Real-Time Benefit Check: Key Insights and Challenges

A technology intended to improve pricing and dosage transparency for patients in the electronic health record is slated to become a requirement under Medicare Part D plans by 2023. Some organizations have begun work on integration already, but what are the pros and cons, and will this technology contribute to lower health care costs overall? 

Real-time benefit check (RTBC), a technology that displays a patient’s personalized out-of-pocket price for a specific drug and dose in the electronic health record (EHR) at the point of care, is slated to become a requirement for Medicare Part D plans by 2023. Some health systems are getting an early jump. In April, the American Journal of Health-System Pharmacy published a research letter about the University of Colorado Health System’s experience with RTBC, including key insights and challenges observed during a pilot program [Gross F, Sinaiko A, Podhajsky T, Lin C. Real-time medication prices at the point of care: Experiences of prescribers. Am J Health Syst Pharm. 2021;78(7):550-551. doi:10.1093/ajhp/zxaa428]

We asked a panel of experts to weigh in on how RTBC differs from other drug price-lowering initiatives; the pros and cons; chances of adoption in commercial health plans; and its potential impact on the nation’s overall drug spend. Our panelists include: 

• Debra Devereaux, MBA, RPh, principal and chief pharmacy and clinical officer, Rebellis Group, El Dorado Hills, CA
• Larry Hsu, MD, medical director, Hawaii Medical Service Association, Honolulu, HI
• Charles Karnack, PharmD, BCNSP, assistant professor of clinical pharmacy, Duquesne University, Pittsburgh, PA
• David Marcus, director of employee benefits, National Railway Labor Conference, Washington, DC
• Gary Owens, MD, president of Gary Owens Associates, Ocean View, DE
• Edmund J Pezalla, MD, MPH, founder and CEO, Enlightenment Bioconsult, Hartford, CT
• William Rogers, MD, chief medical officer, Applied Policy, Washington, DC
• Arthur Shinn, PharmD, president, Managed Pharmacy Consultants, Lake Worth, FL
• Norm Smith, principal payer market research consultant, Philadelphia, PA
• Daniel Sontupe, associate partner and managing director, The Bloc Value Builders, New York, NY
• F Randy Vogenberg, PhD, RPh, principal, Institute for Integrated Healthcare, Greenville, SC

Washington DC has certainly had no shortage of proposals and executive actions designed to lower drug prices. How does RTBC compare to these other strategies? 

Dr Pezalla: There are 2 different drug cost issues. Different strategies and policies are focused on these 2 distinct problems: (1) actual drug costs and their impact on the cost of public and commercial health plans; and (2) the drug costs seen by patients. 

Policies such as most-favored-nation or international indices are intended to lower prices to the system at large and focus on the actual costs of drugs paid for by Medicare. RTBC, like generic substitution rules, are intended to reduce the out-of-pocket costs of patients themselves but have little direct impact on drug costs to the overall health care system.

In the short run, patients will benefit more, and more quickly, from RTBC because it helps them choose therapies that are appropriate but cost less. RTBC will also benefit more people. Most-favored-nation and similar polices are focused on the most expensive drugs, which are used by a small number of people. 

Dr Karnack: RTBC will likely have a more direct effect on drug pricing compared with other strategies, since prescribers and patients will be driving the process and making decisions in real time. 

Mr Marcus: It’s a very different approach in that the prescriber is considering cost as part of the prescription process.  If applied within the context of a value-based contractual arrangement, it places pressure on prices that doesn’t exist with other strategies. 

Dr Rogers: I think it’s brilliant and it is long overdue. We practicing physicians have not a clue of what a drug is going to cost our patients. And that is particularly true if you have a patient population with multiple different payers. So it is very helpful to know which drug is going to represent the lowest out-of-pocket cost to the patient. They are more likely to be compliant, so the impact will be felt downstream. 

Mr Sontupe: RTBC is a technology that is long overdue. We have had the ability to share copay prices at the point of prescribing for years. However, our health care system continues to draw the line between the medical and pharmacy sides of care. Price transparency is unrealistic, based on the nuance around drug price—list price, rebates, distributors, wholesalers, chain markups, etc. However, the copay should be easily accessible whether you havecommercial insurance, Medicare Part D, or Medicaid. 

Dr Hsu: RTBC can potentially save money for the individual patient but may not lower drug prices overall. The authors of the research letter suggest that RTBC can be used as a lever to place pressure on total drug prices, but the jury is still out on that. 

Dr Owens: The concept of doing a real-time pre-adjudication of a pharmacy claim at the time of prescribing can educate both the physician and the patient about the cost of the intended medication and the potential alternatives.  But, as the authors note, the system that does not always recommend reasonable or appropriate alternatives. Additionally, the process could be time-consuming, especially for patients with multiple prescriptions. This could result in other important heath issues being overlooked in the interest of time during short appointment times.   

