Three Ways Health Plans Can Address Inefficiencies and Medication Adherence

It is well known that Americans are grappling with rising health care costs and that all sectors of the health care industry have a role to play in addressing this issue.

A 2018 JAMA study found that 8% of national healthcare spending in the U.S. was spent on administrative and governance costs and 54% of surveyed physicians in the U.S. identified time spent on administrative issues related to insurance claims as a significant problem.

Additionally, the implications of non-adherence go beyond patient outcomes and impact the entire healthcare system. