2018 Real-Time Benefit Check National Adoption Scorecard

This first edition of the Real-Time Benefit Check National Adoption Scorecard utilizes new survey data, market research and industry statistics to present a comprehensive, objective overview of real-time benefit check (RTBC). The report serves as a baseline for industry status, and will be updated at least annually.

The report includes original data revealing patient and provider success factors for RTBC, implementation models the industry must consider as we evaluate solutions, status of RTBC adoption, and the development status of an RTBC standard led by the National Council for Prescription Drug Programs (NCPDP). The standard in development is currently limited to use cases between the payer and electronic health record (EHR) and does not account for some functionality providers indicate they value most in an RTBC solution, including cash price and availability of patient assistance programs. This report will cover all possible use cases.

The report is published with counsel from an advisory board of leaders from The American Medical Association, athenahealth, BestRx, Blue Cross Blue Shield of North Carolina, eMDs, Humana and University of Virginia Health System.

According to a survey of 1,000 patients, half did not fill a prescription because it cost too much when they arrived at the pharmacy.1

This is partially attributed to a lack of price transparency at the point of prescribing where formulary and benefit (F&B) coverage information, patient assistance, pharmacy cost and cash price options – among other cost-contributing factors - are rarely available. In situations where formulary and benefit data is available, providers indicate they do not trust the accuracy of the data. In a survey of over 1,300 providers, the average trust factor in the accuracy of F&B data was only 5.7 out of 10.2

Real-time benefit check is a technology innovation that surfaces prescription benefit details, such as patient out-of-pocket cost, drug alternatives and prior authorization (PA) information, enabling providers to make informed medication choices at the point of prescribing. An effective RTBC solution facilitates discussion between a provider and patient about the most clinically appropriate and affordable medication for the patient. By providing true price and coverage transparency, the patient is less likely to be surprised at the pharmacy and more likely to remain adherent.

RTBC & the
Patient Experience

75% of patients report they have received a prescription that cost more than they expected. 3

Cost transparency for patients is critical to successful treatment because prescription cost is the primary predictor of medication abandonment. 4 Thirty-seven percent of patients surveyed responded that they stopped taking a medication because it was too expensive.5

As a result, they abandon treatment before taking their first dose, contributing to billions of dollars each year in avoidable health care spending. Currently, medication non-adherence costs the U.S. health care system up to $289 billion and accounts for 10 percent of all hospitalization admissions.6

Eighty-six percent of providers surveyed stated that a reliable RTBC solution would benefit their patients and assist them in making more informed decisions when it comes to treatment.7

Current RTBC solutions support pharmacy benefit investigation; however, the need for medical RTBC is apparent. That being said, because the prescribing and PA process for treatment covered under medical benefits is more complex and without standardization, we expect RTBC for medical benefits to require a longer implementation. Real-time benefit check for medical benefits is often referred to as electronic benefit verification (eBV). This report will be updated as developments occur.

A donut graph with 87% of its circle filled in

The majority of patients do not expect a provider to know the cost of medication; however, 87 percent of patients surveyed indicate it would be valuable to them if their provider knows the cost of the medication they intend to prescribe.8

Stakeholders & RTBC Standard

Who Are the RTBC Stakeholders & What Do They Contribute to the Solution?

Payers, providers, pharmacies, EHR systems and pharmaceutical manufacturers can all play a role in bringing real-time benefit check technology to the point of prescribing to facilitate better prescribing decisions and improved patient outcomes.

Impact by Stakeholder

  • EHR
  • Patient
  • Payer
  • Manufacturer
  • Pharmacy
  • Provider

By participating in RTBC, EHR systems can surface better quality data and methods of providing the right information to the provider (and patient) at the right time, directly within their E-Prescribing workflow.

As it stands, many providers do not trust their current system of formulary and benefit information, so by having an innovative solution that provides true cost transparency at the point of prescribing, EHRs can improve and enhance the way providers prescribe medications.

Patients are the beneficiary of an effective RTBC solution.

They reap the rewards of prescribing decisions and increased insights when they are able to have informed dialogue with their provider about out-of-pocket cost and other factors that impact adherence at the point of prescribing. In order to avoid sticker shock at the pharmacy, patients can have more say in their care in terms of what they are able to afford and their preferred method of delivery.

Payers assist their members by surfacing the most cost-effective and clinically appropriate medication options to providers based on patient benefit information and formulary guidelines.

By participating in RTBC, payers create awareness with the provider of patient-specific benefits that dictate patient out-of-pocket cost, and have the opportunity to surface formulary and pharmacy alternatives while creating operational efficiencies when PA is required.

