We’ve all seen the headlines—the cost of healthcare is increasing. According to the Centers for Medicare and Medicaid Services (CMS), retail spending on prescription drugs will increase from $335 billion in 2018 to $560 billion in 2028. This costly burden can limit the access that patients have to the treatment they need. In fact, just a $10 copay increase raises the likelihood of prescription abandonment by 10 percent. And the ripple effect of a patient’s non-adherence to medication is felt throughout the healthcare system, contributing to 10 percent of hospital admissions.
With chronic conditions on the rise, mounting economic pressures and increasing expectations for convenient consumer experiences, medication access and affordability are at the forefront of the national healthcare conversation. A majority of pharmacists (82%) and two-thirds of prescribers say the cost of prescriptions is one of the top three issues facing healthcare today, and 19% of patients report their ability to afford medication has become harder in the past 18 months.
So what are we doing about it? I recently sat down with Mike Pritts, Chief Product Officer, to explore how Surescripts is driving innovation in prescription pricing tools.
When a prescriber doesn’t know how much a prescription will cost their patient, the downstream impact can be so far-reaching. What’s at stake here?
When patients are caught off guard by costs or prior authorization requirements, they lose trust and satisfaction in their provider. They may abandon treatment, creating worse outcomes and higher costs. Those consequences can range from administrative headaches like restocking a prescription to significant clinical events like hospital readmission, but they all add up to a serious problem for all of us. Consider diabetes and chronic obstructive pulmonary disease (COPD)—two of the most common chronic conditions. Both are treatable with medicine, but insulin and COPD inhalers can be costly. When patients can’t afford treatment, they are at risk of significant, sometimes life-threatening, complications, and they can add significant cost to the system.
Why is this such a tough nut to crack?
Until recently, healthcare providers lacked tools to easily choose a prescription that they're confident a patient can access, afford and adhere to. What should be a simple process actually has heavy administrative burdens. But all of that changes when clinicians have accurate information on pricing and prior authorization requirements in their electronic workflow, at the point of care.
“All of that changes when clinicians have accurate information on pricing and prior authorization requirements in their electronic workflow, at the point of care.”
What options are out there?
Prescription pricing is extremely complex, and there’s been a ton of innovation in this space, but not all approaches are created equal—many take the patient’s provider out of the decision-making process or don't leverage the patient’s benefit plan. There are tools that deliver price information directly to patients through a variety of channels.
Our approach is different. There are a couple of non-negotiables that we established at the outset. First, we give prescribers and pharmacists access to benefits-based, patient-specific information directly in their electronic health record or pharmacy management software. Second, we protect the patient's choice of pharmacy and prescriber's choice of therapy. This means no steerage to just one drug or pharmacy.
“We protect patient and provider choice. This means no steerage to just one drug or pharmacy.”
What does that look like for providers who use Surescripts Real-Time Prescription Benefit?
Our service gives clinicians, including both prescribers and pharmacists, access to patient-specific price and coverage information straight from their benefit plan. They can view out-of-pocket costs for the selected medication and multiple therapeutic alternatives, if available from the benefit plan. Medications requiring prior authorization are flagged, and prior authorization can be initiated within the same workflow.
Other approaches deliver price information directly to prescribers through their health technology software, so how is our approach different?
It really comes down to those two non-negotiables: we deliver benefits-based, patient-specific information in the provider’s electronic workflow, and we protect patient and provider choice. There are other approaches that share estimates or comparisons, but these present challenges. If a prescriber has to use multiple tools in different ways, with different price options available, then it could steer them away from a patient's chosen pharmacy and add confusion to the conversation with the patient.
We’ve seen remarkable progress in terms of adoption of Real-Time Prescription Benefit. How are we continuing to enhance the service to improve providers’ experience?