Dr Shinn: My clients use electronic prescribing, which at the point of patient contact gives the clinician an opportunity to prescribe a most cost-effective preferred agent for that specific plan. And that can save the patient considerable money. It is not always the same formulation of drug, or it may be a totally different drug, but prescribers are given that information, so they are not functioning blindly. The one benefit RTBC has over electronic prescribing without RTBC is that the physician and patient know going in what the copay is going to be.

RTBC is mandated for Medicare Part D. Why haven’t we heard more about it? 

Ms Devereaux: The directive came out late in 2019, but implementation was delayed first during the pandemic and then with the change in [presidential] administrations. 

Dr Pezalla: Many Medicare members rely on generics, with lower copays to them, for their medications. They ask for lower cost drugs and may be guided by their doctors. The RTBC will help with this but does not go into effect until 2023. It remains to be seen if there is more room for increased use of generics or lower cost brands.

Mr Marcus: We have not heard a lot about it for several reasons. It is lost in the noise of other actions, the public may not think that prescribers could be more efficient, and it doesn’t necessarily benefit the plan sponsor or insurer.  It is also accurate to state the effects are not known.

Dr Hsu: Ideally, there should be research performed to evaluate RTBC and other drug price-lowering tools. The findings in the research letter are a good first step. Once thorough research is complete, the tools can be prioritized for discussion and then implementation. I realize that is an oversimplification. It is extremely difficult and politically challenging to get consensus.

Dr Rogers: In order for RTBC to work, changes must be made to EHRs. But the insurance plans don’t own the EHRs, so it is challenging to figure out how to enforce the requirement. I don’t think that this particular regulation can mandate that EHRs comply. The Department of Health and Human Services manages EHR interoperability standards, which have been delayed due to the costs of complying. 

Dr Karnack: I think the siloed nature of EHRs is an issue. In my experience, few of the common EHRs have developed, integrated, interfaced, or evolved an RTBC provision. I agree with Mr Marcus and Dr Hsu because there are so few examples of working RTBC programs nationwide, knowing the ultimate impact is unknown. 

Ms Devereaux: In my experience, most of the EHR organizations can or have already implemented this. If you are part of a health system with providers as employees, they have access to the tool. 

Dr Owens: I suspect that there is no process in place to monitor the use of RTBC or even whether physicians can just override it and move on.  As far as impact goes, one would need a way to monitor costs before and after implementation. 

Mr Sontupe: RTBC may not end up having much of an impact. Many providers will prescribe the drugs they believe in most. Sure, RTBC might suggest a generic, but if a prescriber thinks a newer brand will get the best outcome, the lower out-of-pocket cost will most likely not change prescribing.

Mr Smith: But then you run into the issue where the patient says the copay is too high and does not pick up their prescription. The threshold dollar amount for prescription abandonment is not that high. So giving patients money in the form of low or no copay is beneficial. I think the big problem with RTBC is it will be difficult to implement through executive action. Legislation will likely be needed. 

Can you expand further on the benefits of RTBC? 

Ms Devereaux: There has long been minimal knowledge by providers about the costs of medication to patients. Conversions between capsules and tablets, brand and generic, and dosage strengths are helpful to providers and benefit the patient. It also saves a lot of time for providers and patients both to avoid the submission of a coverage determination request—which takes additional time and effort—and delays therapy in some instances. 

Dr Owens: Most of the time both prescribers and patients are unaware of the actual costs of medications, because a third party pays most of the cost. RTBC can help educate both on cost considerations. I think the key issue will be whether the provider and patient will take the time to actually use the comparative information. If used properly, it could lead to informed discussions about less expensive but equally effective therapeutic options.

Dr Rogers: The physician is not at all interested in getting the screaming complaint the day after a patient visit that the prescription is going to cost them $300 to fill when the physician could have written something that is equally effective and cheaper. I’d be very receptive to a tool that told me which formulation of the drug or which alternative would result in the lowest out-of-pocket
cost. 

Dr Pezalla: Many patients are aware of lower cost generics, and in most states, pharmacists will provide or substitute AB rated generics. RTBC expands the information provided to patients from just AB rated generics to medications that may be therapeutic equivalents but are not identical to the requested medication. This creates more opportunity for selection of lower costs drugs based on the patient’s drug benefit. It also reduces the time spent contacting providers for changes. It improves efficiency for the provider and pharmacist and makes the process smoother and less time consuming for the patient. 

Mr Marcus: There may be some residual savings to plan sponsors and insurers as well, but we do not yet know for sure. RTBC primarily benefits the patient. 

