Prescription Decision Support

Deciding the best medication option and payment method incorporates patient benefit type and status, drug class, financial constraints and preferred pharmacy, to name a few — and the choice isn’t always clear.

Often, these variables aren’t considered until the patient arrives at the pharmacy. At this point, if a patient hears their medication requires a prior authorization (PA), or is surprised by the price, they’re likely to leave without a prescription in hand. According to a survey of 1,000 patients, half abandoned their medication because it cost too much.¹CoverMyMeds Patient Survey, 2018

From sickness to wellness, prescription decision support solutions (PDS) provide timely information at critical touchpoints throughout the health journey so patients, providers and their staff can trust they’re making the best choices surrounding medication.

PDS at the Point of Care

According to the National Council for Prescription Drug Programs, “access to real-time prescription benefit information has the potential to transform the patient experience and speed time to therapy by making patients’ formulary and benefit information available to providers at the point of prescribing.”

A real-time benefit check (RTBC) solution, also known by related names such as real-time benefit transparency (RTBT) and real-time prescription benefit (RTPB), can surface prescription benefit details, such as patient out-of-pocket cost, drug alternatives and PA requirements, enabling providers to make informed medication choices at the point of prescribing.

Effective solutions facilitate discussion between a provider and patient about the most clinically appropriate and affordable medication. By providing true price and coverage transparency, the patient is less likely to be surprised at the pharmacy and more likely to remain adherent.

Inclusive of RTBC, prescription decision support before the patient leaves the provider’s facility encompasses off-benefit information, as well as prescription pickup details. Information can also include more acute drug facts such as interactions, dosing and side effects. Prescribers and staff can help patients select the best option for where they are in life at that moment in time.

This includes options for using benefit as well as options which forego it in favor of a cash option. An optimal workflow allows providers and patients to evaluate the best options depending on remaining deductible and prescription cost.

A full-spectrum PDS workflow considers office and administrative staff after prescribing. Nurses are often tasked with looking up medication information, and 58 percent reported doing so most frequently after the patient visit — and after the prescription has been sent to the pharmacy.²CoverMyMeds Nurses Survey, 2019

Nurses reported searching for information such as history of tried and failed drugs, prescription benefit details, dosing, financial assistance resources and copay, and 73 percent reported they can’t find this in one place. Not only are they in need of a solution to help patients, but 59 percent of those surveyed said they provide information to prescribers that influences the medication decision several times weekly.²CoverMyMeds Nurses Survey, 2019

An electronic prior authorization (ePA) solution helps improve the efficiency of the PA process by removing the phone- and paper-based components.

Initiating and submitting PA requests electronically allows for health plan determinations up to three times faster than traditional methods,³CoverMyMeds Data on File getting patients the medications they need sooner.

Many ePA requests are completed retrospectively by the patient’s pharmacy upon a PA-related claim rejection. The most effective PDS tools today identify PA requirements prospectively, allowing electronic initiation at the point of prescribing. This enables easier prescription claim processing at the pharmacy, saving patients valuable time and opening the door for more productive conversations at the pharmacy.

More patients want to take charge of their healthcare, which means they’re looking for smart tools to do so.⁴19 Recent Healthcare Tech Start-Ups Attract Instant Consumer Appeal, Black Book Survey PDS tools for patients include the ability to price-compare across local pharmacies, as well as price via benefit or cash option, and receive medication in a way that’s most convenient to them — sometimes right to their door.

PDS at the Pharmacy

A true end-to-end solution takes the pharmacy into account. If every tool in the journey up to this point has operated effectively, this is an opportunity for patients to discuss payment options, drug manufacturer coupons, copay information and drug information such as interactions and ingestion details.

Effective tools clear the path of obstacles such as PA and sticker shock so pharmacists can shine as part of the patient advocate team.

The prescription benefit and cost information providers can access within their EHR is inconsistently visible, and static formulary and benefit files are often outdated — and therefore unreliable.

If patients are equipped with this information at the point where they can have a conversation about their options, or at least be more informed about the implications of abandoning a high-cost medication, they can confidently make a better decision at the pharmacy.

PDS provides accurate, personalized data to help providers and patients align on the best option for adhering to the medication prescribed.

The Rise of High-Deductible Plans

In 2018, 45.6 percent of Americans under 65 with private health insurance were enrolled in a high-deductible health plan, subject to a minimum deductible of at least $1,350.⁵Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–September 2018,⁶Healthcare.gov During 2017, the average out-of-pocket cost on prescription claims for patients with high-deductible plans was $270, compared to $29 for those with copayments.⁷Devane K, Harris K, Kelly K. Patient Affordability Part Two: Implications For Patient Behavior & Therapy Consumption. Plymouth Meeting, PA: IQVIA; 2018

For the 75 percent of those on high-deductible plans who won’t meet their deductible within the year,⁸Triangulated Data, IQVIA Report on Emergence and Impact of Pharmacy Deductibles all medication costs must be paid out of pocket. This can lead to prescription abandonment. When cost exceeds $125 per script, 52 percent of patients abandon their prescriptions. Above $250, the abandonment rate increases to 69 percent.⁷Devane K, Harris K, Kelly K. Patient Affordability Part Two: Implications For Patient Behavior & Therapy Consumption. Plymouth Meeting, PA: IQVIA; 2018 Patients who aren’t adherent to their medically necessary treatments can face worsening health outcomes and readmissions.

