Patient Assistance Pivot: What’s Next for Retina Practices?
Refocusing revenue strategies after program interruptions
Bryan McGuire, Sr. Strategic Account Director, McKesson Brian Schmidt, Sr. Director, Onmark Provider Engagement, McKesson Sara Aley, Revenue Cycle Management Advisor, McKesson
Retinal disease affects millions of people in the United States each year. With medication costs rising and patient assistance programs facing financial uncertainty, it’s critically important for practices to take action to help their patients get necessary treatment and proactively adapt to changes in the marketplace.
Patients who do not receive financial assistance through a patient assistance program may be required to pay their full cost-sharing amounts. This financial burden can lead to delayed treatments, as patients try to prepare for the expense, or even cause them to cancel their retinal treatments altogether—putting their vision at serious risk.
The Impact Goes Beyond Patients’ Expenses
For healthcare providers, this situation presents additional challenges. Many are shifting to other medications, but the rising demand for these alternatives is now so high, keeping enough inventory on hand may be a challenge. At the same time, if patients delay or stop treatment, practices may experience a significant drop in income. Moreover, providers are still obligated to collect unpaid deductibles, copays, and coinsurance from Medicare and Medicare Advantage patients, adding to the administrative and financial strain on practices.
Retina Practices May Have the Best Remedies
Even amid rising costs for specialty medications and uncertain funding for patient assistance programs, there are steps that retinal disease practices can take to support patient health and finances.
Keep Looking Ahead
Practices have the power to manage the uncertainty of funding for patient assistance programs by taking charge of other clinical and business variables they can control. Because even small steps, when combined, can have a large and positive impact.
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Maintain Ongoing Conversations with Patients
In addition to ongoing clinical conversations, it’s increasingly important for providers to schedule time to counsel patients on their medical plans, financial responsibilities and insurance coverage, especially as they face uncertainty with patient assistance programs.
Communicating with patients in person and one on one can help practitioners learn what is affordable and within an individual’s budget. It can also motivate providers to stay educated and share information on new patient assistance opportunities from pharmaceutical companies; local, state or federal government programs; or patient advocacy groups. A variety of tools are available that analyze medical insurance coverages, diagnoses, treatments, Federal Poverty Level (FPL) patient percentages and more in order to intelligently match eligible patients with relevant financial assistance providers. These insights can guide informed conversations to give patients a clear understanding of their out-of-pocket costs. And, if patients have chosen to delay or discontinue therapy, it’s important for practices to reach out to understand why.
Stay Informed
Interruptions to patient assistance programs can have dramatic effects on both patients and their practices. One of the best ways for providers to prepare for possible decreases in patient assistance program funding is to stay up to speed on relevant shifts in the healthcare landscape and share that information with patients as it emerges. Retinal practitioners are encouraged to attend leading industry events, such as those of the American Academy of Ophthalmology and the American Society of Retina Specialists . In addition, subscribing to industry publications including those of the American Society of Retina Specialists,
Modern Retina and Retina Today can often provide more details into why such changes are taking place.
Leverage AI to Improve Visibility, Analytics and Accountability
In this age of advanced technology and artificial intelligence (AI), there’s no shortage of products and coaching tools that can help practices improve how they buy, track and administer high-value prescription drugs; streamline the oversight of revenue; and, importantly, gather and analyze patient data as a means of simplifying patient scheduling, optimizing treatment plans and confirming medical outcomes. Practices would benefit from revenue cycle technology designed to improve claims acceptance rates, recover every possible dollar, speed up claim reimbursements and more.
Don’t Rule Out Biosimilars
Biosimilars are a rapidly growing treatment option for physicians treating advanced diseases, with more than 20+ unique biosimilars expected to enter the U.S. healthcare market over the next decade. Despite the various differences between biosimilars and branded injections, it’s worth exploring how biosimilars might be leveraged for some patients to make treatment more affordable.
Run a Tight Ship
It’s vital for practices to manage their billing office in a disciplined manner with a thorough and consistent attention to detail — obtaining prior authorizations, providing accurate patient information, and troubleshooting coding errors prior to submission to ensure that claims are filed correctly the first time. Instead of relying on manual processes and spreadsheets, equipping an internal financial team with advanced clinical data software or a proven medical-practice management system can help ensure that they’re capturing every single charge, submitting claims in a timely manner, and receiving payments on schedule. Working with a trusted distributor can streamline the selection and implementation of optimal resources. In addition, medical practices can remain open to the possibility of payment plan options so that patients are incentivized to continue with scheduled treatments instead of terminating them because of unaffordable costs.
Implement a Strong Inventory Management System
As mentioned earlier, scaling back one’s medication inventory can help keep costs under control. Specialty distributors are great resources to tap into for this. Their internal teams, such as revenue cycle managers and account advisors, can identify the optimal balance of supply, demand and expense. Group purchasing organizations (GPOs) can also assist with inventory optimization, as well as qualification for higher rebate tiers to help practices improve profitability and financial security. Some GPOs are specifically designed for retina practices, offering tools and cloud-based technologies to help streamline the purchase and administration of high-value retinal treatment medications and provide practices with better visibility and analytics for the metrics that matter.