Payer input to RTBC solutions:

  • Patient-specific pharmacy benefit information
  • Formulary alternatives
  • PA requirement
  • Alternative pharmacies (i.e. 90-day retail or mail order)
  • Drug safety information

Pharmaceutical manufacturers can provide significant cost savings that help patients initiate and adhere to therapy through patient assistance programs. These programs provide assistance to help patients avoid out-of-pocket costs.

By participating in RTBC, manufacturers increase awareness of the availability of patient assistance programs, which can be critical when patients are evaluating if they can afford the medication. Seventy-four percent of U.S. providers agree that it would be valuable to know about availability of these programs at the point of prescribing.9

By participating in RTBC, pharmacies can provide information that is relevant to patients, regardless of their insurance (example: cash price), and have the ability to provide benefit information for all payers for any prescriptions, directed to the patient’s preferred pharmacy.

Additionally, it allows pharmacies to ensure their pharmacists and technicians are not doing the heavy lifting when it comes to providing patients with medication cost and cost assistance information, since that information was given when the patient was with the provider. This in turn could help the pharmacy fill more prescriptions, provide medication education and get the patient out the door with their medication in hand on their first visit.

Pharmacy input to RTBC solutions:

  • Cash price
  • PA required
  • Patient-specific data
  • Deductible information
  • Patient assistance/affordability programs

A provider’s adoption of RTBC directly impacts their patient’s experience. It is important that the price data be as accurate and reliable as possible.

The prescription benefit information, including out of pocket cost, is presented to the prescriber up front, within their normal E-Prescribing workflow. When displayed, the information can be utilized to drive a productive conversation between the provider and their patient. This conversation can result in the removal of cost barriers by way of assistance programs which can be understood before the patient arrives at the pharmacy to pick up their medication.

NCPDP & RTBC

There is currently no published RTBC standard; however, a standard is being developed by NCPDP. As mentioned in the executive summary, the standard in development is currently limited to use cases between the payer and electronic health record (EHR) and does not account for some functionality providers indicate they value most in an RTBC solution, including cash price and availability of patient assistance programs.

There is no timeline for the establishment and release of a standard. While the standard continues to be written, stakeholders are quickly implementing RTBC functionality to meet the demand of the industry, as illustrated by the fact that 83 percent of EHRs have already committed to a solution. We will continue to monitor for updates through NCPDP work and task groups.

The standards in development are for “Real-Time Prescription Benefit” and will include the “Telecom Standard” or “SCRIPT Standard” model.

Telecom & SCRIPT

NCPDP supports different standards for transmitting data between partner organizations. The two most widely used are the Telecom Standard and the SCRIPT Standard. Historically, while both standards transmit similar data, they have been used for different purposes.

Telecom: Supports pharmacy drug claims and workflows.

SCRIPT: Supports E-Prescribing and ePA workflows.

Real-time benefit check intersects these two purposes, and as a result, an RTBC transaction is being developed within both standards, allowing individual partners to determine which standard works best for them.

The Need for RTBC Implementation

Patients as Consumers

With the evolution of consumerism and patient access to health-related technology such as patient portals and fitness trackers, patients are insisting they participate in decisions related to their own care now more than ever.

Patients look to software such as GoodRx and BlinkHealth to research the lowest possible out-of-pocket expense and available discounts. In fact, 42 percent of patients with a high deductible have used or tried one of these platforms when deciding where to purchase their medication, indicating price shopping is on the rise.10 These tools are not as comprehensive of a solution as patients want.

Without an RTBC solution, patients are creating workarounds to improve access and adherence, such as relying on manufacturer portals to see what coupons are available.

Real-time benefit check is the answer to the growing trend of consumerism on behalf of the patient by providing the information they are looking for earlier in the prescribing process and saving them valuable time in the process.

Nearly Half of Patients Surveyed with High-Deductible Plans Have Tried Price-Shopping Platforms

Two bar graphs, one with the label 'High Deductible' filled to 42%, the other with the label 'Low Deductible' filled to 30%

The Rising Trend of High Deductibles

According to the Centers for Disease Control and Prevention (CDC) high-deductible plans are on the rise — escalating from 25.5 percent in 2011 to 43.2 percent in 2017, resulting in patients being required to pay more for their medication on the way to meeting that deductible for themselves or their family.11 High-deductible plans are defined as any plan with a deductible of more than $1,350 for an individual, and over $2,700 for a family.12

The average annual premium contributions are $1,129 for single coverage and $5,277 for family coverage. The average dollar contribution for family coverage increased 78 percent from 2006 to 2016.13

Due to these statistics, 46 percent of patients surveyed on high-deductible plans stated that the cost of medication is a burden.14 That same percentage say they price-shop at multiple pharmacies, potentially delaying therapy.

