Printing the Patient Support Legend (AFPs, Part 3)
What Jimmy Stewart teaches us about who really can duel Alternative Funding Programs (AFPs)
Back in the saddle! This post is public.
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Y'know, if I could figure out a way to make a living just writing about Patient Access issues in the United States, I would be living the dream. But I got a day job.
Don't get me wrong; I love my client work. And keeping in the mix is in no small part why I can write about these issues with some confidence. But holy cow, month of May, I hardly knew ye. I don't know what happened. Life was life-ing.
And this Mama has been hustling.
I received two messages yesterday. Funny thing: two very different senders: one a parent for whom the reality of Alternative Funding Programs (AFPs) has already added some teeth to the edge that is walking the path of Rare Disease, and the second from a manufacturer vice president of Access who's trying to figure out, and I quote, "What can we do about the foundations? We can't pretend that's just an advocacy play anymore."
I've previously written about why I don't touch copay foundations. I won't revisit that topic other than to say that the thinking that the $2,000 annual max for Medicare Part D out-of-pocket (OOP) cap will decrease foundations’ applications is flawed. Totally reminds me (circa 2013) when the Affordable Care Act was supposed to make the need for Patient Assistance Programs (PAPs) go away altogether, just kidding, ha ha.
But I do want to talk about the idea of "play," and how it's used in commercial Pharma. The term "play" often refers to a tactic or lever you can pull that has a very specific anticipated outcome. Commercial copay assistance, for example, is largely an adherence play: removing the barrier that is a Patient's "walkaway" point (in terms of out-of-pocket costs) makes the Patient more likely to fill their new prescription, and their total prescriptions should be higher. Lest my Commercial Operations and Analytics friends harangue me about using aggregate references for individual Patients, let me gently remind you: every pill or vial is a Patient.
Some manufacturers often house the management of their commercial copay assistance programs under brand marketing, rather than Patient Support. Some of that is because the spend is directly tied to brand performance, which affects gross-to-net calculations closely tracked by marketing and finance. And some of it is because, while not overtly promotional, copay assistance influences behavior. It can drive initiation and adherence, especially at the point of prescription fill, which aligns with brand objectives like market share and persistence.
Another Patient Support service that's often managed under brand rather than market access? Supplemental clinical nurse educators. No one can tell me that the most trusted role in healthcare doesn't influence perception when your brand offers a nurse visit to support therapy initiation. Let’s be honest: nurse educators often carry promotional weight. Nurse educators are absolutely a play in Pharma.
But understanding insurance coverage? Providing information on prior authorization requirements or how to appeal a coverage denial? Status checks on benefits and eligibility? Those fall squarely under Patient Support, which is 99.9% of the time under market access. There's no play here.
I mean, I get pelted (ahem, "sent") vendor pitch requests every day, and honestly, it's not often that I'm glad I took the call. I know that sounds awful, but the truth is that they're all trying to build a better mousetrap.
Ten years ago, I first heard about leveraging non-dispensing pharmacies in the electronic medical record (EMR) so that a healthcare provider (HCP) could directly refer a Patient to a Patient Support Program (PSP). Thanks to covered entity-to-covered entity capture, action could be initiated on behalf of the Patient while consent and program opt-in were pending. I remember who was explaining it to me, I remember where I was sitting, and I was gobsmacked. I thought it was… elegant. Obvious, (or maybe not, because why was no one doing this sooner?) but elegant. As a former practice manager and administrator who still sports several battle scars from multiple electronic health record (EHR) implementations, I loved it.
Honestly, I still haven't seen anything that evokes that same level of "Wow." There are a few artificial intelligence (AI) platforms I keep an eye on because I believe they have the potential to shift health plan behavior in favor of the Patient, and there is some fascinating AI work on understanding Patient sentiment and behavior. But I digress.
There's no play when it comes to Patient Support, because ultimately its value, its return on objective, isn’t realized in the outcome (Patient ability to leverage insurance coverage to obtain medicine, Patient identifying appropriate and compliant financial assistance) but in the execution of the service itself: speed of service and accuracy of information provided are the differentiators.