Regimen Profiler: Financial Analysis and Treatment Estimator
Regimen Profiler is a web-based tool that helps you evaluate the financial impact to both your specialty practice and patients by analyzing different treatment regimens and payer fee schedules. It provides a comprehensive view of expected drug and non-drug costs and reimbursement rates for administering specific regimens. With Regimen Profiler, you can access financial analytics to review and evaluate economic data for different treatment regimens, as well as prepare a written financial estimate to help patients prepare for the cost of treatment.
Glide Health: Improving claims acceptance rates
Glide health is a first-of-its-kind revenue intelligence solution leveraging AI, machine learning technology, and advanced analytics to improve claim acceptance rates. It’s the only solution on the market that dynamically predicts billing errors, ensuring your claims are approved and your practice is reimbursed faster. By analyzing your practice’s historic claims submission data, Glide catches outbound claims errors in real time and notifies your employees of the necessary changes prior to submission.
RetinaOS: A clinical workflow and inventory management technology
RetinaOS is a cloud-based clinical workflow and inventory management system built for the changing demands of today’s Retina practices. RetinaOS streamlines inventory, revenue, and payment management, transforming how practices buy, track, and administer high value prescription drugs. It helps provide better accountability, visibility, and analytics for the metrics that matter, all at the point of care.
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Sources
1 “Today’s investments, tomorrow’s breakthroughs: 2024 Macular Degeneration Research Projects.” Bright Focus Foundation. https://www.brightfocus.org/wp-content/uploads/2024/11/MDR-2024-Yearbook-WCAG-2024-2.pdf
2 “Age-Related Macular Degeneration.” National Eye Institute. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/age-related-macular-degeneration.
3 “Age-related Macular Degeneration (AMD) Fact Sheet.” Genentech. https://www.gene.com/patients/disease-education/amd-fact-sheet.
4 “Eye Disease Statistics.” National Institutes of Health / National Eye Institute. https://www.nei.nih.gov/sites/default/files/2019-04/NEI_Eye_Disease_Statistics_Factsheet_2014_V10.pdf
5 “Diabetic Macular Edema (DME) Fact Sheet.” Genentech. https://www.gene.com/patients/disease-education/diabetic-macular-edema.
6 “Understanding Retinal Vein Occlusion.” Genentech. https://www.gene.com/stories/understanding-rvo.
7 “Trends in Medicare ACO Cost and Use of Biologic Therapies to Treat Age-Related Macular Degeneration.” Institute for Accountable Care. December 2023. https://www.institute4ac.org/wp-content/uploads/2023/12/IAC_Part-B-AMD-Drugs_White-Paper_Dec-2023_FINAL.pdf
8 Veronica Salib, “The Top 5 Most Expensive FDA-Approved Gene Therapies.” Informa TechTarget. May 24, 2023. https://www.techtarget.com/pharmalifesciences/feature/The-Top-5-Most-Expensive-FDA-Approved-Gene-Therapies
The cost of common medications for these retinal eye diseases can be extremely expensive. Costs for patients can range widely based on disease state and treatment therapy — with some as low as $507 or as much as $425,0008 per injection. The financial impact on patients can be even more daunting with treatments usually scheduled monthly.
Nonprofit patient assistance programs were created to help reduce out-of-pocket costs for patients. For example, Good Days is a charitable foundation that has established a fund for retinal disease to help qualifying patients afford high-cost treatments for certain retinal diseases. As of April 2025, Good Days stopped enrolling new patients in its retinal disease fund and financial assistance for those already enrolled remained in flux. To the extent that the fund remains closed, this could significantly limit the number of patients who receive assistance with out-of-pocket costs for treatment of their retinal disease.
~1.1M
Americans are affected by Retinal vein occlusion (RVO).6
~750K
patients in the U.S. are affected by Diabetic macular edema (DME).5
~7.7M
patients suffer from diabetic retinopathy, the leading cause of blindness in working-age adults ages 20-74. That number is expected to jump to 11.3 million by 2030.4
~20M
American adults are living with age-related macular degeneration (AMD)1, a leading cause of central vision loss among older adults2 — and about 200,000 new cases are diagnosed annually in North America.3
In 2025, millions of people in the United States will be treated for some form of retinal disease.
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As a member of Onmark® Vision GPO, you can be part of a collective purchasing group to secure better pricing on crucial retina and eye disease products. This collaborative network’s goal is to deliver significant cost savings for your practice and help you get the best economics on essential retina drug products, ultimately enhancing your practice's financial health.
We work closely with our biopharma partners to negotiate better contract structures that maximize performance, aiming to provide you with the most advantageous terms and support for your needs.
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