Dr Karnack: From a patient care standpoint, prescribers knowing the financial impact of prescriptions to be filled is a critical element of compliance. It also saves time, increases transparency, and decreases the need for prior authorizations and step therapy. It is possible that prescribers may alter their overall prescribing habits as a result of seeing what a drug costs patients in real time. 

Mr Sontupe: Transparency has value. A physician should be aware at the point of care that a 100-mg tablet has a lower copay than a 50-mg tablet and share how to split the tablet to save the patient money. However, as I mentioned previously, switching based on copays of different classes of medication will provide little change if the physician believes in the original medication choice.

Dr Vogenberg: RTBC sounds good, but it may be an altruistic concept that is harder to implement in the real-world mix of drugs with a rapidly changing pipeline.  

What are the drawbacks of RTBC? 

Ms Devereaux: There are many medications that have different mechanisms of action [that are more appropriate for the patient] vs the least costly generic. This is especially true for many chronic diseases.

Additionally, the drug names need to be standardized by generic names, strengths, and then brand names so that comparisons are able to be made by the provider. Training for providers in the correct usage is key. The tool is available on almost all EHR platforms at this time so interoperability is not a huge issue. 

Mr Smith: If the primary driver of RTBC is the price of the drug, that can be a problem. What about compliance, efficacy, and safety? The drug selected should be the best one for the patient based on all of these factors, not just price. 

Mr Sontupe: I agree. It is important for patients to get the right product, not the cheapest product. It comes down to aligning incentives. 

Dr Vogenberg:  Selecting the wrong product—or choosing simply based on price—could negatively impact medication compliance, especially in the senior population.

Dr Owens: I think the big issues are the time it takes to review the information with patients and the fact that the algorithms in such a system may not always provide useable information.  However, these can be overcome with continuous improvement in the logic. That will depend a good bit on provider feedback that may not happen, also due to the time it takes to provide such feedback. 

Dr Hsu: Lack of time is an important factor to consider. RTBC requires additional work for the physician to access the information, review it, and make a decision. Physicians are already overworked and may not welcome another tool. The system must be user friendly.

Dr Vogenberg:  I don’t think we really know how easy or difficult this will be to implement and sustain in the face of a changing mix of marketed
products. 

Dr Pezalla: There could be downsides, especially when a physician is attempting to solve a particular patient problem. For example, tablets may be cheaper but the patient may have more trouble swallowing them than the capsules. Other more serious issues can also arise that would then require more discussion with the patient to explain why a more expensive medicine is required.

EHR systems are very different and require a lot of fine tuning. It will take some time to integrate into the systems, and especially to avoid miscommunication. If brand names are to be included, they should include the generic name with a note that only brand is available. This may be difficult and expensive to achieve. 

Additionally, some patients might be concerned about being steered toward lower price drugs, which they may equate with lower quality or efficacy.

Dr Karnack: We should be careful not to dismiss the potential drawbacks. Prescribers confuse brand and generic names; software can choose a poor therapeutic substitute. The patient’s disease states and stage can impact drug dosing.  Also, RTBC may be less useful with complex patients.  Slow response from the EHR could be an issue. However, my biggest concern is a lack of standards for EHRs to communicate with prescribers, pharmacy benefit managers, insurance companies, health systems, community and chain pharmacies, and government agencies. 

Dr Rogers:  I don’t see most of these issues as drawbacks. To me they are failures of implementation. When the software first comes out it is going to be imperfect, but that is the sort of thing that the programmers sort out over time. 

Mr Smith: It will be interesting to see more results like the ones presented in the research letter. Taken together, they can be analyzed to determine whether or not RTBC is an effective strategy. If more people who were switched to a drug with a low or no copay ended up in the hospital, that would be good to know before a more extensive
rollout.  

What are the chances that RTBC will eventually be adopted for commercial plans? 

Dr Pezalla: The chances are high for uptake by both commercial and Medicare D plans given the upside for the plans to save money and the need to be competitive. RTBC could be a selling point for both consumers and self-insured clients. This will have the impact of increasing use of lower priced drugs and preferred drugs. 

In fact, this rollout is already starting. Last fall, Prime Therapeutics announced the introduction of RTBC through the DrFirst program. 

Ms Devereaux: As is often the case, once something begins in government programs, it is often implemented in commercial plans, employer group plans and the ACA.

Dr Owens: Once the technology is in place and working well, I think it could be easily adapted to any payer or plan.  

Mr Marcus: RTBC seems to be a natural fit with members who are enrolled in high-deductible health plans or health savings account-qualifying plans. Such a mechanism would be appealing to both commercial insurers and employer sponsored plans.

