Hi, everyone. This is Lucas Voss with Becker's
Healthcare. Thanks so much for tuning in to
the Becker's Healthcare podcast series. Fantastic to have
you. Today, we're talking about how provider organizations
are leveraging EHRs and EMRs to coordinate care
and navigate insurance requirements for HIV prep patients
prescribed long acting injectables or
LAIs.
Joining me for today's discussion, very excited to
have him, is doctor Stephen k Barnett, senior
vice president medical services and chief medical officer
at Canned Community Health. Doctor Barnett, thanks so
much for being here today. It's great to
have you.
Thank you. And I'm so glad to be
here and talk about something this
we've been working on for the last few
years and,
really excited about sharing our experience with you
guys. Yeah. Really excited to hear about it
too. To kick us off, though, before we
get started and hop into our conversation, I'd
love to start off with just a quick
introduction, a little bit about yourself and and
your work in health care.
Well, good. I'm currently the chief medical
officer at Can Community Health. So, you know,
my in my role,
I
kinda manage all the providers and a lot
of the clinical pieces in our clinics,
including nursing,
clinical research,
behavioral health, and so forth.
I came to Can about eight years ago.
I had been in group and private practice,
in a very underserved
community in South Carolina. That's where I did
the first I hate to admit it, but
I've been practicing for
soon to be thirty years. I'm getting old.
But started in this small rural town, which
was very one of the poorest counties in
South Carolina
and did full scope primary care on family
medicine.
But in a situation like that, we had
four doctors for about a population of 40,000.
Didn't have
a lot of specialty,
care available in the community.
Back in those days, the HIV epidemic was
in its early stages, and
I did have to rely on, you know,
infectious disease to help me with my patients.
And then over the years, as the treatment
got more,
refined and and just amazing these days, we
didn't have prevention back then,
just treatment.
Learned learned about HIV, became an HIV specialist
so I could care for those people in
that community without
specialists around.
And then came to Cannes,
started as a provider in our first clinic
outside of Florida and South Carolina,
became a regional medical director for South Carolina,
Virginia, and New Jersey, and then they asked
me to be the the chief medical officer.
So that's where I've been for about the
last four years in that role.
Well, it's so great to have you again.
I wanna start us off with sort of
level setting the conversation a little bit. You
mentioned a couple of important things here in
your intro as well. When we talk about
long acting injectable prep,
there's a lot of complexity
around it. You know, obviously, we talk about
scheduling and getting
getting it to patients, it's itself.
But also,
when we talk about insurance navigation.
Right? We talk about dose timing. There's so
many factors that influence this space.
Before
optimizing
your
EHR work flows, what were some of those
biggest pain points that you've encountered
in coordinating
care for these patients?
Yeah. I would say, initially, the biggest challenge
was coverage by the payers. You know? And
you always have to go through that with
a new product. So when, you know, the
first long acting injectable for prep came out,
it takes, I would say,
four to six months. There were alternatives,
oral
prep,
and one of them had become generic.
And, of course,
you have to go through that process. And
so, initially, just getting approval by the insurance
companies was the biggest barrier.
And at the when they first came out
is they they have two different ways you
can do this. One is through a pharmacy
benefit.
So you send a prescription in if it's
approved, and once we it got much easier
to get approved,
we would then rely on the pharmacy to
ship the medication
to us.
Occasionally, a patient could pick it up at
a local pharmacy,
but then they were tasked with bringing it
to us.
Once we got the medication on hand,
we had to get them scheduled.
And usually, that went pretty well. And then
once we did that initial
injection, there were follow-up injections. And so
making sure there's windows with these, like, you
don't want to go beyond the window where
you have to start over. It requires a
loading dose,
which is more frequent than maintenance.
So,
you know, initially,
that the challenge was when someone didn't show
up for their scheduled injection,
you know, really have the
the the bells and whistles went off like
we have maybe seven days
to get them in or that prescription,
you know, potentially couldn't be used
is
sent specifically for that patient. And some people,
if they fall out of care,
you know, if we can't get them back
in, then that medication goes wasted.
