. You

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mentioned a couple of important things here in

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your intro as well. When we talk about

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long acting injectable prep,

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there's a lot of complexity

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around it. You know, obviously, we talk about

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scheduling and getting

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getting it to patients, it's itself.

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But also,

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when we talk about insurance navigation.

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Right? We talk about dose timing. There's so

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many factors that influence this space.

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Before

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optimizing

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your

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EHR work flows, what were some of those

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biggest pain points that you've encountered

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in coordinating

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care for these patients?

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Yeah. I would say, initially, the biggest challenge

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was coverage by the payers. You know? And

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you always have to go through that with

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a new product. So when, you know, the

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first long acting injectable for prep came out,

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it takes, I would say,

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four to six months. There were alternatives,

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oral

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prep,

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and one of them had become generic.

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And, of course,

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you have to go through that process. And

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so, initially, just getting approval by the insurance

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companies was the biggest barrier.

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And at the when they first came out

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is they they have two different ways you

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can do this. One is through a pharmacy

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benefit.

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So you send a prescription in if it's

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approved, and once we it got much easier

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to get approved,

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we would then rely on the pharmacy to

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ship the medication

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to us.

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Occasionally, a patient could pick it up at

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a local pharmacy,

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but then they were tasked with bringing it

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to us.

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Once we got the medication on hand,

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we had to get them scheduled.

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And usually, that went pretty well. And then

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once we did that initial

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injection, there were follow-up injections. And so

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making sure there's windows with these, like, you

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don't want to go beyond the window where

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you have to start over. It requires a

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loading dose,

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which is more frequent than maintenance.

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So,

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you know, initially,

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that the challenge was when someone didn't show

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up for their scheduled injection,

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you know, really have the

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the the bells and whistles went off like

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we have maybe seven days

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to get them in or that prescription,

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you know, potentially couldn't be used

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is

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sent specifically for that patient. And some people,

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if they fall out of care,

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you know, if we can't get them back

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in, then that medication goes wasted.

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So it's really a lot of stress and

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strain for those that

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just didn't come. The next one was with

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oral prep. You know, typically, people came in

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every three months to get their refills, and

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we could do the testing.

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The first long acting injectable was every two

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months. So they had to make a commitment

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to come in a little more frequently and

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get, you know, labs more frequently

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for some

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some patients. You know, when you're getting more

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services, you have more co pays.

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And so we had to make sure they

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were aware of that.

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And then we moved into something called buy

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and bill, which made it easier for us

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where

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we could buy the

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the long acting injectable

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stock in our clinic, and it wasn't patient

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specific. So we weren't sitting there with stocks

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of this is for Joe Smith, and this

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is for, you know,

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Anne Jones.

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Mhmm. And they're the only ones that can

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use it.

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But we did take that risk. You know,

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if

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it wasn't approved and we gave the injection,

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we had spent a lot of money to

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buy that medication, and we wouldn't get reimbursed.

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So those were the biggest pain points, scheduling,

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of course,

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and making sure they did show up for

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those injections on time. Frequency

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of the visits, you know, could be a

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barrier for some,

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but it did get them on a better

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routine.

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And then just kind of the

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challenge of making sure we,

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you know, had the going through the

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process to make sure it was completely authorized

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before we gave the injection.

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Otherwise,

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you know, you could run into some financial

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issues.

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Talking about these challenges, they're very multifaceted.

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Right? And and one of the things that

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is obviously very important to this is being

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able to optimize

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workflows to then say, okay. How can we

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make these things easier, not just for providers,

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obviously, but also for for patients and the

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folks that actually are getting these treatments?

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What are some of those steps that your

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team took to streamline these workflows specifically within

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your EHR or EMR?

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Yeah. The you know, what we

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realized over that early period is that we

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needed a team approach to this, and we

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had to have,

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you know,

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the nursing team and the providers on the

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ground being very cognizant of the process

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and following it. We leveraged our EMR

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to be able to coordinate this.

