Due to the lack of transparency of drug prices, physicians often prescribe medications with little to no information about how much the drug will cost their patient. Increased awareness could result in better treatment decision-making and ultimately, improved medication adherence and outcomes for patients. In this discussion, we’ll explore current availability and accessibility of EHR, pharmacy and payer functionalities that support transparency, where barriers exist, and what can be or is currently being done to address these barriers.
There are two scenarios: (i.) EHRs using Formulary & Benefit data (i.e. Pre-RTPB) for medication coverage requirements, and (ii.) EHRs with Real-Time Prescription Benefit (RTPB) services deployed. If the EHR is “Using Formulary & Benefit Data”, likely there is an indicator to communicate if a prior authorization review is required for a medication. Because the indicator is set at the payer, line-of-business, or plan level, the flag may represent a false positive/negative scenario for a patient/medication. If the EHR has deployed “RTPB Services”, the transaction response communicates if a prior authorization review is allowed. The RTPB communication of prior authorization requirements, at the patient level, is a fundamental capability for RTPB Services. As such, and recognizing some variability between EHRs on how a prior authorization alert is presented, it should be easy for a physician to identify if a prior authorization is allowed/required for a patient/medication.
I agree with the challenges that Roger cites above regarding the accuracy of formulary and benefit data in EHRs. False positives/negatives on prior authorization requirements for a specific drug and patient are unfortunately common due to the limitations of the traditional formulary data in EHRs. In fact, 69% of physicians in an AMA survey reported that it is difficult to determine whether a prescription or medical service requires prior authorization. (See survey summary: ama-assn.org/system/files/2019...).
As Roger mentioned, RTPB technology holds the promise to make prior authorization requirements much more transparent at the point of prescribing. Improved transparency of formulary structure and utilization management requirements was a topic of discussion throughout yesterday's House Committee on Energy & Commerce hearing titled, “Lowering Prescription Drug Prices: Deconstructing the Drug Supply Chain." A video recording of the hearing is available here: energycommerce.house.gov/commi...
In my primary care private practice which uses Amazing Charts EHR, it is not. Having such information available at the time of writing the script would be beneficial. Currently, we can easily e-prescribe to our patient's preferred pharmacy, but that is the extent of our prescription specificity.
Many EHR's, including Allscripts do present information on drug tiering and coverage, through use of the coverage and copay files which accompany the formulary information sent from the PBM's and health plans. This information can be helpful in a general way, but does not eliminate the need for true price transparency.
EHR's update formulary information regularly. Most EHR systems update formulary information on a weekly basis. One of the biggest challenges with formulary information is that the information is at the healthplan group level, and drug coverage for an individual can vary, particularly with the need for prior authorization of a medication. For EHR systems with electronic prior authorization capability, this can lead to 'false positive' prior authorization alerts and initiation of a prior authorization processes, which are not needed. Price transparency features often include prior authorization information which is patient/drug/pharmacy specific and more reliable than plan coverage information available through formulary information.
There are many companies focused on the exchange of real-time prescription benefit information. Focus areas include: Integration of Patient/PBM communications, Integration of Provider/PBM communications, and Integration of Pharmacy/PBM communications, including Specialty Pharmacy. Integrations are further divided into companies that exchange/facilitate the exchange of real-time prescription benefit data and those that provide value added services, including content.
IMO this does not yield a simple answer since we are very early in rolling out this function. The application of AI has great potential but the politics and economics of our competitive landscape have created some obstacles that still exist.
The technical part is less difficult, particularly now that HHS has started to promote greater standardization of Web friendly APIs, e.g. the HL7 FHIR API to start. Also, private sector PBMs and Healthplans are more open to AI than in the past.
Looking forward it would be helpful to have a tool that would notify the physician office support staff whenever there is a breakthrough in cost effectiveness for a class of patients with selected diagnoses. This could also apply to an individual patient whose specific healthplan has recently offered a significantly lower cost drug as an alternative to what is currently prescribed.
There could be many other examples, but we must be careful about not loading up the clinical office "Inbox" with messages that are not relevant or are disguised advertisements
I agree with Dr. Sullivan's response that a simple answer does not exist and recognize the potential. That being said, I expect AI will intersect patient data, prescriber data, and medication data, including patient cost information to identify the scenarios that will drive desired outcomes like medication adoption and adherence.
While adoption is very early, there will likely be a role for AI in price transparency. The value that price transparency has in prescribing process and choices that patients have as consumers will guide the industry to continue to evolve price transparency solutions.
Two key aspects of the importance drug transparency in value-based care are adherence and total cost of care.
Medication cost is a critical factor in medication non-adherence. (cdc.gov/nchs/products/databrie...) One study demonstrated that a drug with a co-pay of more than $50 was 4.7 times more likely to be abandoned at the pharmacy compared to a drug with no co-pay. (Shrank WH, Choudhry NK, Fischer MA, Avorn J, Powell M, Schneeweiss S, et al. The Epidemiology of Prescriptions Abandoned at the Pharmacy. Ann Intern Med. 2010;153:633–640.) Achieving success with value-based care outcome measures for diabetes, hypertension and others is directly related to medication adherence. Any tool that can lower medication costs for the patient should lead to improved adherence and outcomes.
Accountable care organizations and other population health models are focused on total medical cost, and medication non-adherence is associated with substantially higher total cost of care. (Cutler RL, Fernandez-Llimos F, Frommer M, et al Economic impact of medication non-adherence by disease groups: a systematic review BMJ Open 2018;8:e016982. doi: 10.1136/bmjopen-2017-016982.) In addition, when an organization is at risk for overall drug spend, price transparency tools should be directly aligned with the patient’s benefit plan and show alternatives that are lower in cost to both the patient and to the plan.
