Medication Access Breakdowns: Why They Happen and and Cinnamon’s Solution

Many patients never receive the medications that could help them. We see it in healthcare every day: A persistent gap exists between how many patients could benefit from a therapy and how many successfully receive and stay on it as intended.

Often, this gap gets framed as a non-adherence issue. In many cases, however, even patients who are motivated to get and stay on therapy are stymied by an access journey so difficult that they ultimately don’t complete it.

A better access infrastructure can change this. Here, we examine where access breaks down, why, and what can be done about it.

The unwritten prescription

Ideally, clinicians prescribe the therapy they believe will be most helpful to a patient, and the patient receives it in a timely manner, with ease, and at an affordable price. In reality, practitioners have to navigate insurance coverage, or lack thereof, and consider how quickly the patient will be able to start therapy. Too often, patients get lost in the system.

This means clinicians take into account how difficult the prior authorization (PA) process will be. In one national survey of gastroenterologists, for example, more than half reported choosing an inferior treatment at least weekly because of the perceived PA burden for the medication they would have preferred.

Some PAs demand a disproportionate share of the 13 hours the average clinician and their staff spend on PAs each week. Completing the form often requires toggling between the EHR and PA portal, writing clinical narratives that cover years of patient history, and pulling together supporting documents. Specialty therapies can require multiple rounds of back and forth with the payer. When a clinician anticipates weeks of effort to get a drug to a patient, they may opt for an alternative with a faster path to fill.

Financial considerations also factor in. A clinician may know one therapy is typically affordable for their patient’s insurance, but not know about another’s robust patient assistance program, defaulting to the option they know should be financially manageable.

Access infrastructure that both automates the PA process to make it faster and more accurate, and that surfaces financial assistance options the moment a prescription is written, provides a fix to this gap. This helps ensure that clinical value, rather than administrative or financial hurdles, remains at the forefront of patient care.

The prior authorization stall

Once a PA is submitted, clinicians and patients often face extended waits, sometimes involving multiple rounds of submissions as the payer requests additional information.

Outright denials can add another level of delay. According to a KFF study, about a quarter of all in-network claim denials happen for administrative reasons, like a missing supporting document or an incomplete field. Fixing them requires another round of work, another submission, and another wait.

Many of these delays can be prevented by improving the PA process at the front end. Automating form completion saves time and reduces human error. Pharmacist-trained AI can draft clinical narrative portions for clinicians’ review, learning over time to anticipate the additional information payers tend to ask for. Delays and denials drop, and patients get on therapy faster.

The affordability gap

Even after PAs are approved, many patients can’t afford their insurance-dictated copay. High copays are common for specialty therapies, and when out-of-pocket costs top $500, abandonment rates hit 60%.

Many financial assistance programs exist to support patients, from manufacturer copay cards to foundation grants. But the support is fragmented across dozens of organizations, each with its own eligibility criteria, application process, and funding cycles. This multitude of resources, while helpful, can create an awareness gap for patients and care teams alike. Even when awareness isn’t a barrier, care teams may lack the necessary bandwidth to optimize every patient's funding stack.

Patients may also enroll in a manufacturer's patient assistance program (PAP), even if they meet criteria for insurance-reimbursed coverage with copay support and/or a foundation grant. When that happens, the brand absorbs the full cost despite a sustainable funding source being available.

To ensure patients get the best source of funding they’re eligible for, care teams need infrastructure that scans every funding layer in real time, identifies which programs the patient qualifies for, and works through them in the right order. This keeps PAPs working as intended, providing need-based care for patients without other funding options.

The persistence drop-off

Many patients who successfully start therapy fall off in the weeks or months that follow. Only 29% of patients on novel medicines remain on therapy after one year.

Some stop therapy because their financial support expires. Many PAPs, foundation grants, and copay support programs require periodic re-enrollment, sometimes with new physician attestation. If the deadline passes without action, the patient’s copay can spike without warning.

Life changes can also trigger drop-offs. When a patient switches jobs or insurance plans, a new PA and financial enrollment may be required. On the clinic side, the coordinator managing a case can move or get reassigned, and patient files can go untracked.

Solving these issues requires infrastructure that tracks deadlines and alerts the team well before they hit. Combined with centralized task management that lets one staff member easily pick up for another, the medication access journey has a much higher chance of staying in motion until the patient no longer needs the therapy.

The visibility lag

By the time retrospective hub reports reveal problems in the access journey, many patients have been affected and may have already given up. Reports often don't explain whether patients got stuck at PA, couldn’t secure financial assistance, or encountered another problem.

Fixing this lag requires giving frontline health system staff who are closest to the patient real-time visibility into both prior authorization and financial assistance approval processes. With that clear view, they can catch issues as they happen, while the patient is engaged.

Connecting the access journey

These access breakdowns may seem like they require multiple tools to fix, but are in fact connected issues that require a single, connected solution. We built Cinnamon as a unified platform that addresses these failure points end to end.

With Cinnamon, automated PA workflows pull from the EHR and use pharmacist-trained AI to draft highly accurate clinical narratives, so clinicians don't have to factor PA difficulty into their prescribing decisions. Further, our Coverage Waterfall algorithm scans every funding layer in real time, so patients land on the most sustainable form of support for which they qualify.

Cinnamon also keeps patients on therapy after the first fill, with automated alerts that go out before re-enrollment deadlines and a centralized task management system that lets staff pick up where colleagues left off. Health systems get real-time visibility into PA and financial assistance approvals, so they can catch issues while there's still time to act on them.

With our end-to-end solution, more patients can get and stay on the therapies their clinicians choose for them. To see what a connected access journey could look like for your brand, get in touch with us.

Photo by Etactics Inc on Unsplash