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We have multiple clinics, so it makes it

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a little more challenging.

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But using the EMR and

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what we call in our EMR actions, we

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could build that out. We have structured data

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built in to say where they're at in

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the process

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when it's authorized.

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Yeah. Almost like good to go is what

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we call it. If if we get it

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to the point that says,

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you know, we've been through the prior auth

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process.

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We've got it approved. We've actually got confirmation

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that it's

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approved. Then we give the green light and

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say, okay.

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Everything's ready to go. Schedule the patient. And

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then we have,

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you know, case managers,

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nursing team,

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patient experience experts, all those work together

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utilizing that information in the EMR to get

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the patient scheduled,

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you know, when they can come in. And

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then we built a process to do appointments

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in advance. In other words, when someone came

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in for that first injection, they needed one

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in a month.

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They needed the next one two months after

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that, and we knew every two months.

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And so we would build out those appointments

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ahead of time

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so the patient was aware. And then really

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working with our case managers, And we also

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have some additional what we call

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they're they're

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I'll call them patient care coordinators,

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and they would

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work with that with the patients to make

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sure they were, you know, not only electronically

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reminded,

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but this is so important that we would

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have, you know, messaging through the portal

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or phone calls to just remind them. And

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if they,

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for some reason,

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you know, did not make that appointment,

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we built a system in place to work

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towards communicating with the patient. Say, hey. We

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have, you know, five days or seven days.

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What can we do to get you in

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kind of thing? So we've we've leveraged multidisciplinary

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teams. We have,

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you know, some centralization

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of that,

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but we use our EMR heavily to

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track and assist and remind and things like

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that. And that's that's really been a big

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help for us.

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You mentioned prior auth, which is an important

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step

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in all of this.

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How

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much of a game changer

279
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was it to have this in electronic form?

280
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Right? EPA electronic prior authorization.

281
00:10:28,289 --> 00:10:30,370
And then we also talk about enhanced medication

282
00:10:30,370 --> 00:10:32,149
administration records or MARs.

283
00:10:32,929 --> 00:10:35,429
How did that change day to day operations?

284
00:10:36,370 --> 00:10:38,870
Yeah. I would say most importantly was

285
00:10:39,809 --> 00:10:40,549
the electronic

286
00:10:41,009 --> 00:10:42,230
prior auth. And

287
00:10:42,690 --> 00:10:44,544
each you know, we now

288
00:10:45,085 --> 00:10:46,705
have two long acting injectables

289
00:10:47,085 --> 00:10:49,884
in from two separate companies, and they have

290
00:10:49,884 --> 00:10:50,784
built out

291
00:10:51,485 --> 00:10:53,184
systems where we can

292
00:10:53,725 --> 00:10:55,664
enter that into their system,

293
00:10:56,090 --> 00:10:58,269
and then they do the benefits analysis.

294
00:10:59,210 --> 00:11:01,389
We do have to check behind that,

295
00:11:01,850 --> 00:11:03,549
but we have people that do that.

296
00:11:04,009 --> 00:11:06,429
So the actual manufacturer

297
00:11:07,290 --> 00:11:08,669
has Teams built,

298
00:11:09,215 --> 00:11:10,434
and it's all electronic

299
00:11:10,975 --> 00:11:13,215
that we can submit. And then it comes

300
00:11:13,215 --> 00:11:15,934
back because it's not only is it approved

301
00:11:15,934 --> 00:11:17,774
or not, we have to look at some

302
00:11:17,774 --> 00:11:20,035
payers will approve it through the pharmacy,

303
00:11:20,735 --> 00:11:21,554
some through

304
00:11:22,139 --> 00:11:24,460
the met what we call medical benefit, which

305
00:11:24,460 --> 00:11:26,460
is where we stock it and we buy

306
00:11:26,460 --> 00:11:26,960
it

307
00:11:27,500 --> 00:11:29,980
and administer it. And then some will do

308
00:11:29,980 --> 00:11:33,200
both. The newest LAI has both the oral

309
00:11:33,740 --> 00:11:34,240
loading

310
00:11:34,860 --> 00:11:36,399
tablets, and then there's

311
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the injection.

