Real-Time Benefit Check Solutions Pull in Functionality To Help Solve Prescription Abandonment

February 11, 2019  |  By Miranda Gill MSN, RN, NEA-BC, Senior Director of Provider Services & Operations, CoverMyMeds

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Prescription abandonment is a major problem plaguing the U.S. health care system. When patients realize they can’t afford their prescribed medications, they often opt not to fill them. And in many cases, they don’t learn the true prescription cost until they’ve left their provider’s office and arrive at the pharmacy.

Prescription cost is the top cause of medication abandonment, making cost transparency at the point of prescribing critical to successful treatment.

According to a survey of 1,000 patients, 75 percent have been prescribed a medication that cost more than they expected. Consequently, half reported that they have avoided filling a prescription because it cost too much when they arrived at the pharmacy, while 37 percent reported that they stopped taking a medication because of the refill cost.

This type of medication non-adherence contributes to billions in costs to the U.S. health care system, including costs related to emergency department visits and hospital readmissions (often due to treatable symptoms).

Solving for these issues seems straightforward enough: tell patients how much the medication will cost them, at the point of prescribing, and determine if it is affordable to them. However, true prescription cost transparency is multi-faceted and complex.

Providers are often the only stakeholder to interface with patients before they arrive at the pharmacy, and when armed with accurate pricing information, providers can help reduce prescription abandonment. First, they can explain and set realistic expectations around prescription cost, helping to alleviate patient sticker shock. They could also recommend alternative, clinically appropriate medications that meet the patient’s affordability needs. Finally, they can determine if patient assistance programs exist to help the patient pay for their recommended prescriptions.

To provide patients with accurate cost information, providers need true prescription cost transparency in their e-prescribing workflow. This can be accomplished through a real-time benefit check solution that includes:

  1. Alternatives: A different, but clinically appropriate, medication may exist—at a lower cost than the originally prescribed medication. An alternative with the same therapeutic outcome and lower out-of-pocket cost may impact the patient’s ability to fill their prescriptions.

  2. Cash Price: The amount a patient has to pay if they choose to not go through or do not have insurance. With the cash price readily available at the point of prescribing, providers can discuss potential issues with patients, review alternative medications and offer any available assistance programs. This helps give patients confidence that they can afford their prescribed therapies.

  3. Patient Assistance/Affordability Programs: These programs, designed to help patients obtain medication at a lower cost, can make the difference in whether prescriptions are abandoned. If providers had this information when prescribing, they could encourage eligible patients to apply.

  4. Patient Out-of-Pocket Cost: Even if the patient has insurance, out-of-pocket costs are often unknown until they arrive at the pharmacy. With this knowledge, providers can help a patient understand exactly what they will pay for their prescription at the pharmacy, helping to reduce sticker shock and increase the likelihood that they’ll remain adherent.

  5. Prior Authorization (PA) Requirement: The traditional, paper-based PA process on average can take days, or even weeks, to receive a determination. If a provider knows at the point of prescribing whether the patient’s health plan will require them to obtain more clinical information before deciding to cover a medication, they can immediately begin working to complete the PA request. With a comprehensive real-time benefit check solution, the provider can proactively initiate a request electronically for any medication and all health plans, helping to streamline the prescribing process and increase speed to therapy.

The key factor for a successful real-time benefit check implementation is whether the solution can surface the most accurate patient pay amount prior to prescription submission. Providers indicate this does not exist within the current formulary and benefit model, and more than 80 percent agree that better accuracy would make their jobs easier.

To learn more about real-time benefit check solutions, including a comprehensive, unbiased look at the various implementation models, read the 2018 Real-Time Benefit Check National Adoption Scorecard.

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