This is the second in a series of articles that looks at the current state of drug cost transparency for prescribers, pharmacists, and patients. The first article can be found here.
The first article in this series looked at both the promise and challenges with Real Time Prescription Benefit Check (RTPB). RTPB is designed to provide drug cost information at the point of prescribing through electronic health records (EHRs).
While an important addition to provider workflow, confining drug cost transparency to the point of prescribing limits potential savings in several ways.
First, the EHR e-prescribing workflow is mainly designed to support the process of prescribing new medications. Prescription renewals for existing medications are a separate workflow that is often delegated to support staff who are not authorized nor licensed to change medications. These staff members are typically authorized to renew a limited number of medications based upon drug type but often require having the patient to come in for a follow up appointment with the prescriber to make more significant changes. Since the majority of a Plan sponsor’s drug spend is on maintenance medications, requiring periodic renewal as opposed to new prescriptions, the effectiveness of RTPB is limited primarily to newly prescribed and acute drugs, which leaves the majority of saving opportunities unaddressed.
A second significant shortcoming of RTPB also relates to provider workflows. Prescribing a new medication is most commonly performed at the very end of a clinical encounter and after discussion of diagnosis and treatment plan are completed. Often it is the final step before the clinician moves on to the next patient and not necessarily an optimal time for contemplation and reconsidering of clinical alternatives.
A third significant shortcoming of RTPB is the limitation in empowering clinical pharmacists to assist in optimizing medication regimens. Over the past few decades, the roll of clinical pharmacists as part of the patient care-team has expanded significantly. Driven by market forces including Medicare Star Ratings, Value-Based Care and accountable care organizations (ACOs), these pharmacists are focused on medication adherence, therapy appropriateness and cost-efficiency.
Some are able to prescribe or change medications based upon Collaborative Practice Agreements and others work closely with prescribers to change medications on behalf of their patients. Cost transparency from RTPB is not always available to them because they may not have access to EHRs and RTPB information and are often tasked with making decisions based on limited data in formats that are challenging to work with. Arguably, lower-cost therapeutic alternatives should be an important consideration in any clinical pharmacist’s recommendations and engagement with patients especially for those often targeted through MTM and related medication utilization programs.
RTPB and the focus on new medications means that patients on existing therapy do not fully benefit from savings achievable through drug cost transparency. RTPB for new medications is, therefore, necessary but not sufficient to harness the power of drug cost transparency which optimally would entail:
- Delivering drug costs and lower cost alternatives to prescribers in EHR workflows for newly prescribed and existing maintenance medications.
- Engaging prescribers with lower cost alternatives early in the patient encounter.
- Providing a proactive approach that empowers clinical pharmacists to identify lower cost therapeutic alternatives and savings information based on the patient’s formulary and patient specific data including patient-specific costs, alternatives and savings.
While many payers have limited their drug cost transparency efforts to RTPB at prescribing in EHRs, others, led by Blue Shield of California, have collaborated with key medical group partners and reported tens of millions in drug cost savings by targeting drug costs transparency for maintenance medications integrated into prescriber and clinical pharmacists workflows.
"Physicians and their staff see patient-specific reports for Blue Shield of California members listing lower cost alternatives to existing medications at the outset of office visits” explained Salina Wong, PharmD, senior director of pharmacy at Blue Shield of California. “Since the reports are integrated into EHR workflow and triggered automatically by patient appointments, enhancing cost effective prescribing becomes part of the patient encounter.”
Dr. Elsie Wong, PharmD, staff pharmacists at Torrance Memorial Medical Center, explained that “our health system pharmacists can request and securely receive lower cost alternatives for cohorts of Blue Shield of California patients. Information is provided for all the medications the patients are currently taking. The pharmacist can then work with patients directly or with the prescribing physicians to move patients to lower cost clinically equivalent alternative when appropriate, reducing costs and overall cost of care. We wish that all of our patients could benefit from this level or service.”
"By collaborating with key provider groups, Blue Shield of California has created a system for ongoing drug cost savings through transparency covering new and maintenance medications. It is our hope that this approach will be adopted by other players in the healthcare system."
Edward Fotsch, M.D., is CEO of Gemini Health.