How to Lose a Site in 10 Ways
Survey Insights on Investigator Grant Payments
In 2003, the movie How to Lose a Guy in 10 Days was released. I remember watching as the lead character committed various dating “sins” (on purpose and concealing her true intentions from the man she was dating) to showcase all the things many people do wrong in a relationship. Unknown to her, the man also had underlying intentions that he was not communicating. The relationship lacked transparency and communication – resulting in its failure (until the end, of course, when the truth came out and the two reconciled as they must in any romantic comedy).
Sadly, this lack of transparency and communication is not just something that occurs in movies; it happens in everyday relationships, including those between sites and sponsors/CROs. However, unlike in the movie, it is typically not an underlying motive that causes the disconnect, but rather a lack of opportunity or medium for the parties to communicate.
In partnership with the Society for Clinical Research Sites, Greenphire has conducted a survey1 to hear directly from sites regarding Investigator Grant Payments. As such, we would like to share insights from the survey and suggestions for improving site satisfaction as it relates to invoicing and payment processes.
Why are so few sites (26%) satisfied with the current invoicing process? What are the challenges they are facing? I dug into the results more and found some trends. So, here is a list of 10 things sites say sponsors and/or CROs do that add stress to the relationship.
- Pay quarterly (or less frequently)
From a separate survey2, we know that 89% of sites prefer to be paid more frequently – yet there continues to be a resistance to switch to payments more frequent than quarterly.
For sites outside the United States (OUS), 79% are contracted to be paid quarterly or less frequently. Even in the United States, it is quite common with 42% of sites reporting quarterly payment schedules to be the standard.
What you can do to help as a sponsor/CRO: Contract to pay sites monthly (or even more frequently).
- Pay late
Cash flow is a major issue for many sites. In fact, 67% of sites have 3 months or less operating cash, and 81% have less than 6 months.3 Getting paid quarterly would put a strain on the site’s cash flow, but the problem is even though they are contracted to be paid quarterly, many sites report being paid even less frequently.
Of the OUS sites contracted to be paid quarterly, 52% report being paid less than 4 times per year. For budgets that were already tight, late payments put even more stress on the site’s ability to operate as a business.
What you can do to help as a sponsor/CRO: Pay sites as quickly as possible. With automated technology many sponsors and CROs pay within 1 business day of being invoiced.
- Pay on monitored data
The survey showed that “Length of time to get paid” was a challenge for 99% of sites. (Yes, there were 4 sites out of the 286 who answered the question that did not think it was a challenge.) One of the contributing factors to the length of time to get paid is waiting for the data to be monitored or verified prior to paying the site for the visit/activity.
Data quality and accuracy is of the utmost importance – however, waiting to verify data prior to marking it eligible for payment typically delays the time between the visit/activity being completed and the payment arriving at the site. These delays can compound the issues previously discussed around quarterly/late payments – resulting in (what I have heard from a few different sponsors/CROS) AVERAGES of 6 months between activity/visit completion date and payment date. Could you imagine starting a new job in January, but not getting your first paycheck until July? That is what it is like for many sites.
Naturally, this problem is even further exacerbated during COVID-19 where travel is greatly restricted, and many sites are unable to have monitors on site.
What you can do to help as a sponsor/CRO: Pay sites based on activity/visits entered. You can minimize the risk of overpayment by automating the credit/corrective actions process once data has been monitored if any discrepancies are found.
- Pay the minimum
Many sites accept the budgets presented to them during the negotiation process – regardless of where it falls on the FMV spectrum, how much overhead is included, or what administrative fees are missing. As one site commented to me during a webinar, these budgets “will cause sites to go into debt.”
One survey respondent noted, “We are currently considering advising a sponsor that we cannot continue to conduct the study at our site due to the financial loss associated with the study.”
What you can do to help as a sponsor/CRO: When setting your budget parameters, include feedback from internal Clinical / Operations teams and accommodate local budget subject-matter expertise to ensure the parameters adequately reflect effort associated with implementing subject-level effort onsite.
- Neglect automated technology
Dozens of automated technologies exist to make clinical trials run smoother, and most sites prefer for sponsors/CROS to provide them on the study.
In fact, 97% of sites see a benefit in automating their invoice process, and 78% indicate that they would rather work with a sponsor or CRO who invests in technology to alleviate invoicing challenges.
Despite the overwhelming preference for automation, over 60% of all sites, and 86% of sites in central/eastern Europe, are still relying on manual and outdated invoicing payment processes. The 38% who reported using “automated” technology to manage invoicing processes noted using technologies not designed specifically for invoice and payment management. Some sites even listed Microsoft Excel as their payment “technology.”