Dr Karnack: Once benefit is demonstrated, word is going to spread, and any EHR vendors who have not implemented RTBC will feel pressure to do so. 

Dr Hsu:  As Dr Shinn mentioned at the outset, e-prescribing tools already exist in the EHR. Expanding this functionality to include cost to the patient at the point of care is not a major leap. 

Is it possible that (at least initially) cost shifting might occur if the mandate is limited to Medicare Part D? 

Dr Pezalla: It is possible that pharmaceutical companies will adjust by shifting rebates to commercial plans. However, plans can counter by restricting use. 

Mr Sontupe: If the Medicare D prices come down, I think pharma will make this up in volume. If cost is the biggest driver of non-compliance, then lower prescription out-of-pocket costs will drive better adherence and overall revenue.

Which is more likely: RTBC will lead to increased drug prices outside of Medicare Part D or as the researchers suggest, downward pressure be placed on the nation’s overall drug spend? 

Dr Pezalla: Downward pressure is the most likely medium- to long-term possibility. As mentioned, in the short term we may see some adjustments of rebates shifting costs toward commercial plans, but that will be tempered by adoption of the program by commercial plans.

Dr Shinn: On paper it appears that overall cost reduction is possible, but we don’t have data yet that demonstrates this. We need good studies that shows RTBC saves money. 

Mr Marcus: I think the revenue shift to other payers is more likely. In plans where members have a fixed copay, they are likely to be indifferent to changes unless there is compelling financial argument. This would require tier shifts and I don’t think there is sufficient volume for pharmaceutical manufacturers to reconsider formulary positioning financial adjustments.

Dr Owens: I agree that cost-shifting is a possibility, but pharma has always been adept at managing through such initiatives. 

Dr Vogenberg: It’s complicated because there are so many moving parts. Ultimately, lowering the drug spend in Medicare Part D could upend the value proposition for manufacturers and create the inability to be competitive in commercial plans. Third party payers and the supply chain might also be negatively impacted. 

Mr Smith: One stakeholder no one will feel sorry for is the pharmacy benefit manager (PBM). PBMs are not really interested in transparency. 

Dr Rogers: Actually, I think RTBC works to the PBMs’ advantage because if a drug is used with very little out-of-pocket cost, the formulary and the plan will try to steer the patient toward that drug because it is the one that costs them the least in the wholesale market. 

Dr Shinn: The PBMs that that I deal with would see RTBC as a benefit because it gets them involved with the prescriber right up front. 

Ms Devereaux: In general, I believe that Medicare Part D drug pricing is going to decrease through transparency and perhaps a negotiation requirement. There will be a period when manufacturers try to recoup revenue through cost-shifting to the private marketplace and by increasing the price floor for all drugs, including specialty medications. 

Are you suggesting there is a better way for pharmaceutical companies to drive revenue? 

Ms Devereaux: Yes. As evidenced by the impressive speed by which COVID-19 vaccines were designed and manufactured, the innovation potential from pharmaceutical manufacturers is endless. New medications that cure cancer, ameliorate devastating and crippling chronic diseases, and improve the daily life of patients would be welcome goals. 

Featured Sidebar: A Pharmacist’s Perspective on RTBC 

By Catherine Cooke, PharmD, research associate professor, University of Maryland School of Pharmacy, Baltimore, MD

When initiating a new treatment, we focus heavily on the balance of benefits and risks with an impression of relative cost. It is easy to distinguish that generic medications are less costly than brand medications, and medications on lower formulary tiers are associated with lower out-of-pocket costs for patients. But it is impossible to accurately know the cost to the patient. Moreover, the complexity of incorporating cost into prescribing decisions has increased in recent years because more therapeutic options are available, and contracting strategies with pharmaceutical manufacturers that affect drug costs are becoming more complicated.

In the past, we performed lots of manual processes. We would call the pharmacy and have them run a test claim. We would review the formulary coverage documents. We would also provide the patient with written prescriptions for different products to fill whichever one was least expensive. Now, RTBC offers the promise of not having to do these manual processes. But these tools need to be made available and to interface with e-prescribing systems. Plus, prescribers need training. Most aren’t yet using these systems for a number of reasons, including technological challenges and a lack of perceived value. There are also unintended consequences that will need to be addressed once RTBC is implemented. 

Even with the promise of RTBC, affordability is still a major concern. For example, the recent explosion in availability of antihyperglycemic medications provides more options for people with diabetes. However, these medications are expensive, leading to a high first fill failure rate. About 1 in every 5 people fail to pick up their newly prescribed diabetes medication. Strategies that more directly affect the cost of a specific medication will have a greater impact on reducing first fill failure and improving secondary medication adherence.