By Pooja Babbrah, Practice Lead, PBM Services
“I just want to say thank you. Thank you from me, my family and the millions of other people that this will help,” the stranger said, as I was packing up my computer.
It was the end of the day after a weekend-long HL7 FHIR Connectathon and we had just finished reporting out our results from the event. This weekend-long event brings together health information technology experts, from vendors to programmers to graphic artists to pharmacists. The mission of our project was to allow a mobile app developer to pull together insurance benefit information and cash price comparisons for a single drug, then display the results on a smart phone screen that could be accessed by a patient or a patient’s caregiver. The app would show whether a drug is covered by insurance, how much it would cost the patient out of pocket if they used insurance, but also how much it would cost if they paid cash for the prescription as well as the cash price for up to 5 different pharmacies within a specific location range.
Until recently, prescribers had difficulty determining how much a drug would cost the patient out of pocket. This would lead to the patient often “abandoning” their prescription at the pharmacy counter as they just couldn’t afford the medication. The electronic prescribing industry responded by creating the Real-Time Pharmacy Benefit Check (RTPBC), which provides that information in real time as part of the electronic prescribing process. This is expected to be a game changer for prescribers and patients. The RTPBC, or a “Real Time Benefit Tool” as the government refers to it, will be required for use by Medicare Part D in January 2021. Private insurance companies are expected to follow suit.
But there are a few critical pieces missing from the RTPBC: for one, the RTPBC only shows out of pocket cost if the patient uses their insurance to pick up the medication, the doctor has no visibility into cash price, and even if this is available, prescribers don’t always have the time to have this “medication cost” conversation with the patient during their visit. By putting this into the hands of the patient or their caregiver, they can do their own research and would know if they are better off paying cash for a prescription (if they have insurance), what they are up against financially if the drug isn’t covered, and if there are any cheaper alternatives.
So why was I, a healthcare technology consultant at a developers connecathon? I was at there because of my ongoing work on drug price transparency. This is a hot-button issue in healthcare and I have worked on the issue in various ways. As an expert in electronic prescribing standards, I can tell you these behind-the-scenes “cornerstones” of the prescribing system help ensure that the patient’s insurance, medication history and clinical information are captured and exchanged uniformly, regardless of insurance company and sites of care. I also have testified before Congress about the need for accurate, real-time drug price information at the point of care, including the RTPBC.
So back to the connectathon, as a test case, I proposed we use a popular drug that reduces pain and swelling for certain types of arthritis; it also treats certain skin disorders and digestive diseases. I knew that the drug is very expensive. It didn’t take long before that hit home. Participants in the room gasped when the cash prices at three pharmacies, known for low prices, showed up on the screen. A loud murmur filled the room when an alternative was only $25 for a 30-day supply.
After the demonstration, Bill and I had a heart-to-heart conversation. His wife was recently prescribed the high cost medication I had identified as our test drug. Following her diagnosis, he searched for information on affordable treatment options. It took a lot of time and legwork to come up with the same information the draft app provided with the push of a button.
“Having all this information in one place on my phone is a huge blessing,” Bill said. “Without it, I would have given up. The drug my wife needs is not covered by my insurance. The cash price for a one-month prescription is more than I make in a year. But now I have information I can use to ask the doctor possible affordable alternatives.”
Bill’s situation is not unique. Many patients get sticker shock at the pharmacy, causing them to abandon their prescription or not take the medication as directed to save money. This has expensive and avoidable consequences, including deaths, unnecessary doctor and emergency room visits and lost productivity. It is estimated that medication noncompliance costs the healthcare system between $100–$289 billion a year.
Bill’s story reminds me that my work is making a difference. One day, when the app we worked on (or one like it) is on the market, millions of patients can benefit from easily knowing the true, out-of-pocket costs of their prescription drugs in advance. In the meantime, having to give up my weekend to work was totally worth it.