312
00:11:38,825 --> 00:11:40,365
And sometimes it's interesting.

313
00:11:40,665 --> 00:11:42,825
We have to know for both both the

314
00:11:42,825 --> 00:11:45,225
oral and the injectable, and they can they

315
00:11:45,225 --> 00:11:46,044
can differ.

316
00:11:46,504 --> 00:11:49,225
So but that makes it pretty smooth to

317
00:11:49,225 --> 00:11:50,285
get that initial.

318
00:11:50,629 --> 00:11:53,509
Hey. It's not covered at this time. That's

319
00:11:53,509 --> 00:11:54,330
pretty clear

320
00:11:54,789 --> 00:11:56,789
cut. Or it's covered, and here's the ways

321
00:11:56,789 --> 00:11:59,289
you can prescribe it or administer it.

322
00:11:59,750 --> 00:12:02,570
So that's been helpful. We have found, though,

323
00:12:03,664 --> 00:12:06,565
insurances change, and it's hard to keep up.

324
00:12:06,625 --> 00:12:07,605
So we typically

325
00:12:08,144 --> 00:12:10,725
try to follow that up with a actual

326
00:12:10,784 --> 00:12:13,524
call to the payer, the insurance company,

327
00:12:13,904 --> 00:12:16,639
and confirm it once once we've got that

328
00:12:16,639 --> 00:12:19,039
information, and they will typically give us an

329
00:12:19,039 --> 00:12:19,539
approval

330
00:12:20,240 --> 00:12:20,740
number.

331
00:12:21,120 --> 00:12:23,940
And once we get that, we can absolutely

332
00:12:24,240 --> 00:12:26,179
proceed. You know, there have been,

333
00:12:26,879 --> 00:12:29,120
luckily rare, but there have been times where

334
00:12:29,120 --> 00:12:31,404
the system tells us it's approved. We get

335
00:12:31,404 --> 00:12:32,144
the medication,

336
00:12:33,004 --> 00:12:33,745
and then we

337
00:12:34,365 --> 00:12:36,205
submit the claim. And they go, hey. Wait

338
00:12:36,205 --> 00:12:37,665
a second. It wasn't approved.

339
00:12:38,045 --> 00:12:40,045
So we make sure we go that extra

340
00:12:40,045 --> 00:12:41,745
step and get that authorization

341
00:12:42,045 --> 00:12:42,545
number.

342
00:12:43,019 --> 00:12:44,620
I will say that if you're doing it

343
00:12:44,620 --> 00:12:47,279
through the pharmacy, pharmacies are built

344
00:12:47,899 --> 00:12:48,399
to

345
00:12:49,019 --> 00:12:51,440
do this for you. They tell you,

346
00:12:51,740 --> 00:12:53,580
hey. It's approved or not. And if it's

347
00:12:53,580 --> 00:12:54,320
not approved,

348
00:12:54,620 --> 00:12:56,560
they help us with prior authorizations,

349
00:12:56,940 --> 00:12:59,524
which is it's not approved. You're gonna have

350
00:12:59,524 --> 00:13:00,904
to go through more steps.

351
00:13:01,764 --> 00:13:03,945
And then there's a there's a

352
00:13:04,805 --> 00:13:06,504
platform out there called CoverMyMeds.

353
00:13:06,965 --> 00:13:09,365
Often, it'll get shifted over to that, and

354
00:13:09,365 --> 00:13:10,825
that allows us to electronically

355
00:13:11,769 --> 00:13:13,769
submit the data they need to get a

356
00:13:13,769 --> 00:13:14,269
decision.