In 2017, patients spent $57.8 billion in out-of-pocket costs for medication.15 Patients having a co-pay of $50 were nearly four times more likely to abandon a prescription at a pharmacy than patients paying $10.16 Providers report discussing cost with their patients when they realize the medication may cost the patient more than $50.17

An effective RTBC solution can provide patients with what they are asking for, which is more say in the direction of their therapy and better decision support at the point of prescribing. Specific models can even offer deductible information so patients with high-deductible plans can gain understanding of what they still need to pay, and visibility into any programs that could assist them.

Worker Contribution Increased 78% in a 10-Year Period

Two bar graphs, one with the label '2006' depicting a value of $2,973 and the other with the label '2016' depicting a value of $5,277

The Path Forward

Real-Time Benefit Check Functions Required for Success

The key determinate for a successful RTBC solution implementation is surfacing the most precise patient pay amount prior to prescription submission which providers are stating does not exist within the current formulary and benefit model. Additionally, providers have to be willing to adopt a solution. In order for them to factor RTBC into their workflow, the solution has to deliver the elements they say are important, for example: cash price, patient assistance programs, PA requirements and medication alternatives.

From a patient perspective, three out of every four report that a medication cost more than they expected when they arrived at the pharmacy, and 50 percent of those same patients surveyed chose not to fill the prescription — this is why transparency at the point of care is so critical.18

RTBC Implementation Models

Each implementation model centers around the same need: surface RTBC information to the providers at the point of care when they can have a conversation with the patient about the most clinically appropriate and affordable treatment options.

There are several implementation models for EHRs by way of payer direct connect, via an intermediary solution, or both. Third-party intermediary solutions leverage direct connections to the payer or pharmacy networks, or provide an open network solution with multiple stakeholders.

Intermediary Solutions

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Payer
Network

The intermediary contracts directly with individual payers and individual EHRs to surface formulary data and patient out-of-pocket cost information to the provider. The payer provides patient-specific formulary information and rules.

An icon depicting a mortar and pestle

Pharmacy
Network

The intermediary contracts directly with individual pharmacy chains and systems with individual EHRs to surface data, including patient pay amount and pharmacy specific information.

An icon depicting an interconnected network

Open
Network

The intermediary contracts directly with both individual payers, pharmacies and EHRs to deliver detail for a patient’s benefit information and medication pay amount. An open network may also surface patient assistance programs made available through pharmaceutical manufacturers.

Without Intermediary

An icon depicting a hospital

EHR-to-Payer
Direct Connect

The EHR contracts directly with individual payers to surface formulary data and patient out-of-pocket cost information to the provider. This model would require each EHR to contract with every payer and for each payer to develop connectivity to every EHR in order to bring widespread functionality to providers.

Functionality by Solution An icon depicting a shield An icon depicting a mortar and pestle An icon depicting an interconnected network An icon depicting a hospital
Cost
Cash Price
Patient Out-of-Pocket Cost
Patient Assistance / Affordability Programs
Coverage
Deductible Information
Alternatives
PA Required
All Payer
Delivery
Mail Order
Retail Availability
Adoption
All Payer
All Pharmacy

Glossary

  • All Payer/All Pharmacy – The RTBC solution includes connections with all payers and pharmacies.

  • Alternatives – An alternative medication that may cost less than a prescribed medication but have the same therapeutic outcome or efficacy as the original.

  • Cash Price – Patient pay amount if they choose to not go through, or do not have, insurance.

  • Deductible – An amount of money a patient must pay before their health plan will pay a claim over a period of time.

  • Mail Order – Prescription medication sent directly to a patient via their pharmacy benefit manager (PBM).

  • Patient Assistance/Affordability Programs – Programs designed to help patients obtain their medication at a lower cost.

  • Patient Out-of-Pocket Cost – A payment made by a patient for a particular service or medication.

  • Patient-Specific Data – Plan/PBM details returned on an individual member level.

  • Pharmacy-Specific Information – Payment details for a patient from a specific pharmacy location.

  • Prior Authorization – A requirement from a health plan to obtain more clinical information before deciding whether or not to cover a medication.

  • Retail Availability – The RTBC solution indicates which retail pharmacies carry the medication.