So it's really a lot of stress and
strain for those that
just didn't come. The next one was with
oral prep. You know, typically, people came in
every three months to get their refills, and
we could do the testing.
The first long acting injectable was every two
months. So they had to make a commitment
to come in a little more frequently and
get, you know, labs more frequently
for some
some patients. You know, when you're getting more
services, you have more co pays.
And so we had to make sure they
were aware of that.
And then we moved into something called buy
and bill, which made it easier for us
where
we could buy the
the long acting injectable
stock in our clinic, and it wasn't patient
specific. So we weren't sitting there with stocks
of this is for Joe Smith, and this
is for, you know,
Anne Jones.
Mhmm. And they're the only ones that can
use it.
But we did take that risk. You know,
if
it wasn't approved and we gave the injection,
we had spent a lot of money to
buy that medication, and we wouldn't get reimbursed.
So those were the biggest pain points, scheduling,
of course,
and making sure they did show up for
those injections on time. Frequency
of the visits, you know, could be a
barrier for some,
but it did get them on a better
routine.
And then just kind of the
challenge of making sure we,
you know, had the going through the
process to make sure it was completely authorized
before we gave the injection.
Otherwise,
you know, you could run into some financial
issues.
Talking about these challenges, they're very multifaceted.
Right? And and one of the things that
is obviously very important to this is being
able to optimize
workflows to then say, okay. How can we
make these things easier, not just for providers,
obviously, but also for for patients and the
folks that actually are getting these treatments?
What are some of those steps that your
team took to streamline these workflows specifically within
your EHR or EMR?
Yeah. The you know, what we
realized over that early period is that we
needed a team approach to this, and we
had to have,
you know,
the nursing team and the providers on the
ground being very cognizant of the process
and following it. We leveraged our EMR
to be able to coordinate this.
We have multiple clinics, so it makes it
a little more challenging.
But using the EMR and
what we call in our EMR actions, we
could build that out. We have structured data
built in to say where they're at in
the process
when it's authorized.
Yeah. Almost like good to go is what
we call it. If if we get it
to the point that says,
you know, we've been through the prior auth
process.
We've got it approved. We've actually got confirmation
that it's
approved. Then we give the green light and
say, okay.
Everything's ready to go. Schedule the patient. And
then we have,
you know, case managers,
nursing team,
patient experience experts, all those work together
utilizing that information in the EMR to get
the patient scheduled,
you know, when they can come in. And
then we built a process to do appointments
in advance. In other words, when someone came
in for that first injection, they needed one
in a month.
They needed the next one two months after
that, and we knew every two months.
And so we would build out those appointments
ahead of time
so the patient was aware. And then really
working with our case managers, And we also
have some additional what we call
they're they're
I'll call them patient care coordinators,
and they would
work with that with the patients to make
sure they were, you know, not only electronically
reminded,
but this is so important that we would
have, you know, messaging through the portal
or phone calls to just remind them. And
if they,
for some reason,
you know, did not make that appointment,
we built a system in place to work
towards communicating with the patient. Say, hey. We
have, you know, five days or seven days.
What can we do to get you in
kind of thing? So we've we've leveraged multidisciplinary
teams. We have,
you know, some centralization
of that,
but we use our EMR heavily to
track and assist and remind and things like
that. And that's that's really been a big
help for us.
You mentioned prior auth, which is an important
step
in all of this.
How
much of a game changer
was it to have this in electronic form?
Right? EPA electronic prior authorization.
And then we also talk about enhanced medication
administration records or MARs.
How did that change day to day operations?
Yeah. I would say most importantly was
the electronic
prior auth. And
each you know, we now
have two long acting injectables
in from two separate companies, and they have
built out
systems where we can
enter that into their system,
and then they do the benefits analysis.
We do have to check behind that,
but we have people that do that.
So the actual manufacturer
has Teams built,
and it's all electronic
that we can submit. And then it comes
back because it's not only is it approved
or not, we have to look at some
payers will approve it through the pharmacy,
some through
the met what we call medical benefit, which
is where we stock it and we buy
it
and administer it. And then some will do
both. The newest LAI has both the oral
loading
tablets, and then there's
the injection.
And sometimes it's interesting.
We have to know for both both the
oral and the injectable, and they can they
can differ.
So but that makes it pretty smooth to
get that initial.
Hey. It's not covered at this time. That's
pretty clear
cut. Or it's covered, and here's the ways
you can prescribe it or administer it.
So that's been helpful. We have found, though,
insurances change, and it's hard to keep up.
So we typically
try to follow that up with a actual
call to the payer, the insurance company,
and confirm it once once we've got that
information, and they will typically give us an
approval
number.
And once we get that, we can absolutely
proceed. You know, there have been,
luckily rare, but there have been times where
the system tells us it's approved. We get
the medication,
and then we
submit the claim. And they go, hey. Wait
a second. It wasn't approved.
So we make sure we go that extra
step and get that authorization
number.
I will say that if you're doing it
through the pharmacy, pharmacies are built
to
do this for you. They tell you,
hey. It's approved or not. And if it's
not approved,
they help us with prior authorizations,
which is it's not approved. You're gonna have
to go through more steps.
And then there's a there's a
platform out there called CoverMyMeds.
Often, it'll get shifted over to that, and
that allows us to electronically
submit the data they need to get a
decision.
You've touched on a very important point earlier
in our conversation, which is the the human
element to this and the team element to
this, which I think is very crucial.
And I was just wondering if we can
come back to that and if you could
share just a little bit more about how
collaboration
across those teams, right,
supported
this optimization that we just touched on and
and what kind of impact it's it you've
seen it had on on the organization.
Yeah. And I and I will tell you,
we learned
through going through this process and having some
difficulties and some failures. Right? And as AVA,
we started when the first long acting injectable,
it was for treatment, came out.
So we we had to we had to
go through this process. We actually,
published a white paper on our experience and
our
and how we're now doing it. But it
took going through that, and our hope is
that, you know, others can
learn from our lived experience, which
was not always pretty
to be able to optimize this and not
have to go through those pain points that
we went through. But, basically,
you know, the best way I can describe
it is kinda walk you through patient
decides they
want to go on a long acting injectable.
That's usually
there with the provider,
and then the provider needs to get the
nursing team involved
to start the process.
And then they
you know, we basically
will use those
manufacturer platforms, and we have to fill out
a form electronically
to get it submitted to run the benefits
analysis, and then we get that information back.
We actually now have I'll I'll call it
a centralized team. We actually have outsourced a
little bit of it. And once we get
it to that point,
they do their stuff, but then they have
to come back and say, hey. They need
more information. So that's gotta go to the
nursing team and the provider,
and they have
to provide more information.
So it's a it's a back and forth
thing until we get the full approval.
And so coordinating that, again, what we've leveraged
is
a way to do that with some structured
data in our EMR,
because we're actually you know, we're big on
looking at what we do and, you know,
using things like Power BI to analyze
how this is working.
And so that structured data allows us to
analyze our process and continue to refine it.
But that communication
within the EMR
is kind of the mainstay of how we
can do this, you know, with we actually
have about 30 clinics in six states.
And if each clinic
is trying to
master this by themselves,
it is much more complex. So we kinda
have that centralized
process
that
in each clinic, we have
users of that process. And we've been able
to it's taken a lot of time, but
we've been able to train them
to
communicate and and utilize the information to get
it back to the patient.
Such a fascinating process. And at the end
of the day, again, everybody benefits in terms
of the provider, but then also the patient,
obviously, which is crucial.
Doctor Barnett, it's so fantastic to have you.
Thank you so much for taking some time
for us today.
Thank you. And I I again, I appreciate
the opportunity, and reach out at any time
if I can be of help. It's great
to have you, and you could tune into
more podcasts from Becker's Healthcare by visiting our
podcast page at beggers hospital review
dot com.