357
00:13:15,450 --> 00:13:17,850
You've touched on a very important point earlier

358
00:13:17,850 --> 00:13:20,809
in our conversation, which is the the human

359
00:13:20,809 --> 00:13:23,049
element to this and the team element to

360
00:13:23,049 --> 00:13:24,669
this, which I think is very crucial.

361
00:13:25,095 --> 00:13:26,534
And I was just wondering if we can

362
00:13:26,534 --> 00:13:27,735
come back to that and if you could

363
00:13:27,735 --> 00:13:29,815
share just a little bit more about how

364
00:13:29,815 --> 00:13:30,315
collaboration

365
00:13:30,695 --> 00:13:32,315
across those teams, right,

366
00:13:32,774 --> 00:13:33,274
supported

367
00:13:33,654 --> 00:13:36,134
this optimization that we just touched on and

368
00:13:36,134 --> 00:13:38,639
and what kind of impact it's it you've

369
00:13:38,639 --> 00:13:40,779
seen it had on on the organization.

370
00:13:41,720 --> 00:13:43,659
Yeah. And I and I will tell you,

371
00:13:43,720 --> 00:13:44,539
we learned

372
00:13:45,559 --> 00:13:48,220
through going through this process and having some

373
00:13:48,759 --> 00:13:52,139
difficulties and some failures. Right? And as AVA,

374
00:13:52,199 --> 00:13:55,235
we started when the first long acting injectable,

375
00:13:55,455 --> 00:13:57,235
it was for treatment, came out.

376
00:13:57,615 --> 00:13:59,934
So we we had to we had to

377
00:13:59,934 --> 00:14:01,955
go through this process. We actually,

378
00:14:02,975 --> 00:14:06,014
published a white paper on our experience and

379
00:14:06,014 --> 00:14:06,509
our

380
00:14:06,910 --> 00:14:09,470
and how we're now doing it. But it

381
00:14:09,470 --> 00:14:11,389
took going through that, and our hope is

382
00:14:11,389 --> 00:14:13,570
that, you know, others can

383
00:14:14,750 --> 00:14:17,250
learn from our lived experience, which

384
00:14:17,629 --> 00:14:19,009
was not always pretty

385
00:14:19,715 --> 00:14:22,355
to be able to optimize this and not

386
00:14:22,355 --> 00:14:24,355
have to go through those pain points that

387
00:14:24,355 --> 00:14:26,375
we went through. But, basically,

388
00:14:26,915 --> 00:14:28,995
you know, the best way I can describe

389
00:14:28,995 --> 00:14:31,815
it is kinda walk you through patient

390
00:14:32,355 --> 00:14:33,254
decides they

391
00:14:33,699 --> 00:14:35,720
want to go on a long acting injectable.

392
00:14:35,860 --> 00:14:36,679
That's usually

393
00:14:37,299 --> 00:14:38,519
there with the provider,

394
00:14:38,899 --> 00:14:41,059
and then the provider needs to get the

395
00:14:41,059 --> 00:14:42,360
nursing team involved

396
00:14:43,299 --> 00:14:44,600
to start the process.

397
00:14:44,980 --> 00:14:45,940
And then they

398
00:14:46,674 --> 00:14:47,654
you know, we basically

399
00:14:48,035 --> 00:14:49,174
will use those

400
00:14:49,795 --> 00:14:52,295
manufacturer platforms, and we have to fill out

401
00:14:52,514 --> 00:14:53,894
a form electronically

402
00:14:54,434 --> 00:14:56,774
to get it submitted to run the benefits

403
00:14:57,154 --> 00:15:00,215
analysis, and then we get that information back.

404
00:15:00,514 --> 00:15:02,819
We actually now have I'll I'll call it

405
00:15:02,819 --> 00:15:05,299
a centralized team. We actually have outsourced a

406
00:15:05,299 --> 00:15:07,779
little bit of it. And once we get

407
00:15:07,779 --> 00:15:08,839
it to that point,

408
00:15:09,220 --> 00:15:11,059
they do their stuff, but then they have

409
00:15:11,059 --> 00:15:12,579
to come back and say, hey. They need

410
00:15:12,579 --> 00:15:14,579
more information. So that's gotta go to the

411
00:15:14,579 --> 00:15:16,759
nursing team and the provider,

412
00:15:17,274 --> 00:15:18,095
and they have

413
00:15:18,634 --> 00:15:20,014
to provide more information.

