Adoption Barriers - Stakeholder specific barriers to cost transparency adoption include: (i.) Electronic Health Records (EHRs) - Software development, workflow integration, PBM integration, allocation of screen real-estate, and financial investment justification (ii.) Pharmacy Benefit Managers (PBMs) – Software development, alternatives identification, and integration with EHRs.

Stakeholder Benefits – Stakeholder specific benefits include: (i.) Patients – Lower cost of medication care, quicker initiation of medication therapy, and better adherence to medication therapy, (ii.) Payers – lower cost of care, better adherence to medication therapy, & (iii.) Prescribers – Improved productivity, and improved patient outcomes.

The most significant barriers are creating and curating the network connections and interfaces necessary to provide real-time pricing details at the point of order, when the patient is still in the room with the provider. This means accurate, up-to-date information from the PBM, and identifying in the moment the total out-of-pocket cost to the patient.
Roger makes a great point regarding alternatives - whether generic form or a completely different medication. Again, information that's most useful at the time of the encounter.
Ultimately, the provider, the EHR vendor, the PBM manager, care managers, and everyone else in this process is working to assure success for the patient, who is the most important stakeholder involved. Their ability to adhere to the prescribed regimen without adverse financial impact is paramount.

The barriers were seemingly insurmountable, as mentioned in the two prior responses. However,in the past year and especially the last 2-3 months considerable progress has been achieved. DrFirst (I have done the beta testing as a staff physician) pioneered this with Humana over the past 12-18 months and more recently, Surescripts has added a feature that makes Real Time Benefit Checks (RTBC) a widespread function. Most physicians are still unaware, but this will go viral soon. T
This benefits all stakeholders but especially patients. Even CMS is now very interested and asking for assistance to roll this out.

The ability to check the prescription benefit and determine the actual cost to the patient will remove a significant barrier to pricing transparency. As Thomas describes, this is being addressed and will allow a candid conversation between the prescriber and patient about the cost of treatment. If necessary, discussions about alternative treatment options can occur in real time with the patient present as opposed to an asynchronous interaction between prescribers, pharmacists, and patients.

All three stakeholders benefit: prescribers can address pricing and benefit issues at the point of care rather than having to address them after the patient goes to the pharmacy. Patients benefit by having a clear understanding of their treatment before leaving their prescriber's office. Pharmacists benefit by spending more time focused on patient care and education and less time addressing denied adjudication claims or talking to patients who have "sticker shock" due to high out-of-pocket prices.

I think that one big, looming challenge for the industry is building solutions that allow physicians to access real-time pharmacy benefit data across all patients/all PBMs. Right now, many products only support certain EHR/PBM combinations, which limits their utility and will no doubt frustrate physician users, who need this information for all of their patients.

I agree with what everyone has said above about who benefits -- we all do! This technology is win-win-win-win for all stakeholders. Physicians and patients obviously benefit from information that supports informed discussions on drug selection and costs at the time of prescribing. Pharmacists benefit from not being faced with prescriptions they can't fill due to unmet prior authorization requirements -- or unhappy patients learning about costly co-pays at the pharmacy counter. And PBMs benefit, as physicians have information about formulary structure and preferences when they prescribe. This is complicated technology, particularly as prescription benefit designs get more and more complex -- but the advantages of building these tools (and doing it right) are great.

Knowing the cost of a drug is important. Affordability to a patient is the next critical concept in ultimate acquisition of a medication then adherence to its consumption (The prescription). What is affordable by one patient is not by another. With high variability amongst drug plans (from 100% coverage to 100% deductibles), I propose the concept of developing an algorithm/formula that helps automates the affordability of medications based on patient's individual economics. Ideally, this would be module in the EHR based on open standards. The end product would inform physicians in the EHR of cost and affordability.