There's no play available when a Patient cannot afford their drug and they have no insurance. You can offer free drug or you can make a donation to a third-party foundation (which may or may not grant a Patient financial assistance… which they may or may not apply toward your therapy). For reasons I don't entirely understand, pharmaceutical companies have been slow to take on AFPs, which offer a cruel paradox:
The Patient has insurance because they’re employed, but the Patient doesn’t have coverage because of choices their employer has made.
Their income is too high to meet most PAP financial eligibility criteria, but they wouldn’t have that income if they didn’t work for the employer that won’t cover the (often life-saving, only standard of care) therapy that they need.
I've been up to my eyeballs lately evaluating existing Patient Support Programs (PSPs) through multiple lenses. My very first industry gig was as an operations manager for a very large manufacturer PAP, so I admit some bias and interest when I explore PAPs and how manufacturers are electing (and don't let anyone ever tell you that pharmaceutical companies are forced into making tough decisions from a menu of bad choices). I've flagged in Part 1 and Part 2 of this series how manufacturers are reassessing their PAPs, and how it’s less about tightening generosity and more about guarding program integrity in response to AFP exploitation.
AFPs divert resources meant for the uninsured, plain and simple.
But I was taken aback last week when I found a PAP for a medication with an annual wholesale acquisition cost (WAC) well into the six figures, with a household income limit of 233 percent of the federal poverty level (FPL). Random: if I ruled the world, geographic pricing index in PAP eligibility would be a thing. Then again, if I ruled the world, we’d have universal healthcare and PAPs wouldn’t exist.
Two hundred thirty-three percent. So if a PAP sets its income cap at 233 percent of FPL, any household of three earning more than approximately $57,000 annually would be ineligible, even if the drug costs six figures per year.
I haven’t seen anything that low, aside from a few retail products whose annual WAC is well under $500. Not drugs with price tags in the hundreds of thousands.
Gut punch. I don’t think it’s an outlier. I've been seeing 300 percent of FPL since 2023, but I hadn't seen any manufacturer (and no, I won’t name names, but this is a big one) dip below that until now.
And honestly? Something in me snapped.
I’ll be the first to compare Patient Support strategy to a tango: payers zig, we zag. There’s something satisfying in that push-pull. No one in healthcare today is wearing a white hat, but there’s a case to be made that Jimmy Stewart is to John Wayne what Patient Support is to Pharma, standing against Lee Marvin… er, the health plans.
The Man Who Shot Liberty Valance. One of John Ford’s best.
“When the legend becomes fact, print the legend.”
We’d like to think Patient Support is John Wayne. But we’re not.
We’re Jimmy Stewart. We think we got the bad guy. We believed it was us.
But no. It was John Wayne, standing in the shadows. He wanted us to get the credit. Those optics served him better.
If this resonates, feel free to forward it or share. These conversations matter.
If you want to take out AFPs, it's not going to happen through Patient Support. It’s not going to happen by bullying Patients with 233 percent of FPL income criteria.
It’s going to happen through how you interact with self-funded employers.
It’s going to be rebate guarantees.
It’s going to be payer channel strategies.
It’s going to have nothing to do with individual Patient need and everything to do with economics.
It’s going to be about price. Capital P.
That’s not a knock on Patient Support, by the way. It’s a reality check. We’re the safety net for a system that doesn’t actually want one. We’re built to cushion the fall, not to stop the push.
So when I see PAPs shaving down eligibility to 233 percent of FPL, or when I hear another access lead say, “But we have to protect the integrity of the program,” I want to ask: integrity for whom?
Because if the answer isn’t “for the Patient,” then let’s not call it Support. Let’s call it what it is: a cost-containment strategy.
So where do we go from here?
Talk to employers. AFPs exist because self-funded employers are being sold a way to save money by quietly excluding coverage from their plans. I hear over and over again that the employers don’t fully understand what they’re signing up for when they purchase health plan coverage for their employees. I don’t think the employers are inherently evil, but I respect their savviness too much to give them the benefit of the doubt. Don’t think of this as education; do consider it a value prop.