What you can do to help as a sponsor/CRO: Partner with a site payment technology to add automation to the process and reduce the burden on sites.
- Neglect justification for automated technology
We once had a survey2 question that asked sites how many portals or applications they worked with for each study. Many of the responses were both alarming and hilarious.
“too numerous to count”
“damn a lot”
And my personal favorite – “7 – an absolutely ridiculous amount”
Technology for the sake of technology is not helpful. When you also consider that 81% of sites are conducting 6 or more studies and 35% are conducting more than 21 studies(!) you can imagine how the number of portals and applications to track, learn, and manage is overwhelming for sites.
What you can do to help as a sponsor/CRO: Provide an overview of the technology, the benefits for the site, the plan for training/educating them on how to use it, and follow through and deliver the training to help the site be successful in utilizing the technology.
- Withhold data
Over the years I have become quite adept at managing our household’s budget. At any point in time, I can log in to my accounts and check my balance and/or any amounts owed. This allows me to appropriately plan the upcoming days, weeks, and months so that we can afford our lifestyle.
Similarly, sites need access and transparency to both their history and upcoming payments. What have they already been paid for? What visits have already occurred but haven’t been paid yet? Answers to these questions allow sites to understand the past and plan for the future.
What you can do to help as a sponsor/CRO: Provide access to payment history, visits completed but not yet paid, contracted rates, and other items necessary to allow sites to appropriately track and predict site payments.
- Assume homogeneity
Treating sites identically, across the board, will lead to lower quality experiences and relationships.
Respondents to the survey were asked what country they were from, allowing us to filter the results and compare across the world. Unsurprisingly, some of the results were significantly different from one country to another. For example, 57% of Polish respondents noted that managing pass-through costs was very or extremely challenging, but only 36% of respondents from the United States felt the same way.
In addition to variances across countries, even respondents within the same country had drastically different opinions and experiences. Each site, and person, is unique and has their own people, process, and tools leading to an overall experience – sometimes making something “extremely challenging” for one site but “not at all challenging” for another.
What you can do to help as a sponsor/CRO: Provide systems and processes that account for local variances, like split payments in Poland, VAT/GST taxes AND site/payee-specific needs like desired payment frequencies or invoice upload options.
- Pay without remittance
Inevitably, on every study, there is always someone from finance at the site that receives a deposit/payment but cannot figure out what study it is for or what visits, procedures, or invoiceables are being paid. 80% of respondents noted that a lack of “transparency into amount being paid and what it is for” was a challenge. Without remittance, finance personnel must spend time to track down what the payment was for to appropriately manage the site’s finances.
What you can do to help as a sponsor/CRO: Provide systems and processes that automate remittance, allowing emails to be sent or official documentation to be reviewed/downloaded noting exactly what invoices are being paid and what visits, procedures, and invoiceables are included. Ideally, access to this information can be provided to multiple site personnel as needed.
- Limit flexibility
Have you ever completed a clinical trial without an amendment?
If the answer is yes, then please publish what you did so that everyone else can learn from your wizardry.
For the rest of us who answered no, we know the importance of flexibility. Traditionally, clinical trials are ever changing – requiring amendments, updates in service offerings, and various approaches to bring a clinical trial successfully to the finish line. For the past few months, the demands for flexibility have increased due to COVID-19.
For some sites pre-existing cash flow issues have gotten worse and for other sites, issues they have never experienced before are putting financial strain on their budgets. Sponsors and CROs that lack the flexibility to address these issues are putting extra burden (sometimes unnecessarily) on the sites.
What you can do to help as a sponsor/CRO: Release holdback, send prepayments or advances to be drawn down upon at future visits, or increase your payment frequency so sites get paid weekly or monthly.
I vividly remember a conversation I had recently with the CEO of a bio-tech company. We were talking about software options for his upcoming trials and he paused the conversation to ask how it would impact his sites because “at the end of the day, sites are our customers.” He wanted to make sure what he was doing to benefit his company would also benefit the sites.
This sentiment is prevalent in so many of the conversations I have with our clients. Sponsors and CROs care about the site experience but may just lack the insight into how they can improve it.
Instead of ‘losing a site in 10 ways’, take action to win them over with trust, transparency, and communication. Build a positive and lasting relationship that will ensure a romantic comedy-like happy ending.
12019 SCRS Greenphire Investigator Payments Global Challenges Survey, n=286 for most, n=211 for satisfaction question
22018 SCRS Greenphire Site Financial Challenges Survey, n=356
32019 SCRS Global Summit Landscape Survey, n=226
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