For me the biggest difference in my practice has been access to websites and smartphone apps that easily display cash pay price (and co-pay prices in some circumstances) for drugs and allow folks to compare prices at local pharmacies. In many cases the cash-pay price beats the patients co-pay. GoodRx, LowestMed, Blink etc. have transformed the issue of drug price transparency.

My favorite anecdote is a story where one physician detailed to us how they communicated the price of a prescription to one of their patients based on our price transparency solution. The patient then went to pick their prescription up from the pharmacy where the pharmacist told them a different price. The patient said, "No, that's not right, my doctor told me $X". The pharmacist re-ran the claim with the patients other health plan, and lo and behold, the price the physician had told the patient was correct and lower than the original price quoted by the pharmacy.

I think that anecdote illustrates how embedding price transparency at the point of care can help equip and empower patients, not to mention build trust between the patient and their doctor.

It is important to include the payer financial responsibility (price paid by the plan) in the information shown to the prescriber. For some prescribers, the information is an eye-opener.

I agree with Roger. While accessing the patient's financial responsibility is obviously critical, physicians also need to know the cost to the plan -- particularly as we move to value-based and other types of new payment models. If physicians are going to be held accountable for managing a patient's overall health care costs, they need to know the total cost of the drug to the plan. Unfortunately, we've heard that this may be a challenge for real-time pharmacy benefit technologies, as plan costs may be considered proprietary contract data. Thoughts on how to overcome this and include plan costs in EHR drug pricing data?

If we are talking true transparency, Pharmacy benefit plans (PBMs) must be addressed. They need to be at the table as we seek resolution of the drug price crisis. Without them giving full disclosure on costs to patients and insurers, that aspect of quality measures in the value-based payment system evolution will not be successful.

I don't think the cost to the healthplan is as important to the prescriber as is the cost to the patient. However, anyone who helps manage the physician's practice (particularly in the larger groups that are common now) should see those costs. In a large group that has the possibility to negotiate with the health systems or with the payors, knowing the gap between the payor cost and the patient cost is an import negotiating tool.

Typically, primary care physicians and a few other specialists are prepared. However, since the "real time benefit check" is quite new and there are a few "bugs" in the system, not everyone is prepared or familiar with this recent feature of EHR systems.
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Also, if the patient daily visit load is very heavy, there is little time to discuss actual drug prices, though this also depends on the specific medication prescribed.
If the physician has a trained and experienced clinical staff, some of this can be offloaded to "the team" allowing the physician to concentrate on more complex issues despite the growing importance of price transparency.
Properly balancing the clinicians' workflow and modifying/improving the clinical IT UI/UX will always be needed given the rapidly changing nature of healthcare delivery.

(Slightly off topic) Finally the incentives to change must be aligned so there is a "win win" for all parties. Right now, it appears that physicians involved with direct care are not on equal footing with many intermediaries designing these paradigm shifts.

I'm an optimist so I feel the balance will be restored sooner or later.

I agree that in primary care with the help of office staff medication prices can be optimally reviewed and considered during visits, provided the EHR is capable of that. However, not all EHRs are and there are a lot of other activities already being asked of staff. Medication price is but one more task for them, which without this capability in our EHR, will be perhaps "the straw that breaks..."

I think having the ability to compare relative prices is useful in making decisions between different therapies, especially considering older generic drugs vs. new-to-market drugs that may cost more.

The challenge is knowing which price is included in the EHR and how it relates to what the patient will actually pay. Is it the Average Wholesale Price (AWP)? Wholesale Acquisition Cost (WAC)? Is it the price the pharmacy pays the wholesaler? Is it the cash price if the patient has no insurance? The last two are unlikely since they will vary from store to store, but they are likely the most meaningful to the patient. Other factors include whether patients have met their deductible or if they've hit their annual out-of-pocket maximum.

Confused yet? Without running a test claim for the drug, it's very difficult to know exactly what the patient will actually pay for the medication.

