Biopharma Real Time Benefits Check

HIT Perspectives Biopharma Insights – June 2015

Real-Time Benefits Check: Coming to the Point of Care

By Brian Bamberger, Life Sciences Practice Lead

What is the patient’s financial responsibility for a proposed medication? Are any drugs in the same therapeutic class less expensive? These are among the many questions confronting providers and patients when a medication is selected and then electronically prescribed (ePrescribed) at the point of care through the EHR. Some answers to these kinds of questions are currently provided through the formulary and benefit (F&B) check, but the data regarding individual patients are not always complete or accurate. That will be changing over time with the development and adoption of the real-time benefit check at the point of ePrescribing, which will offer significant improvements over what is available today.

The F&B transaction identifies a patient’s insurance benefits, which affect how treatment decisions often are made – or delayed. Providers try to select the most appropriate, cost-effective medications for patients. Payers often use formulary tiers and prior authorization (PA) to accomplish those goals. For patients, it’s not just about a treatment’s efficacy, it’s often just as much – if not more – about cost. They want to know how much their insurance will cover and what their copays and deductibles might be. Without this information, they are at risk for being prescribed a medication they cannot afford, leading to abandoned prescriptions or medication noncompliance – situations that result in costly comorbidities, unnecessary office visits and trips to the emergency room. Time frames also are important for getting the proper medication to the appropriate patient at the right time. For patients who are diagnosed with a rare disease or in need of a treatment requiring complex therapy, health outcomes might be affected by the lag time involved in determining whether the medication they need will be approved by their insurer, how much they will have to pay out of pocket and if alternatives are available.

One solution is the real-time benefit verification transaction at the point of ePrescribing. Use of this transaction would replace the downloaded data files that are used today, which have limitations due to latency of the updating process and the quantity and quality of the data. Real-time benefit verification will greatly improve the breadth, accuracy and effectiveness of formulary data available to the prescriber at the point of care. This will address many prescribers’ perception that currently available F&B data are neither correct nor complete, which serves as a barrier to use. Moreover, having real-time benefit information in the electronic health record will allow the prescriber to see dollar copay amounts for individual patients at the point of prescribing. This will help with formulary compliance and medication adherence.

Some proposed versions of the transaction give payers the ability to mention specific alternatives to a requested drug. This information was popular in retail pharmacy messaging in the past and used to switch patients to preferred drugs, including generic alternatives. This proposal offers payers the opportunity to message prescribers away from less desirable products to selected products that may be less expensive to the payer and patient. This message will impact pharmaceutical companies by further penalizing high copay options and benefiting formulary compliance of preferred drugs. Whenever an appropriate generic alternative exists, even more savings may be found for the payer and patient. Without transparency about these messages and the decision process, pharmaceutical companies could be in the dark about the positive impact of these messages. As part of the proposed real-time benefit verification, which is currently in development, savings program offers may not be displayed with copay amounts.

Point-of-Care Partners (POCP) is monitoring some early activity by payers to develop pilots. After initially slowing down the process, a few payers are moving forward with pilots to demonstrate its value. Although it may be some time before a standard is approved, the impact will be far reaching once use gains traction.

POCP also is active in the development of – or enhancements to – other ePrescribing standards.  We would be happy to explain their impact on prescribing, pharmacies and drug manufacturers.