414
00:15:20,554 --> 00:15:22,634
So it's a it's a back and forth

415
00:15:22,634 --> 00:15:24,894
thing until we get the full approval.

416
00:15:25,674 --> 00:15:28,975
And so coordinating that, again, what we've leveraged

417
00:15:29,034 --> 00:15:29,534
is

418
00:15:30,309 --> 00:15:32,570
a way to do that with some structured

419
00:15:32,629 --> 00:15:33,850
data in our EMR,

420
00:15:34,470 --> 00:15:37,370
because we're actually you know, we're big on

421
00:15:37,910 --> 00:15:40,389
looking at what we do and, you know,

422
00:15:40,389 --> 00:15:42,970
using things like Power BI to analyze

423
00:15:43,509 --> 00:15:44,809
how this is working.

424
00:15:45,174 --> 00:15:47,495
And so that structured data allows us to

425
00:15:47,495 --> 00:15:50,475
analyze our process and continue to refine it.

426
00:15:50,535 --> 00:15:51,514
But that communication

427
00:15:51,894 --> 00:15:53,035
within the EMR

428
00:15:53,415 --> 00:15:55,995
is kind of the mainstay of how we

429
00:15:56,295 --> 00:15:58,949
can do this, you know, with we actually

430
00:15:58,949 --> 00:16:01,769
have about 30 clinics in six states.

431
00:16:02,230 --> 00:16:03,850
And if each clinic

432
00:16:04,389 --> 00:16:05,529
is trying to

433
00:16:05,909 --> 00:16:07,289
master this by themselves,

434
00:16:08,230 --> 00:16:10,309
it is much more complex. So we kinda

435
00:16:10,309 --> 00:16:11,289
have that centralized

436
00:16:12,230 --> 00:16:12,730
process

437
00:16:13,269 --> 00:16:13,769
that

438
00:16:14,414 --> 00:16:16,034
in each clinic, we have

439
00:16:16,414 --> 00:16:18,735
users of that process. And we've been able

440
00:16:18,735 --> 00:16:20,174
to it's taken a lot of time, but

441
00:16:20,174 --> 00:16:21,794
we've been able to train them

442
00:16:22,654 --> 00:16:23,154
to

443
00:16:23,615 --> 00:16:26,815
communicate and and utilize the information to get

444
00:16:26,815 --> 00:16:28,834
it back to the patient.

445
00:16:29,920 --> 00:16:31,759
Such a fascinating process. And at the end

446
00:16:31,759 --> 00:16:34,000
of the day, again, everybody benefits in terms

447
00:16:34,000 --> 00:16:35,680
of the provider, but then also the patient,

448
00:16:35,680 --> 00:16:36,980
obviously, which is crucial.

449
00:16:37,600 --> 00:16:40,160
Doctor Barnett, it's so fantastic to have you.

450
00:16:40,160 --> 00:16:41,759
Thank you so much for taking some time

451
00:16:41,759 --> 00:16:42,580
for us today.

452
00:16:43,205 --> 00:16:45,625
Thank you. And I I again, I appreciate

453
00:16:45,684 --> 00:16:48,325
the opportunity, and reach out at any time

454
00:16:48,325 --> 00:16:50,485
if I can be of help. It's great

455
00:16:50,485 --> 00:16:52,004
to have you, and you could tune into

456
00:16:52,004 --> 00:16:54,644
more podcasts from Becker's Healthcare by visiting our

457
00:16:54,644 --> 00:16:56,825
podcast page at beggers hospital review

458
00:16:57,365 --> 00:16:58,184
dot com.