There can be a significant difference between drug "price" and a patient's out-of-pocket cost. The latter is what will truly matter in patient-physician decision making and is the information that is most important to know at the point of care. So while drug prices being made available in EHRs would be helpful, what we really need is incorporation of a patient's pharmacy benefit/formulary information in to EHRs. CMS has made some proposals that would mandate this information for the Medicare/Medicaid population, but nothing has been finalized yet.

I agree with you both, there is a lot of complexity in not only which price to display, but how that price compares to what the patient will actually pay when they pick their medication up at the pharmacy. Displaying the wrong price, could actually be worse in some instances that displaying nothing at all.

What some are currently doing across the industry is supporting the concept of a mock claim adjudication at the time of prescribing based primarily on the patients health plan, the medication, medication days supply, and the pharmacy. This mock adjudication results in giving the physician confidence in telling the patient what they will pay when they show up to pick up their medication.

As mentioned, there are many models for medication pricing, but the most relevant one is the actual, out of pocket cost for the patient which can be determined by the PBM with the drug, dose, days supply, quantity and dispensing pharmacy. Only the patient’s plan can calculate the out of pocket price as it will vary by the insurance plan design, the pharmacy network, and how much the patient has paid towards the deductible for the year. Many PBMs now offer a service to do this with a different transaction than the pharmacy claim that is based on the same data as the claim, and most EHRs have incorporated the information in real-time into the prescribing workflow. The other advantage of this approach is the PBM can return alternative choices, such as lower cost options or different medications that would not require a prior authorization.

The benefits of delivering patient specific pricing at the point-of-care (a.k.a. Real-Time Prescription Benefits) accrue to Patients, Prescribers, Payers, and Pharmacies. Major benefits include: timely initiation of therapy, improved adherence/continuation of therapy, improved healthcare practitioner productivity, lower costs of care, and timely clinical alerts. Drug price information should include: (i.) The patient's financial responsibility for a medication and quantity, and (ii.) The payer's financial responsibility for a medication and quantity, inclusive of rebates.

Though we use Cerner as our EHR at Keck, Allscripts is probably the leader in Rx price transparency and has integrated it into all of their platforms from what I hear. Benefit pricing and GoodRx (comparing cash pay price to out of pocket price) pricing is available across the board.

I'd like that EHR in my 2-physicians private practice of Internal medicine. Pricey, right?

The AMA 2018 Prior Authorization Physician Survey (ama-assn.org/system/files/2019...) shows that physicians and their staff devote significant time to completing prior authorizations for their patients. Practices report that, on average, they complete 31 prior authorizations per physician per week, which consumes nearly TWO BUSINESS DAYS of physician and staff time! Physicians would much rather be spending this time engaged in direct patient care, but they are forced to complete this administrative work to ensure that patients get the care that they need and that insurers will cover the treatment.

PA is necessary for very expensive drugs as well as many procedures and referrals. Instead of it's initial promise as a useful tool to help lower costs and promote appropriate use of expensive resources, it has become a blunt instrument to reduce the cost of care. In addition, it is now one of the top contrubuters to physican frustration and burnout associated with clinical information technology.

AMA advocacy has been helpful in identifying the widespread scope of this problem and in promoting more reasonable and justifiable applications of PA.

True, though many prior auths we do are not expensive drugs (Detrol LA, Adderall XR). Agree with PAs being an area of burnout and frustration, and for our Type 1 Diabetics where PAs for their insulin delay refills...frankly bad for patient care.

Similar to transparency to price, real-time transparency to coverage status and prior authorization requirements when prescribing should help the physician and care team initiate the PA process earlier, or avoid it altogether if possible. Interoperability between EHRs and PBMs needs to continue to improve so that, in the event a PA cannot be avoided, that process can be initiated and completed in an expedited manner electronically so that the patient can start their therapy as quickly as possible.