Regardless, Pharma needs to bring them into the conversation. That might look like employer-direct coverage guarantees, or bridge programs tied to diagnosis, or data to show what happens when Patients can’t get the therapy they need. This is a channel problem. And we’ve been treating it like a charity one.
Start with the contracts. If a plan carves out a therapy, there’s no claim to rebate. So technically, no rebate is due.
But that’s not the real issue.
Plans can selectively exclude therapies, especially ultra-high-cost ones, from their pharmacy benefit to enable AFPs. But they don’t walk away from the rest of the deal.
They still maintain formulary access and preferred pricing for other products across the same book of business. Diabetes. Immunology. Oncology, if it’s not the carved-out agent. They cut Drug A, redirect the Patient, AND keep rebates on Drugs B, C, and D.
That’s the contradiction. That’s the loophole.
And most manufacturers don’t treat AFP enablement as a trigger to renegotiate the broader contract. They leave the rest of the rebate structure intact. The plan avoids costs on one end while still collecting savings on the other.
If a plan quietly removes access, they shouldn’t get to keep the rest of the perks. Price should mean something. Not just for the drug that’s excluded, but for everything else that stays.
Fix your PAP design. A Patient making $60,000 a year, two kids, no coverage, and a six-figure prescription, isn’t gaming the system. They’re being failed by it.
Too many PAPs still operate with a binary view: either you’re uninsured or you’re not. But AFPs have broken that logic. A Patient might be employed, insured, and still have no access, because their plan carved out coverage entirely.
Stop relying on outdated eligibility screens that don't account for carve-outs. Income thresholds stuck at 300 percent of FPL, or even lower, were never built for this world.
If there’s no coverage and no alternative, that Patient needs help. Full stop.
Build in flexibility.
Clear documentation of coverage denials can decrease income documentation burdens.
Consider limited-duration bridge support, tied to diagnosis.
A rigid FPL cutoff doesn't reflect what Patients are actually up against, especially in high-cost geographies or when employer coverage is effectively hollow.
If your PAP excludes them, they’re not going to appeal. They’re going to walk away. That’s not integrity. That’s attrition. And we’re letting the wrong party off the hook.
Make AFPs prove it. Don’t let them hide behind paperwork the Patient never sees. Too often, alternative funding vendors are allowed to short-circuit the process by skipping prior authorization, bypassing appeals, and redirecting the Patient straight to a manufacturer’s charity program, all without a clear denial or even an attempt to bill the plan.
That’s not how this is supposed to work.
If a Patient is uninsured, fine. If a plan truly won’t cover a therapy, fine.
But prove it. Require documentation. A real denial letter. Evidence that the claim was submitted and rejected. Not “anticipated denial.” Not “excluded class.” Not “it wouldn’t have been covered anyway.” Submit it. Get the answer.
Make it a condition of access to the Patient Assistance Program (PAP). If a third-party vendor wants to access manufacturer-funded support, the least they can do is tell the truth, not just to you, but to the Patient.
Because the Patient deserves to know:
Was the therapy truly denied, or was the process never started?
Was the claim ever submitted, or was it rerouted before the plan had a chance to weigh in?
Were options like appeals or exceptions explored?
We talk a lot about integrity in Patient Support. But integrity cuts both ways.
If a vendor is asking for free drug, on behalf of a Patient with active insurance, they should be held to the same standard as the Patient or provider: documentation, transparency, and proof.
Make it just a little harder to game the system. You don’t need a 12-step verification process. You need a first step: evidence.
And talk about it. We don’t name employers. Fine. But we can tell the story. We can show how Patients with insurance are going without care because a carve-out happened quietly and without recourse. We can talk about what it looks like when a family earning $60,000 a year is told they’re not poor enough for a PAP, even though they’ve just been told the only drug that works won’t be covered. Silence protects the status quo.
This isn’t about policing Patients. This is about fixing a hole in the system that some have figured out how to exploit. And the fix isn’t more paperwork for the Patient or another checkbox for a nurse navigator. It’s structural. Strategic. And overdue.
Patient Support can’t fix AFPs.
But Pharma can.
If we want to.
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