Nearly half of providers in a recent survey said they never have out-of-pocket medication price information available at the time of prescribing, even though 80 percent say patients are asking them about pricing information.⁹CoverMyMeds Provider Survey, 2020 Moreover, they don’t trust the information they get. Only one in five providers surveyed said they always trust the insurance data they see in their EHR.⁹CoverMyMeds Provider Survey, 2020

And, while patients want prescription price transparency, they rarely receive it at the point of prescribing — 87 percent of patients surveyed said it would be valuable if providers could share the cost of the medications they intended to prescribe during the appointment.¹CoverMyMeds Patient Survey, 2018

Patients need to know how much they’re required to pay — and what their options are to do so — at the point of prescribing. This saves patients valuable time and offers the chance to discuss options with the provider should medication cost be a concern, as it often is.

In fact, cost is the primary predictor of patients abandoning needed medication.¹⁰CVS Caremark Research Finds Correlation Between Amount of Patient Co-pay and Prescription Abandonment Addressing this issue before they arrive at the pharmacy can reduce sticker shock and help get medications in hand.

In a 2018 study, seven in ten people with employer coverage reported engaging in some type of cost-conscious healthcare-shopping behavior in the past 12 months.¹¹Kaiser Family Foundation/LA Times Survey Of Adults With Employer-Sponsored Health Insurance, 2019 Patients stand to benefit from a solution that can surface options for them, including e-vouchers, alternatives and cash options.

Providers sympathize with patients’ desire for more pricing information: three in four surveyed said cost is a factor that influences their decision-making when prescribing a medication.⁹CoverMyMeds Provider Survey, 2020 However, pricing and insurance information isn’t always easy for providers to find, and while many may have access to patient formulary and benefit information within their EHR, the scope of this data is limited. Seventy-nine percent of providers said they seldom trust this information, and 78 percent report out-of-pocket costs are rarely or never available at the time of prescribing.⁹CoverMyMeds Provider Survey, 2020

In a recent survey, 80 percent of nurses said they use an online medication resource at least a couple times per week. Over 73 percent said this was because the information they need is not located in a single source. They are searching for a wide variety of medication information, but the top search topics are coverage and plan requirement information.²CoverMyMeds Nurses Survey, 2019

Eighty-six percent of providers surveyed stated a reliable RTBC solution would benefit their patients and assist them in making more informed decisions when it comes to treatment.¹²CoverMyMeds Provider Survey, 2018

EHR Systems

EHR systems equipped with PDS support the provider and patient with quality, pinpointed information at the right time, directly within the ePrescribing workflow. Not only does this enhance the way providers prescribe information, but it can improve provider trust where it currently lacks in the system of formulary and benefit information.

Payers

Motivation for payer adoption is led by a desire to optimize patient outcomes while controlling healthcare costs.

Life Sciences Companies

PDS solutions can surface brand-specific patient assistance program availability. This off-benefit option can be critical for patients who cannot afford medications during their deductible period and are at risk for prescription abandonment. For life sciences companies, PDS can generate awareness for patients who may need such financial assistance.

Pharmacies

Participating pharmacies can unlock data transparency for providers and patients with relevant information, regardless of their insurance (example: pharmacy cash price), and can provide benefit information for all payers for any prescriptions, directed to the patient’s preferred pharmacy.

PDS tools can also take the heavy lifting off pharmacists and technicians when it comes to providing patients with medication cost and cost assistance information. Since providers can start PA requests prospectively, pharmacists save administrative time which can be used for patient education.

Providers

Provider adoption of PDS solutions directly impacts their patient’s experience. By displaying prescription benefit information, including out of pocket cost, within a prescriber’s normal ePrescribing workflow, they can have a productive conversation with their patient.

PDS solutions can improve prescribing confidence, further increasing the chances the patient adheres to their medication, ultimately improving outcomes.

Patients

Patients are the keystone of an effective solution. They reap the rewards of prescribing decisions and increased insights when they can talk to their provider about out-of-pocket cost and other factors that impact adherence at the point of prescribing.

PDS provides patients with more say in their care in terms of what they are able to afford and their preferred method of delivery.

By definition, RTBC solutions present patient benefit details at the point of medication selection by integrating with the EHR the provider uses daily. To incentivize provider adoption, the right RTBC solution, at minimum, must not interrupt a provider’s regular workflow. Ideally, it improves workflow.¹³Refocusing Medication Prior Authorization on Its Intended Purpose, JAMA 2020

The key determinate for a successful RTBC solution implementation is surfacing actionable insights for the majority of prescriptions.

