Proactive approaches to drug shortages: What payers can do

Out in the consumer healthcare community, communication gaps begin to show. And most of the time, it falls on the patients to go back to their provider or pharmacist for solutions.

In Minnie’s case, after initially finding out about the estradiol shortage from her brick-and-mortar pharmacy when they went to fill it and couldn’t – causing her to have to scramble – she was pleased to get an automated email advance warning of pending lack of availability from her online pharmacy. The earlier warning gave her more time to figure out an alternative to avoid a pause in her treatment.

At the payer level, there is an opportunity to take a population health approach and proactively identify potential shortages for members, particularly if not all pharmacies are reaching out in a timely matter. Reports from claims data could generate a list of any member who's had an estradiol patch in the last six months, enabling a notification at scale to help prepare members for the possibility of losing access to their prescription.

As claims contain the name of the prescribers, too, payers could also generate outreach to specific prescribers and personalize member messaging to direct them to the prescriber who can help them form an alternative treatment plan.

Every member of the commercial healthcare ecosystem tends to look at drug shortages only within their own four walls. When payers look at real-world data, it enables them to adapt to the trends and needs of their healthcare partners and members in mitigating drug shortages.

For example, if Minnie’s health plan is running claims reports, they might see a sharp uptick in prescriptions for Veozah. It would alert them to the effects of the estradiol shortage, and they could adapt policy around those needs.

They might also see an increase in OBGYNs prescribing gabapentin, which wouldn’t be a normal drug for them to prescribe. Using evidence-based drug information resources, payers would be able to confirm that gabapentin can be used off-label to treat vasomotor symptoms, and it might be worthwhile to recommend that members ask their prescribers if it could be appropriate in their situation.

Adapting coverage policies to support alternative therapeutic options

With Minnie now aware that she can't get the estradiol patch she needs alongside the cream, she’s gone to her provider for alternative therapeutic options. She is interested in trying one of the newer agents now available for menopausal vasomotor symptoms but is concerned her insurance won’t cover it.

During the COVID years, the US government altered its policies to make telehealth temporarily more accessible to more people. This same idea, just from a different lens, is something payers could apply to drug shortage scenarios to help alleviate some of the concerns members have about trying therapeutic alternatives.

In the case of newer agents that might be under prior authorization (PA), payers could consider waiving PA during the shortage of a similar older agent. Since payers still, in many cases, need to know a member has tried first-line options before moving on to a newer therapy, they may not be able to entirely waive PA for every shortage scenario, but can simplify processes to accelerate access to newer drugs.

What happens to members after a shortage ends?

As Minnie plans to begin treatment with Veozah, her care team has cautioned her that it may only be a temporary solution. Her coverage may require her to return to the estradiol patch and cream when the shortage period ends. But she’s been wondering what happens if she does better on the new medication and doesn’t want to switch back.

This introduces a tricky challenge for payers: Do you make a policy decision that prioritizes cost-effectiveness even if some members have a better quality of life on an alternative therapy?

It all comes back to member experience. Whether it ultimately is more appropriate for patients like Minnie to stay on Veozah or return to estradiol, members need clear communication about what they should expect.

Established upfront policies and ongoing communication with members about the expectations and available options for when the shortage is over are as important as early notifications about the shortages. It is also valuable to keep members informed of any additional steps they or their provider may need to complete to ensure continued coverage after a shortage.

When members encounter barriers because they don’t understand their payers’ policies, some will just give up taking their medications. If a patient – particularly an elderly patient or one who lives 30 miles or more from their nearest pharmacy or provider – is told a drug is unavailable without offering options and next steps, you may end up with a patient walking out of the pharmacy who thinks their only choice is to stop taking the drug.

To avoid that scenario, member education – on both the medication and the disease state it is being used to treat – can be extremely helpful to keep members compliant with care and help them understand why certain strategies are recommended to mitigate the drug shortages that affect them.

Finding payer solutions backed by evidence

Payers are smack dab in the middle, not just between providers and pharmacists, but also in the middle of the argument between cost containment and member needs. Payers need drug data and evidence-based strategies that help them balance costs, compliance, and quality care while also addressing processes and member needs around mitigating shortages.

Learn more about payer solutions for drug and medical management. For more on medication policies, compliance, and supply management, read the Expert Insight, Complying with CBP regulations: Country-of-origin labeling for prescription and OTC drugs.