By Pooja Babbrah, Practice Lead, PBM Services
Connecting patients with information about the costs of their medications is part of the growing movements toward consumer-directed care and drug price transparency. Price transparency is important because it can help reduce abandoned prescriptions and medication nonadherence, which often result from sticker shock at the pharmacy and cost the American health care system between $100 billion and $289 billion a year. Now a nonpartisan, multisector stakeholder coalition, the CARIN Alliance, is working on an up close and personal way to help consumers understand their out-of-pocket prescription costs before they arrive at the pharmacy. CARIN’s vision is to rapidly advance the ability of consumers and their authorized caregivers to easily get, use and share their digital health information whenever, wherever and however they want.
This new method is the consumer-facing, real-time pharmacy benefit check (RTPBC). It will use technology — application programming interfaces (APIs) — to enable consumers to look up the costs of their prescriptions, as well as what their insurance will cover and pay for, on a smart phone, tablet or other electronic device. This has been a black box for most people. The consumer-facing RTPBC also will give the cash price for a medication and apply the costs of coupons and other kinds of financial assistance, as well as indicate whether prior authorization (PA) is needed, which can also be a barrier to access.
To be sure, some drug pricing and PA information is posted on payers’ patient portals. However, consumers often don’t know about this resource or don’t use it, in part because it doesn’t include prices for cash purchases or financial assistance. Those who do use their payer’s portal often use it solely to look up claims or better understand their benefit parameters and options for new regimens.
Having personalized drug information at their fingertips will enable consumers to find treatment options and alternatives that meet their needs. A recent study found that 40% or more of Americans have difficulty affording their prescription drugs, despite having insurance coverage. Roughly a fifth said they have had trouble paying for such basic necessities as food or housing due to the cost of their medication, and a similar percentage have borrowed money from friends or family, taken out a loan or even declared bankruptcy for that reason. Additionally, benefits are always changing, so certain medications may no longer be covered and consumers will be on the hunt for alternatives.
Work on the patient-facing RTPBC continues to gain speed through a CARIN-sponsored workgroup convened in November 2018. Over the next few quarters, it will be putting together API implementation guides that will leverage transactions using standards from Health Level Seven International and the National Council for Prescription Drug Programs. These will be key for vendors to use in their development work. These guides will also assist health plans in knowing when their member went off formulary and paid cash, thus improving their medication adherence quality scores. Implementation of the API would follow the Patient Right to Know Drug Prices Act of October 2018 and the proposed real-time benefit tool rule for Medicare Part D published in November 2018. Development of the patient-facing RTPBC also will align with the newly issued proposed regulation on interoperability and information blocking from the Office of the National Coordinator for Health Information Technology and the new proposal on making patient data available through APIs from the Centers for Medicare and Medicaid Services.
Point-of-Care Partners is working closely with the CARIN Alliance to advance consumer-facing RTPBC. Want to know more or join the Workgroup? Reach out to me at firstname.lastname@example.org.