HIT Perspectives: Real Time Benefit Inquiry

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HIT Perspectives – June 2016

Real-Time Benefits Inquiry: A New Kind Of Clinical Decision Support

B Pooja Babbrah, Senior Consultant

Clinical decision support (CDS) has long been recognized as a set of tools that can improve clinical decision making and patient safety, both as functionalities in electronic health records (EHRs) and electronic prescribing (ePrescribing) systems. Familiar examples include computerized alerts and reminders to care providers and patients, clinical guidelines and condition-specific order sets. Now the definition of CDS is being broadened to include other tools that provide “knowledge and person-specific information, intelligently filtered or presented at appropriate times.” One of the newest is the real-time benefit inquiry (RTBI), whose value lies in its potential for providing real-time, patient-specific formulary and benefit information at the point of care.

Why benefit verification? Benefit verification is a key step in the ePrescribing process because it helps the clinician know if a medication will be covered under a patient’s medical insurance coverage or prescription benefit coverage; if covered, how much a patient’s insurance will pay and how much the patient is responsible for paying. This is important for several reasons. Prescribing a medication that is not covered by insurance can cause treatment delays while the pharmacy and insurance company identify an alternative that is on formulary. This also can result in claim denials and a bad experience at the pharmacy. High out-of-pocket costs to the patient for an off-formulary drug can lead to prescription abandonment and medication noncompliance. The latter results in as much as $289 billion a year in unnecessary deaths, needless hospitalizations and doctor visits, and lost productivity.

Benefits checks and ePrescribing. Today’s ePrescribing systems and EHRs with ePrescribing modules already have the ability to perform formulary and benefit (F&B) checks. While the information is useful, it is not as complete, accurate or timely as a clinician would prefer. That is why RTBI is viewed as a useful adjunct to today’s ePrescribing F&B check. RTBI provides real-time information about patient-specific utilization management programs (such as prior authorization and step therapy), true out-of-pocket costs for a medication (specific copay/coinsurance amount and deductible information), alternative pharmacy pricing (such as for a 90-day supply) and which pharmacy will be most cost effective in light of the patient’s insurance coverage and available pharmacy benefit. This should help the prescriber identify the most cost-effective medication at the point of prescribing. It also should result in a cleaner prescription, which will minimize treatment delays and unacceptable out-of-pocket costs to the patient.

RTBI Progress. The industry is already making progress toward making RTBI a reality. At the National Council for Prescription Drug Programs (NCPDP) annual meeting in early May, Point-of-Care Partners (POCP) co-presented a session on RTBI with DrFirst and Humana. The latter two presenters discussed how their companies’ partnership created a recently launched RTBI service, which is based on a modified version of the NCPDP Telecomm D.0 Standard. Early results of this service show that prescriber behavior changes when the RTBI reveals that a drug isn’t covered by a patient’s insurance. In addition, use of the RTBI increases adoption of the new electronic prior authorization standard, which ultimately will increase speed to therapy.

The Future of RTBI. In terms of incorporating RTBI in EHRs, it’s not a question of standards so much as prioritization of development, which depends on what the government is requiring or what business model is being used by clients. Both payers and EHRs have expenses and a lot on their plates, so fitting in new ways of communicating formulary information must be prioritized and placed accordingly in the development queue. However, given the broader definition of CDS that has emerged and the early results we are starting to see in the marketplace, payers and EHRs are likely to put RTBI development into their product road maps sooner rather than later. RTBI is a sophisticated CDS component, and it will continue to be an example of how providing clinical decision support at the point of care will help improve patient health and safety. POCP is working on the forefront of RTBI standards and adoption. Write us or give us a call. We’d be happy to bring you up to date.