For healthcare consumers, the patient financial experience begins the minute they realize they need care. From deciding where to get care, to choosing how and when to pay the bill, the financial experience is always top-of-mind.
Even though the patient financial experience is a top-priority for patients and providers alike, when a doctor prescribes a drug regimen, does the patient know the cost they’ll pay before going to the pharmacy? For the majority of adults in the United States, the answer is probably no. How is that possible and why have we accepted it as the norm? Think about buying a television for an unknown price and being asked to pay for it when it arrives at your home. Not only is this lack of price transparency non-existent in most consumer industries, but its persistence in healthcare has led to a deteriorating perception of the system and a more-often-than-not negative financial experience for patients.
Patients today are paying more and more for their care but have less of an idea what they’ll owe – a counterintuitive situation that baffles even the smartest healthcare consumers. Research shows that patients not only care about the cost of their care, but react immediately to price increases, especially when it comes to prescription drugs. For example, an analysis completed by AJMC showed that a $10 copay boost increased the likelihood of prescription abandonment by 10%. Furthermore, the CDC published a report that highlighted the fact that increased drug costs negatively impact medication adherence and overall physical health.
Why is achieving price transparency so difficult?
To start, the payment structure in healthcare is unlike any other since third parties are often responsible for a portion, or the majority, of the total payment. These third parties are often hesitant (for competitive reasons) or contractually prohibited from sharing the prices they pay for the care they cover. Each patient is also working toward their personal deductible amount, and each plan has negotiated rates to cover certain types of care at certain rates. Presenting a personalized amount owed at the point-of-care has been a challenge to say the least.
In the pharmaceutical space in particular, there are complex relationships in place between manufacturers, PBMs, payers, and pharmacies, all of whom want their share of revenue from this multi-billion dollar industry. In many cases, health systems will not directly connect their health or billing record systems with those of payers or PBMs because of ownership structure and data-sharing restrictions. This leads to doctors prescribing drugs that are not covered by patients’ plans, may require a prior authorization, or may be out of the patient’s financial scope.
An additional burden is put on health systems who interface with patients, since it is up to them to maintain accurate patient coverage information, formulary lists, and preferred pharmacies for every patient covered under every plan that might walk through their doors. Hospitals often lack the infrastructure to partner with every health plan/PBM and store up-to-date information on every stakeholder involved.
What is being done to improve transparency and the financial experience?
Imagine a world where doctors inform their patients of 3-4 therapeutic alternatives that are covered under the patient’s health plan. Imagine doctors recommending patients pick up their drugs from a pharmacy nearby, or even one down the hall? And imagine doctors helping patients save money on prescriptions by recommending the most cost-effective options?
What was once a far-off aspiration is now becoming a reality. Patient-provider conversations have hit a critical point where patients are requesting this type of information, and they can be treated like consumers throughout the prescribing process – as they are in nearly every other industry.
Yes, price comparison tools have been around for many years. But most of these tools – for prescription drugs or otherwise – take months of historical transaction data and present average costs to the patient. In the prescription drug space, there is a unique opportunity to present accurate, patient-specific pricing information in real-time.
The technology that allows prescription data transactions to take place is called Real-Time Prescription Benefit (RTPB), often referred to as Real-Time Benefit Check (RTBC). With this type of technology in place, data connections between payers/PBMs and health systems allow for more informed conversations between patients and providers – empowering patients to make financial decisions that are best for them, at that very moment. If a provider initially suggests a drug that is not covered or is too expensive, the RTPB tool will present a cheaper option that is in the same drug class or is available as a generic. In some cases, the tool will even recommend a different delivery mechanism (capsule vs pill), all in an effort to save the patient time and money.
Arrive Health (formerly RxRevu), the industry leader in Prescription Decision Support, leverages partnerships with large payers and PBMs to provide coverage information on nearly 120 million Americans in real-time. This data is then presented to doctors within their typical EHR prescribing workflow, with just the click of a button. By bringing prescription price transparency tools to their fingertips, prescribers can eliminate costly administrative tasks like pharmacy callbacks, while improving medication adherence and reducing sticker-shock at the pharmacy.
The bottom line is that new RTPB technologies exists to make patient visits more open and consumer friendly. Pressure from payers, providers, and patients to increase visibility into drug coverage information, as well as proposed regulations that mandate price transparency, will move the industry forward at a rate we have not yet seen. And as real-time data becomes available to more stakeholders in the care journey, patients will be able to make more educated decisions about their health, and improve their own financial experience.
If you’d like to learn more about how Arrive Health is helping organizations present real-time prescription coverage information at the point-of-care, contact us today.