EHR Availability

The integration of RTBC solutions in EHRs has the ability to transform the way providers make prescribing decisions through discussion with their patient about medication efficacy and cost factors.

When surveyed, providers cited cash price, patient out-of-pocket cost information, alternative options, PA requirements and patient assistance program availability as some of the top elements they require to have a clear plan for patient care and better conversations.19

Integrations missing these capabilities may result in a lack of true pricing information and delayed or avoided treatment for the patient.

We will continue to monitor and provide updates on RTBC adoption as it becomes available.

EHR Vendor Committed Available Functionality
Allscripts
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Amazing Charts
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athenahealth
An icon depicting a prescription medication An icon depicting a dollar sign An icon depicting a stethoscope An icon depicting a payment card An icon depicting a checkmark
Cerner
An icon depicting a prescription medication An icon depicting a dollar sign An icon depicting a stethoscope An icon depicting a payment card An icon depicting a checkmark
DrFirst
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eClinicalWorks
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eMDs
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Epic Systems
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GE Healthcare
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Greenway Health
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MEDENT
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MEDITECH
An icon depicting a prescription medication An icon depicting a dollar sign An icon depicting a stethoscope An icon depicting a payment card An icon depicting a checkmark
NewCrop
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NextGen Healthcare
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Practice Fusion
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Key

  • An icon depicting a prescription medication

    Alternatives
    An alternative medication that may cost less than a prescribed medication but have the same therapeutic outcome or efficacy as the original.

  • An icon depicting a dollar sign

    Cash Price
    Patient pay amount if they choose to not go through, or do not have, insurance.

  • An icon depicting a stethoscope

    Patient Assistance/Affordability Programs
    Programs that are designed to help patients obtain their medication at a lower cost.

  • An icon depicting a payment card

    Patient Out-of-Pocket Cost
    A payment made by a patient for a particular service.

  • An icon depicting a checkmark

    Prior Authorization
    A requirement from a health plan to obtain more clinical information before deciding whether or not to cover a medication.

Advisory Board & Sources

The RTBC National Adoption Scorecard is written and published by CoverMyMeds with guidance from industry experts on the RTBC National Adoption Scorecard Advisory Board:

  • Morgan Bojorquez

    Director, HPS Clinical Integration & Implementation

    Humana

  • Hemal Desai

    President

    BestRx

  • Evan Grossman

    Vice President, Integration Services

    athenahealth

  • Mike Hodgkins

    Chief Medical Information Officer (CMIO)

    American Medical Association (AMA)

  • Melissa Paige

    Pharmacy Patient Medication Access Principal Coordinator

    University of Virginia Health System

  • Brian Stalder

    Manager of Pharmacy Operations

    Blue Cross Blue Shield North Carolina

  • Dr. Eric Weidmann

    Chief Medical Officer (CMO)

    eMDs

Sources

  1. 1 - CoverMyMeds Patient Survey, 2018 ^

  2. 2 - CoverMyMeds Provider Survey, 2018 ^

  3. 3 - CoverMyMeds Patient Survey, 2018 ^

  4. 4 - “Prescription abandonment: a growing trend, but it doesn’t have to be” ^

  5. 5 - CoverMyMeds Patient Survey, 2018 ^

  6. 6 - “The Cost of Not Taking Your Medicine” ^

  7. 7 - CoverMyMeds, Provider Survey 2018 ^

  8. 8 - CoverMyMeds Patient Survey, 2018 ^

  9. 9 - CoverMyMeds, Provider Survey 2018 ^

  10. 10 - CoverMyMeds Patient Survey, 2018 ^

  11. 11 - “Nearly 40% of US adults have high-deductible health plans” ^

  12. 12 - “High Deductible Health Plan (HDHP)” ^

  13. 13 - “Employer Health Benefit Survey”, 2016 ^

  14. 14 - CoverMyMeds Patient Survey, 2018 ^

  15. 15 - “Medicine Use and Spending in the U.S.: A Review of 2017 and Outlook of 2022 Iqvia Institute for Human Data Science” ^

  16. 16 - “Understanding Prescription Abandonment” ^

  17. 17 - CoverMyMeds, Provider Survey 2018 ^

  18. 18 - CoverMyMeds Patient Survey, 2018 ^

  19. 19 - CoverMyMeds, Provider Survey 2018 ^

  20. 20 - Ibid ^

  21. 21 - CoverMyMeds Patient Survey, 2018 ^

  22. 22 - Ibid ^

  23. 23 - Ibid ^

If you have feedback on the content or are interested in a slide deck of the report, please email RTBCscorecard@covermymeds.com