Real-Time Prescription Benefit Checks Could Provide Accurate Cost Estimates at the Point of Prescribing

Leveraging technology to perform real-time prescription benefit checks could give patients and providers personalized cost knowledge when a drug is being prescribed, but standardization of the process is needed for wider uptake, according to a session at the Academy of Managed Care Pharmacy Managed Care & Specialty Pharmacy Annual Meeting.

Currently, medications are prescribed with limited knowledge of their costs, but prescribers want to know this information and tend to respond when they are given cost estimates and differently priced options, said Roger G. Pinsonneault, RPh, vice president, product innovation, Gemini Health. With the increase in prescription tiers, coinsurance, and deductibles, prescribers cannot assess patient-level costs from just a formulary.

When a patient arrives at a pharmacy and is asked to pay an exorbitant amount for their prescription, this creates “a horror story for the prescriber,” Pinsonneault said, especially as providers are more commonly being held accountable for outcomes like adherence and drug spending.

Similarly, having a patient turn down a prescription due to unanticipated costs disrupts the workflow in the pharmacy and can bring down the pharmacy’s satisfaction ratings. While payers looking to decelerate growth in pharmacy spending have turned to utilization management methods like prior authorization (PA), this “is sort of a sledgehammer approach, and it has become burdensome to patients, prescribers, and for payers, their relationships with their prescriber communities,” Pinsonneault said.

Instead, a solution that could help align each of these stakeholders’ goals is to use a process of real-time benefit checks to deliver individual cost information to the prescriber at the point of care. First, a prescriber determines a medication to prescribe, then queries the benefit check system to request an estimate; the system delivers a response from the pharmacy benefit manager (PBM) within 2 to 4 seconds. This allows the prescriber and patient to have a conversation about whether the cost is feasible, and ultimately the physician can send a prescription to the pharmacy through that system.

Pinsonneault explained that the information transmitted to the prescriber extends beyond a single price: It flags any coverage alerts that apply to the chosen drug, like PA, quantity limits, or step therapy; shows differences in costs by channel (eg, retail, 90-day supply, mail order, specialty pharmacy); breaks down patient out-of-pocket costs and deductible information; and presents alternative drug choices that may have preferred formulary status or incur lower cost to the patient.

In effect, not only does this system provide data about coverage and costs, it helps prescribers answer secondary questions around why a certain drug may not be covered and whether therapeutic alternatives are clinically and financially acceptable.

The advantages of such a tool are clear, but he noted that there is debate on the best format for displaying this abundance of information within the prescriber’s electronic workflow on a screen with limited real estate. For instance, there is ongoing debate on the right number of alternatives to display; some options support showing up to 10, but that might be overkill in some cases.

Until an industry standard is developed, most implementations of the real-time benefit check concept have been interim solutions. The most rudimentary of these lack patient deductible information or alternative fulfillment options, making them “minimally viable,” Pinsonneault said. The most current technology uses proprietary e-prescribing systems to align with existing prescribing transactions within electronic health records (EHRs), which he described as being “focused more on the prescriber and where the industry is headed.”

While there is not yet a universal standard for real-time prescription benefit checks, the topic is being addressed by CMS, said Jacqueline Hager, BS, product manager, Surescripts. A proposed rule for 2020 will adjust the Medicare Advantage program and Part D regulations to support drug price transparency and ultimately reduce enrollees’ out-of-pocket drug costs.

The components of the real-time benefit check tool outlined in the rule include many of the key points that Pinsonneault mentioned: providing patient-specific cost-sharing information within the EHR, identifying clinically appropriate alternatives, and displaying utilization management tools like PA flags and quantity limits. Additionally, the CMS rule says that patients should consent to run this transaction and display co-payment amounts, and the rule proposes, but does not require, showing the plan-negotiated drug price plus the patient co-pay cost to show providers the overall cost of a drug.

“It’s trying to find that sweet spot of information that, within those 30 seconds, the prescriber can make the best choice for the patient and the overall best choice for Medicare or any other PBM,” Hager said.

She also presented evidence on the outcomes of having access to that information. For instance, one real-time benefit check informed a prescriber that the requested medication would cost the patient $1775.84 at the patient’s preferred pharmacy, but the same prescription was available for $125 through the PBM’s mail order pharmacy.

While PA will not vanish completely, Surescripts’ implementation of real-time benefit checks found that providers are choosing a drug without PA 28% of the time when they had the opportunity, saving 158,000 hours of potential wait time and avoiding the intangible feelings of frustration when a patient arrives at the pharmacy to find that their prescription is not ready.

Surescripts data show that the average cost savings, when there was an opportunity to save money, ranged from $21 per cardiology prescription to $228 per psychiatry prescription. Hager predicted that prescribers will adapt to having this cost information at hand and change their prescribing habits, just like the adjustment in past decades to prescribe generics instead of branded drugs.

In action, she said, practices implementing real-time prescription benefit checks need to empower the entire care team to have sensitive conversations with patients about the costs of care. For instance, if a patient reports experiencing financial stress, the nurse could add a prompt in the EHR so the physician knows to be cost-conscious at the moment of prescribing.

As these benefit checks are standardized and more widely adopted, Hager predicted that benefits would accrue to patients, prescribers, pharmacists, and payers. “They’re all going to have a little bit different needs, but the goal is that across all stakeholders, there’s value,” she concluded.