That’s right, we just hit a big milestone with more than half of all prescribers now using Real-Time Prescription Benefit, so there is clear demand. And we’ve seen measurable impact from a number of pharmacies who are using the service since we rolled it out to them last year. But we do hear from prescribers about the need to always return a response with a price when they send a request. Until now, that wasn’t possible for uninsured patients or patients whose benefit plan isn’t connected to our service. Today, about 11% of Americans are uninsured. And, while we’ve made significant progress connecting most health plans and pharmacy benefit plans to our service, there are still some gaps in our coverage. In our research, prescribers have told us that they will have a better experience and are more likely to use the service, if we can return a price each and every time it’s requested.
So, in response to market demand, we’re adding a new feature and pursuing new relationships with other technology providers to address this. Now, if a patient doesn’t have insurance or their health plan or pharmacy benefit plan isn’t already connected to Surescripts, then we can display a price derived from accepted payer programs for the selected pharmacy. With this information in hand, clinicians can make more informed prescribing decisions in collaboration with their patients. We just started to introduce this aspect of our service, and health technology vendors need to implement a software update in order to make it available, but we expect this will help drive further adoption.
So how does this feature work for the prescriber?
When we developed this feature, it was important that we stay true to those non-negotiables, especially protecting the patient's choice of pharmacy and prescriber's choice of therapy. This new feature is not consumer-facing, and it doesn’t provide multiple price options or estimates. It’s delivered to the prescriber, who can share the price with their patient and tell them how they can access the price at the pharmacy.
And what about when the prescription arrives at the pharmacy?
Again, we kept those non-negotiables in mind when we developed this. Just like any other prescription, the price isn’t presented to the pharmacist. When the patient arrives at their chosen pharmacy to pick-up their prescription, and the new feature was used by the prescriber, it’s up to the patient to present the price to their pharmacist, and the pharmacist can honor the price or offer the patient their own alternate price. And of course, this is only for uninsured patients and patients whose health plan or pharmacy benefit plan isn’t already connected to Surescripts. The vast majority of the time (nearly 200 million times just in the first six months of this year), we deliver a price based on the individual’s benefit plan.
You mentioned that pharmacies who are using Real-Time Prescription Benefit are already realizing measurable results. Can you share more about that?
You know, we’re out in the field talking with providers all the time. And we’ve heard some incredible stories. One that really resonated with me is an independent pharmacy in New York City whose patients mostly depend on Medicare and Medicaid. They implemented Real-Time Prescription Benefit last year and cut processing time for prescriptions with cost concerns to just five minutes—a 75% reduction. And their medication pickup rate, that used to be around 60-70%, increased to almost 90%.
“With the push of a single button, our staff now has immediate access to each patient's benefit information. Information that used to require multiple steps and several minutes to gather now appears right away.”
So what’s next? What’s the future look like?
Innovation is everywhere, and we’re right in the middle of it. There are so many avenues to explore new opportunities down the road. We are paying attention to the many models that are being developed as the market evolves to ensure we’re always delivering a valuable service. As I mentioned, we’re always looking to enhance the provider experience, and that includes pharmacies. We brought Real-Time Prescription Benefit to pharmacies last year and baked it into the electronic workflow of those who have adopted it. Pharmacists are critical members of patient care teams, so this tool is incredibly powerful there too. Some of our early adopters have seen some really impressive results right out of the gate—both in terms of time savings and efficiency and, importantly, patient adherence to their medications.
There’s no question that rising drug costs, the burden of manual prior authorization and lack of insight on therapeutic alternatives negatively impact medication adherence and present a major challenge for prescribers, pharmacists and patients. My conversation with Pritts opened my eyes to how much is happening in the market today, and how quickly things are changing. Innovation is driving us down the right path, but there’s more work to do and innovation will continue. To realize the full potential of prescription price accessibility, we must continue working to connect prescribers, pharmacies, health plans, and pharmacy benefit plans nationwide. Patients expect (and deserve) high quality and affordable care. Clinicians expect quick and easy access to patient information. With Real-Time Prescription Benefit, we are making it happen.
Learn more about Real-Time Prescription Benefit and download the Surescripts data brief, “COVID-19 Heightens the Need to Improve Interoperability, Provide Price Transparency & Relieve Burnout,” to learn more about how technology is transforming healthcare.