Real-Time Benefit Check (RTBC) Solution Assessment. Requirements for selecting the most valuable RTBC solution for your health system

Transcription

1 Real-Time Benefit Check (RTBC) Solution Assessment Requirements for selecting the most valuable RTBC solution for your health system

2 Prescription cost is the primary predictor of medication abandonment. In fact, 37 percent of patients surveyed indicated they stopped taking a medication because it was too expensive.¹ The primary driver of medication sticker shock is the lack of transparency in patient coverage and prescription cost at the point of prescribing Real-Time Benefit Check National Adoption Scorecard 2 RTBC SOLUTION ASSESSMENT 2018 CoverMyMeds LLC. All Rights Reserved.

3 Real-Time Benefit Check Real-time benefit check provides access to patient-specific formulary, benefit and prescription cost information at the point of prescribing to enable improved decision support, reduce administrative waste and enhance the patient experience. Similar to electronic prior authorization (epa), provider adoption of RTBC is the primary determinant for success across the industry. As such, provider feedback on their needs at the point of prescribing is critical to developing an RTBC solution. Multiple RTBC solutions are available in Epic; however, each offer different capabilities. Leverage this document to determine the right solution for your health system. Providers indicate the following factors as most important in an RTBC solution:² Patient out-of-pocket cost Pharmacy cash price Patient assistance/ affordability programs Prior authorization (PA) requirement Formulary alternatives 2 - CoverMyMeds Data on File 2018 CoverMyMeds LLC. All Rights Reserved. RTBC SOLUTION ASSESSMENT 3

4 RTBC Solution Implementation Models Two primary implementation models exist for surfacing RTBC data in the provider workflow. EHR-to-Payer Direct Connect In this model, EHRs connect directly to payers to deliver formulary and benefit (F&B) information in the prescribing workflow. Epic does not leverage the EHR-to-Payer model. Intermediary Solutions In this model, an intermediary connects to one or more stakeholders in the industry to deliver varying levels of data to providers in the EHR workflow. This is the model Epic leverages for RTBC, with solutions available as a build option in Epic 2018 or through the Epic App Orchard. The value of intermediary solutions varies based on their method for connecting to industry stakeholders for patient-specific F&B, cost and pharmacy information. 4 RTBC SOLUTION ASSESSMENT 2018 CoverMyMeds LLC. All Rights Reserved.

5 Functionality by Implementation Model Payer Network Pharmacy Network Open Network * Cash Price Patient pay amount if they choose to not go through, or do not have, insurance. Patient Out-of-Pocket Cost A payment made by a patient for a particular service or medication. Patient Assistance / Affordability Programs Programs designed to help patients obtain their medication at a lower cost. Deductible Information An amount of money a patient must pay before their health plan will pay a claim over a period of time. Alternatives An alternative medication that may cost less than a prescribed medication but have the same therapeutic outcome or efficacy. PA Required A requirement from a health plan to obtain more clinical information before deciding whether or not to cover a medication. All Payer The RTBC solution includes connections with all payers. All Pharmacy The RTBC solution includes connections with all pharmacies. Mail Order Prescription medication sent directly to a patient via their pharmacy benefit manager (PBM). Retail Availability The RTBC solution indicates which retail pharmacies carry the medication CoverMyMeds LLC. All Rights Reserved. RTBC SOLUTION ASSESSMENT 5

6 Five Critical RTBC Questions The following questions are critical to ask Epic RTBC solution providers before selecting a solution for your health system.

7 01. Which intermediary model do you leverage to surface RTBC data in workflow? (Circle one) If the solution provider leverages a payer network, ask how many and which payers they are performing live transactions with today. Payer Network Pharmacy Network Open Network Number of live payer connections: RTBC INSIGHT The RTBC solution available as a build option in Epic 2018 leverages the payer network, which requires the intermediary to contract payer by payer, and is likely to limit the availability of the RTBC transaction for your providers. It also fails to surface patient assistance programs and information related to retail pharmacies, including medication availability at a patient s preferred pharmacy and cash program details, where available. The CoverMyMeds solution RxBenefit Clarity TM available in the Epic App Orchard is an open network solution, providing the most comprehensive RTBC functionality on the market CoverMyMeds LLC. All Rights Reserved. RTBC SOLUTION ASSESSMENT 7

8 02. Will your solution indicate when retail pharmacy cash price programs are available? (Circle one.) Yes No RTBC INSIGHT Pharmacy cash price programs can be valuable to customers, especially those with a high deductible health plan (HDHP) who may not meet their deductible. In a survey of 1,000 patients, nearly half of patients indicated they use prescription price shopping tools to find a better price for medication. Further, patients with a co-pay of $50 were nearly four times more likely to abandon a prescription than patients paying $104.¹ These statistics indicate that patient awareness of lower-cost cash programs at retail pharmacies may drive improved adherence Real-Time Benefit Check National Adoption Scorecard 8 RTBC SOLUTION ASSESSMENT 2018 CoverMyMeds LLC. All Rights Reserved.

9 03. Will your solution indicate when patient assistance programs are available? (Circle one.) Yes No RTBC INSIGHT Many pharmaceutical companies improve patient access by funding patient assistance programs to lower the cost of medication. According to a survey of more than 1,000 providers, knowledge of patient assistance programs at the point of prescribing is important for providing care and having informed patient conversations.¹ Real-time benefit check solutions that connect solely to payer organizations do not surface information on the availability of patient assistance programs Real-Time Benefit Check National Adoption Scorecard 2018 CoverMyMeds LLC. All Rights Reserved. RTBC SOLUTION ASSESSMENT 9

10 04. How does your solution surface formulary alternatives and patient out-of-pocket cost? Is alternative information available from all payers? Does the displayed out-of-pocket cost account for the cost at the patient s preferred pharmacy? RTBC INSIGHT Formulary alternatives and patient out-of-pocket cost are critical components of a successful RTBC solution because they increase decision support for the provider, particularly when the provider or their patient may want to consider alternate medications covered by insurance. To effectively deliver this information to the provider in every transaction, optimal RTBC solutions will connect to all payers and avoid payer-by-payer implementations. The accuracy of out-of-pocket cost is dependent on information from the payer, as well as the patient s preferred pharmacy, due to pharmacy-to-pharmacy price fluctuation. A solution that calculates out-of-pocket cost based solely on benefit coverage or mail order pharmacy will not provide an accurate cost for a patient purchasing medication at a retail pharmacy. 10 RTBC SOLUTION ASSESSMENT 2018 CoverMyMeds LLC. All Rights Reserved.

11 05. Does the solution indicate in workflow when a PA is needed? What is the solution provider s track record of successfully driving provider adoption of epa? To determine success, ask: How many providers use their epa solution today? What percentage of total epa volume is processed through their system? RTBC INSIGHT By combining real-time benefit check and epa functionality, providers gain improved decision support enabling them to select a covered medication when they deem it clinically appropriate, or to initiate a PA request when a medication is not on formulary. Similar to epa, the success of RTBC will depend on provider adoption. As such, RTBC solutions developed by organizations with a history of success driving epa adoption are more likely to be adopted at scale. As demonstrated with epa, solutions offered at no cost to providers or the health system are most likely to gain widespread adoption, benefiting the industry at large CoverMyMeds LLC. All Rights Reserved. RTBC SOLUTION ASSESSMENT 11

12 For more information on real-time benefit check visit the 2018 Real-Time Benefit Check National Adoption Scorecard at go.covermymeds.com/rtbc To learn CoverMyMeds answers for the five critical RTBC questions, contact