A critical role for EHR vendors is to ensure the information is presented directly in the prescribing workflow with little or ideally no extra work by the providers to see the information. In addition, when an alternative is selected, the EHR should prepopulate the alternative prescription order with as much information as safely possible, again to minimize the amount of extra work a provider has to do to select the less expensive medication.
I agree that EHRs need to focus on making this information easily consumable and actionable for end users. As has been discussed via other questions in this forum, there are a number of different potential inputs when determining cost for a prescription. I get worried a little bit thinking about all the different data that could be displayed and the mental gymnastics a prescriber may have to go through to consume and take action on that data. Focus should be put on identifying the most pertinent information to display and also making it easy to switch to any alternative medications that could also be presented.
I agree that EHRs play a vital role in facilitating drug pricing transparency at the point of care. Because there are many different EHR products on the market, as well as a variety of prescription drug plans, it is important that the industry develop a standard way to exchange drug pricing and formulary benefit information in real time at the point of care. That's why the National Council for Prescription Drug Programs (NCPDP) has been developing a real-time pharmacy benefit (RTPB) electronic standard.
I agree that EHRs play a vital role in facilitating drug pricing transparency at the point of care, and it is critical this information is relayed in a standardized way. NCPDP has been working on the RTPB standard for a few years and is nearing completion of this standard. The standard will support two formats (EDI & XML) within a single implementation guide. The standard will establish patient eligibility, product coverage, and benefit financials for a chosen product, as well as identify coverage restrictions, alternative products, and benefit alternatives when they exist. Anyone interested, including non-NCPDP members, can review the standard under development and provide comments. Please use this link to register as a new user to review the draft standard: dms.ncpdp.org/index.php/new-us...
Electronic Health Record (EHR) vendors play a critical role in the adoption and acceptance of real-time prescription benefit (RTPB) processing. Consistent with the previous comments, successful RTPB adoption of RTPB processing must include: (i.) Automated delivery of an RTPB Request for Information for each contemplated new medication, (ii.) Presentation of the RTPB Response Information into a logical workflow step that does not require a prescriber to take an additional step to access (i.e. right information at the right time), (iii.) Displaying the RTPB Response information in a consistent manner to facilitate processing adoption, (iv.) Make it easy to select an Alternative Medication, select an Alternate Pharmacy, and/or change a medication quantity, and (v.) Ensure that RTPB Response information is presented prior to the e-prescribing workflow steps.
EHR vendors should play a very active role not only in the presentation of information but also as actively work with organizations to provide information that will be reflective of the price that the patient will actually pay at the pharmacy counter. For example, when medications are available generically, EHR vendors should build logic into their systems to request the price for the generic version of the medication from the pharmacy benefit manager unless the prescriber has indicated that brand is medically necessary.
Are there any “financial scripts” that can be shared with providers to help them initiate a conversation about medication price and alternatives?
Make certain you first address the main reason for the visit. Next, there are several simple questions to open the conversation.
For example, "Has the cost of your medication caused you to skip taking it at any point?" ..or "Are you paying more than $30-50 for a 90 day supply for any of your meds?" Even if the patient says "No" to these or similar questions, you can inform him/her there are new tools to make it easy to discover the co-pays and potentially lower cost alternatives.
Be sure to remind the patient to contact you if they decide to stop taking the medication as prescribed and be willing to consider altering the treatment plan, if appropriate.
Other answers in this forum get into the details of the next steps.
Perhaps from a similar resource as GoodRx does. Where do they or others like GoodRx get their data on local cost of drugs?
Electronic Health Records (EHRs) should pull drug pricing information from the Pharmacy Benefit Manager (PBM) corresponding to the patient’s pharmacy benefit if they have pharmacy benefit coverage or from one of several commercial sources for cash prescription prices if the patient uninsured or underinsured. The request for drug price information should be a real-time exchange between the EHR and the PBM and take less than 3 seconds. PBMs are the source of truth for patient specific benefit information, including copays, co-insurance, deductibles, coverage gap, and prior authorization tracking of information.
Agree with Roger. The most accurate price will come from the PBM. While there can be some discrepancies based on timing (i.e. other claims come in to the PBM between the time the prescription is written and the time the prescription is picked up) this is the only way to accurately know what a patient’s out of pocket cost will be when the patient has insurance.
I agree with everyone above. To best determine patient out of pocket costs, it is critical to have patient benefit/coverage information available. PBMs and health plans are best situated to provide important information to best inform treatment decision that need to be mindful of a patient's financial situation. For patients without health insurance forced to pay list prices, that price information would need to come from a pharmacy or directly from the manufacturer.
I agree also with every comment. PBMs and health insurers must agree to transparency if we are going to make any headway in the sky rocketing drug pricing problem.
I have just a couple of comments to add here where I feel that additional data sources are needed to ensure that information is recent, accurate, and complete. First, with the growth in the specialty drug market, insurers will need to provide transparency into the cost of drugs covered under a patients medical benefit in addition to medications covered under the patients pharmacy benefit. Secondly, information about the cash price of medications should be included as patients on high deductible plans may be paying out of pocket for medications.
A Real-Time Prescription Benefit (RTPB) is a standard format used to exchange data between providers and pharmacy claims processors in real-time: (i.) A Provider, prescriber or pharmacist, originates a Request from their practice management system, (ii.) A Pharmacy Claims Processor adjudicates the Request and communicates a Response in real-time, and (iii.) The practice management software (e.g. EHR or pharmacy system) receives the Response and presents the details in the providers workflow
Yes, RTPB transactions are being used to provide cost transparency visibility.
Great question Stacy and thank you Roger for describing what RTPB is and pointing out some of the benefits. The AMA is currently working on a resource that will explain what RTPB is and describe some of the many benefits of RTPB. Be on the lookout for this resource in the coming weeks.