The reality of real-time benefit check solutions and the importance of provider adoption

Real-time benefit check (RTBC) is a relatively new technology that can help address the challenges of rising patient share of medication costs and medication non-adherence by surfacing prescription benefit details for patients and providers at the point of prescribing.

 As with any new technology, it is difficult in the early market development phase to know with certainty what will prove to be the right solution. We spent time with CoverMyMeds’ SVP and General Manager of Provider Solutions, Scott Gaines, to gain perspective on what RTBC stakeholders should consider when implementing a solution, why provider adoption is critical to its success and what it takes to gain that adoption.

The industry is buzzing with talk of real-time benefit check. There’s a lot of noise right now in the space. How would you break down the why and how of this relatively new concept?

The question often asked is, “why now?” What has changed to make supplying real-time, patient specific medication benefit and price information available in the provider workflow? The answer is complicated, but includes insurance benefit designs, medication affordability and access challenges. Patients are increasingly being encouraged to act like consumers of health care through the implementation of high-deductible health plans and growing copays, which is resulting in significantly higher out of pocket costs for patients. From 2006 to 2016, worker contribution of health care expenses increased 78 percent. With increasing costs, patients are naturally more interested in evaluating their options. Forty-six percent of patients recently indicated they are evaluating different options to find a cost they can afford, so there is a clear need and desire for patients to become better health care consumers.

Unfortunately, patients usually lack the information they need to make consumption choices about their prescriptions. New health care technology offerings and advancements in technology in general provide potential pathways for patients to become true consumers of their care, yet we have not seen evidence of adoption or effectiveness in terms of improving access to medications. Half of patients are still abandoning a medication because they discovered it was too expensive when they arrived at the pharmacy. This implies that patients do not have access to benefit and pricing information from a website, app or their care provider, or they do have access to information and but it is incomplete. The result is potential therapy delays and non-adherence risk. Medication non-adherence is costing the health care industry nearly $289 billion dollars a year. Additionally, ten percent of hospitalizations could be prevented if a patient had been able to adhere to a medication therapy. Real-time benefit check and price transparency can address these issues by providing information to prescribers, who can make more informed decisions and discuss therapy options with their patients earlier in the process.

What is required to make real-time benefit check successful in the industry?

Provider adoption is essential to success, but every stakeholder can contribute to and benefit from supporting RTBC to improve patient access to medications. Payers want better means to manage patient health on an individual basis. They view RTBC as an investment with a potential return beyond impact to drug spend, to reducing medication abandonment and improving patient outcomes. Eighty-nine percent of payers are currently committed to an RTBC solution, which seems unprecedented so early on in a product’s life cycle.  

Pharmacies are interested in reducing the frustration and disruption associated with cost and coverage surprises, and ensuring their patients adhere to medications they dispense. Forty-five percent of pharmacies are participating in an RTBC solution because pharmacists see firsthand the impact of patients being aware of cash price and any pharmacy programs that improve affordability and access. Similarly, pharmaceutical manufacturers are interested in ensuring patients have better visibility into existing assistance and affordability programs.

Arguably the most important stakeholder other than the patient is the care provider. The success of RTBC and price transparency efforts is dependent on provider adoption. An example to illustrate the point is the current formulary and benefit (F&B) model. On average, providers scored trust in F&B data a problematic 5.7 out of 10, indicating they often don’t rely on the information to make decisions or inform patients. Real-time benefit check must be dramatically better than current F&B information in terms of accuracy and completeness to earn provider trust and adoption. Industry stakeholders must also engage providers to solicit feedback on what information is most valuable, how and where they prefer to consume it, and what would ensure that providers share insights with their patients. When asked what would prompt providers to use an RTBC solution, they identify five key insights that should be available in workflow, including: medication alternatives, cash price at the pharmacy, patient assistance and affordability programs, patient out-of-pocket cost (in addition to insurance) and an indication if prior authorization (PA) is required. Additional data and workflow changes should be designed to reduce the cognitive load and administrative burden associated with prescribing medications.  

What is the difference between RxBenefit Clarity and other RTBC models?  

While each implementation model centers around the same need (supply providers with prescription information to share with their patients), an open network is the only option that provides a 360-degree view for the patient. While the majority of RTBC intermediaries support payer alternatives and out-of-pocket costs to some degree, the information offered is incomplete. RxBenefit Clarity combines benefit information, such as plan alternatives, PA requirements and deductibles, with pharmacy-specific pricing, including generic programs and cash price outside of insurance, as well as patient assistance programs. Most of this information has not been available at the point of prescribing and cannot be provided without the contribution of all stakeholders.

The 2018 Real-Time Benefit Check National Adoption Scorecard,  which is developed with a group of industry advisors and experts, does a great job of breaking down the different implementation models on the market, and capabilities of each of the solutions. For example, while a payer network offers patient out-of-pocket cost and alternatives, it doesn’t provide insight into patient affordability programs or cash price at the pharmacy like an open network could. Providers have identified these as factors that could impact adoption of an RTBC solution.

The network CoverMyMeds has built for its successful ePA solution was critical for RxBenefit Clarity as well. Can you talk a bit about that?

Our network is built upon a foundation of understanding the pain points of medication access for providers. By studying user behaviors and gathering insight from those who feel these burdens on a daily basis, we’ve tailored solutions to their workflows and addressed significant barriers to their patient’s well-being. With electronic prior authorization (ePA), we developed an approach to a large problem where everyone wins by including the entire network of providers, pharmacies, pharmaceutical manufacturers and health plans. Through these partnerships we were able to fill in existing gaps to make it a solution that works for all medications. We’re applying a similar strategy with RTBC, leveraging this same network and meeting providers where they need decision support most, which is before the point of prescription submission. We are working with partners to fill in gaps here as well, by maximizing the amount of prescriptions accessible with RTBC with features like benefit eligibility completion, pharmacy dispense history and cash price outside of the patient’s insurance. We’ve found that including this data expanded our reach by 26 percent within one of our EHR partner’s implementations.

Our goal is that each patient knows the price of their medication at their pharmacy of choice, avoiding surprises and sticker shock. Patients should be able to fill a prescription at a price they can afford and go about their day. With RxBenefit Clarity, a provider and patient can determine the best price for a medication through co-pay and deductible information, cash price outside of insurance and availability of patient-assistance programs, as well as other valuable information such as PA requirements.

What is the plan for you and the team at HIMSS this year?

We’re hosting a panel to discuss “Industry Trends for Price Transparency at the Point of Prescribing” on Wednesday, February 13 from 3 to 4 p.m. at booth 3278. The panel will include leaders from top EHRs and health systems to share insights on RTBC. I also encourage you to stop by our booth to speak with one of our experts.


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