Prior Authorization is both a clinical and a financial tool. I agree with Dr. Sullivan's comment prior authorization (PA) is a blunt too primarily used to drive cost savings, rather than clinical appropriateness. Real-Time Prescription Benefit information, including whether a prior authorization review is required, enables prescribers to determine if they should proceed with the contemplated medication and prior authorization or chose an Alternative Medication.

After the first new Rx is created, the next most common point is at the time of a refill (if indicated) and the thrid point of the "journey" is whenever the patient asks if there is an alternative drug that is less expensive and just as safe and effective.

There is often quite a bit of education required as this can be a complex issue. However, some of the easy questions can be answered by clinical staff under guidlines from the physician.

Also, this is a relatively new area for EHR functionality and it is by no means well estblished. Rapid, direct, online, automated feedback from the patient's specific health plan benefit database and/or the PBM, is necessary for this new eRx/EHR function to work well and not burden the physician with unecessary and wastful time spent on the keyboard. However, this is a very promising new tool to help every healthcare stakeholder.

Even the federal government is aksing for help to streamline this process - often called "Real Time Benefit Check" (RTBC).

Agree with Dr Sullivan. We all know that cost is one of the main reasons patients don't adhere to their medication regimen. Cost needs to be discussed at the time the rx is written: 1. Reassurance if the rx is a cheap generic option 2. Pill splitting options that may save money 3. Looking for cash-pay price if the generic medication the physician prescribes isn't on formulary (GoodRx, WellRx, etc). 4. Drug manufacturer coupons if available. All of these will help ensure our patients not only fill their rx but adhere to the regimen we prescribe.

I would say that the physician needs to be informed about how much different drugs cost before writing the prescription so that it can play a role in decisions about which drug to prescribe.

Agree with everything said above! Physicians need to have accurate, current information about prescription drug benefit coverage and patients' financial responsibility in their EHRs at the point of prescribing. That's why the Prior Authorization and Utilization Management Reform Principles (ama-assn.org/sites/ama-assn.or... -- see principle #9) and the Consensus Statement on Improving the Prior Authorization Process (ama-assn.org/sites/ama-assn.or... -- see the very last bullet!) support provision of this information in EHRs.

Not knowing the Rx cost in the exam room is a major impediment to providing care to my patients.

Here are 2 articles (I wrote the first) on this subject:

commonwealthmagazine.org/opini...

wbur.org/commonhealth/2018/04/...

Completely agree that reviewing this information at the time of writing the prescription is the ideal scenario.

I will only add that I've additionally heard that making this information available to care managers is also desired as often times those are the roles who are helping the patient ensure they know what medications they need to take, where to get them, etc. This of course poses some workflow issues if the patient and care manager determine, after the prescription has already been written, that the patient can't afford a prescription. I think that goes to the point that making this available at the time of prescribing is the ideal, but others on the care team want this visibility as well.

Physicians need access to Patient and Payer (ACO contracts) financial responsibility information for two scenarios: (i.) Initiation of Therapy - At the point-of-care and prior to e-prescribing, and (ii.) Continuation of Therapy - At the point of reviewing/authorizing a medication request originating from a patient or pharmacy.

CVS Pharmacy apparently has a rule that they cannot provide pricing information to a patient or a physician without a prescription in hand, as they have to access their prescribing database and are only allowed to do so if they have a prescription. Sometimes the pharmacist is willing to ignore this rule, but many times they are not willing to provide pricing information without a prescription.

I know that some physicians will write a prescription for the patient to take to the pharmacy. If the prescription is non-formulary or it is too expensive, the patient has to return for a second office visit to discuss the next medication option.

It is no wonder that physicians detest the current design of our healthcare system as we have forced the most educated members of our society to perform clerical tasks which takes them away from what they are trained to do, which is to take care of patients.

Agree with the comments above - the sooner, the better. Insight at the time of order entry is essential and avoids rework that's necessary when the ordering provider discovers that the patient is unable to adhere to the med regimen because of cost. That's if they find out at all, which they may not.