Urgent Need for Real-Time Pharmacy Benefit Check Confirmed in Senate Committee Hearings

Share this story:

By Pooja Babbrah, PBM Services Practice Lead


In mid-March, I was invited to testify in front of the U.S. Senate Special Committee on Aging at a hearing they held focused on problems seniors face related to the increasingly high cost of drugs, as well as potential solutions.

The Patient Perspective

Senator Collins kicked off the first hearing, which was focused on patient experiences, noting that “more than half of all Americans, including 90% of seniors, take prescription drugs regularly.” She added that, “one out of four Americans has a difficult time affording their medicine.” We then heard testimony from a half-dozen witnesses.

I listened to heart-rending testimony on witnesses’ tribulations related to prescription drug costs. They spoke of crippling debt, poor quality of life, frequent paramedic visits, and cutbacks on food purchases so they could afford medication. Their stories underlined the pressing need for solutions to help patients and their providers navigate the labyrinth of prescription drug coverage and costs.

Price volatility and lack of transparency: a common theme among witnesses.

Many of the patient witnesses spoke of lack of stable coverage, as well as unpredictable pricing, and the experience of sticker shock at the pharmacy counter. Barbara Cisek, a senior citizen with multiple health issues, said that “what makes managing all these conditions worse and more stressful is never knowing what my insurance will cover from year to year and what my prescription drug costs will be.” Echoing that sentiment, another patient described arriving at the pharmacy to pick up what had been a $46 prescription to discover that the price had jumped to over $500. The reason was likely that the drug had been re-categorized to a non-covered medication. But she had no way of knowing that. Other patients expressed similar frustration over the uncertainty of their out-of-pocket costs. Senator Collins described the drug supply chain as “appallingly opaque,” adding that “navigating the complex web of prescription drug prices is not easy, even for the experts.”

Point of Care Partners (POCP) Perspective on RTPBC as a Solution

In a second hearing held the next day the committee sought proposed solutions from several expert witnesses, including myself. Since 2014, Point of Care Partners (POCP) has been working on Real-Time Pharmacy Benefit Check (RTPBC), which was the primary focus of my testimony.

Being in the ePrescribing industry since the late 1990s, I know that significant progress has been made in eMedication Management, but we still have a long way to go when it comes to important prescription cost and coverage information available at the point of prescribing. As mentioned in my testimony, RTPBC is essentially a response to prescriber challenges with benefit information. It advances transparency, but its value far exceeds that.

RTPBC standard and benefits information. RTPBC provides crucial information to facilitate conversations between clinicians and their patients about medication. It fills many of the gaps described by the patient witnesses, including the following:

  • Patient out-of-pocket costs
  • More affordable alternative medications
  • Pharmacy with the lowest-cost option for the particular medication
  • Insights into additional requirements such as prior authorization or step therapy

RTPBC goals. The goal is to provide information about coverage and cost while the patient is still in the provider’s office. So, with RTPBC the witness who learned at the pharmacy counter that his medication had increased by 700% could be informed of this by his doctor, while he’s still in the doctor’s office.

Studies show that cost is the number one reason for medication non-adherence, which can include not filling a prescription, abandoning a prescription at the pharmacy, reducing the prescribed dosage, or opting not to refill a prescription. These medication non-adherence scenarios typically lead to greater health care costs down the road, with increased office and ER visits, and potential hospitalization.

Equipped with the right coverage and cost information, providers can choose prescription options that their patients are much more likely to fill and take as prescribed. This in turn will result in greater public health.

Current RTPBC shortfalls. Though RTPBC represents a dramatic improvement in access to information on prescription benefits, the following additions would enhance its value.

  • Information on discounts and financial assistance. Information on programs such as patient co-pay assistance, manufacturer coupons or additional financial assistance opportunities is not available at the point of prescribing.
  • Prescription benefits covered under medical benefits need to be included. Only information about coverage under pharmacy benefits, not medical benefits, is included. When a drug (e.g., an expensive specialty medication) is covered only under a patient’s medical benefits, the prescriber is informed in the RTPBC transaction that a drug is not covered for the patient.
  • Patient access to information. Today, RTPBC is primarily used by prescribers through their electronic health record (EHR) system. The scope should be expanded to provide information to patients and their caregivers.
  • Cash price. Currently, just the out-of-pocket fee with insurance coverage is provided. To provide a more complete pricing picture, information about the cash price for prescriptions should also be available.

Senators then asked questions about what else could be done to address the problems with lack of transparency. Senator McSally specifically asked why we couldn’t have the equivalent of “an Expedia.com of drugs” so that patients could comparison shop. I explained that with a patient facing RTPBC we could do just that.

What’s Next. POCP has been working with the CARIN Alliance and it’s member organizations to bring RTPBC transaction directly to patients. Not only would patients be able to better understand their prescription coverage, they could see if their prescription may be less expensive at a pharmacy they normally do not use. And they would also have information on whether they’d be better off paying cash or purchasing a medication under insurance. Unfortunately, this has its downsides as well as if a patient pays cash at the pharmacy, their insurer and potentially their prescriber may not know that the patient picked up their medication. This is just one example of why it is imperative to have all stakeholders at the table when we discuss the possibility of a patient facing RTPBC transaction.

Working with payers, PBMs (Pharmacy Benefit Managers), health IT organizations, and other stakeholders, Point-of Care-Partners will continue to be involved in national efforts to advance and foster improvements in RTPBC. We’re hopeful that the Medicare Part D adoption of RTPBC will hasten the adoption by other stakeholders. Our continued collaboration with the CARIN Alliance should also yield widespread benefits. The expectation is that many providers, payers, application companies, and others will voluntarily implement a patient-facing real-time pharmacy benefit check capability, helping millions of consumers to access timely and accurate prescription drug price information.

Want to learn more? POCP is doing a lot of work around RTPBC and drug price transparency, please reach out to me at pooja.babbrah@pocp.com.