Implementation Models

Each RTBC implementation model centers around the same need: Surface prescription and benefit information at the point of care when providers can talk with the patient about the most clinically appropriate and affordable treatment options.

There are several implementation models for EHRs by way of payer direct connect, via an intermediary solution, or both. Third-party intermediary solutions connect directly to the payer or pharmacy networks, or they can provide an open network solution with multiple stakeholders.

Intermediary Solutions

Payer network model: The intermediary contracts directly with individual payers and individual EHRs to surface formulary data and patient out-of-pocket cost information to the provider. The payer provides patient-specific formulary information and rules.

Pharmacy Network Model: The intermediary contracts directly with individual pharmacy chains and systems with individual EHRs to surface data, including patient-pay amount and pharmacy-specific information.

Open Network Model: The intermediary contracts directly with individual payers, pharmacies and EHRs to deliver a patient’s benefit information and medication-pay amount. An open network may also surface patient assistance programs made available through pharmaceutical manufacturers such as coupons and e-vouchers.

Without Intermediary

EHR-to-Payer Direct Connect: The EHR contracts directly with individual payers to surface formulary data and patient out-of-pocket cost information for the provider. For this method to function well, each EHR must contract with every payer, as well as every individual plan, and each payer must develop connectivity to every EHR.

EHR Availability

PDS tools with direct EHR integration have the ability to give providers ease of access to patient-specific benefit and medication efficacy factors. In turn, they provide patients with the transparency they want around their medications. This opens the door for meaningful conversations and, hopefully, better health outcomes.

When surveyed, providers cited cash price, patient out-of- pocket cost information, alternative options, PA requirements and patient assistance program availability as some of the top elements they require to have a clear plan for patient care and better conversations.¹²CoverMyMeds Provider Survey, 2018

The best EHR integrations equip providers and patients with a clear best choice, weeding out unnecessary data. These solutions should support the situational value for patients — and they shouldn’t muddy the decision process.

Payer Availability

When it comes to covering prescription benefits, patients encounter a few types of payers.

Pharmacy Benefit Managers (PBMs) are third parties that solely manage prescription drug benefit programs for health insurance companies. PBMs see the most value in reducing drug spend via member-specific formulary, a more accurate display of preferred drug alternatives and reduction of administrative cost associated with PA.

Integrated PBMs are pharmacy benefit managers integrated directly with a commercial health insurance company. Integrated PBMs and health plans see the most value in member satisfaction and safety, reductions in time to therapy and additional drug-cost transparency.

PBMs and payers with retail and specialty pharmacies are benefit managers that own their own retail and specialty pharmacies, too. These managers see the most value in drug-cost transparency for member satisfaction and directions for payer-preferred prescription dispensing methods (i.e., mail order, preferred specialty pharmacy). These PBMs and payers see the most value in drug-cost transparency for member satisfaction and directions for payer-preferred prescription dispensing method (e.g. mail order, preferred specialty pharmacy). They see an added benefit in specialty drug pharmacy restriction transparency.

Payers should be motivated by their bottom line to directly connect with RTBC solutions. By getting patients on the right therapy quickly, and increasing adherence, RTBC sets patients up for optimal outcomes, reducing readmissions and additional complications. Increasing specific drug use and administrative cost savings by reducing pharmacy and provider back-and-forth are also boons to the industry.

Payers assist their members by presenting the most cost-effective and clinically appropriate medication options to providers based on patient benefit information and formulary guidelines.

To further benefit patients, third-party intermediaries can enhance the direct connection between payers and providers in an RTBC solution to support more complete price transparency. This is accomplished by supplying pharmacy-specific data on member pricing at the patient's preferred pharmacy location.

Pharmacy Availability

Pharmacists are key players in the patient journey: Unfortunately, even if everything goes right, they’re often seen simply as medication cashiers. When medication complications arise, patients’ view of them or the pharmacy itself can sour. Pharmacists are change agents in the industry, and RTBC solutions help clear their path upstream so patients can see them as the healthcare advocate they are.

In a 2018 survey, pharmacists stated they’re only able to spend 10 percent of their time engaging with patients around how to safely and effectively take medication, potential side effects and compliance. This is the same task these pharmacists feel they should spend more time devoted to, along with medication therapy management. Seventy-eight percent of pharmacists said they anticipate a greater role in patient care in the next five years.¹⁴AmerisourceBergen Pharmacy Check-Up: Activities and Barriers to Care Analysis, 2018

While prescription decision support tools have an increasing presence at the point of care, available tools dwindle when it comes to the pharmacy. Nearly half of providers surveyed said they still view the pharmacist as responsible for finding the price of a prescription.⁹CoverMyMeds Provider Survey, 2020

While the responsible party can be subjective, pharmacists stand to benefit by providing patients with the same standard of care by offering prescription visibility and options. The extension would ensure patients are supported and gaps are filled no matter where they are in the journey from diagnosis to medication treatment.

The Report on Prescription Decision Support is written and published by CoverMyMeds with guidance from industry experts on the Advisory Board for the overarching Medication Access Report.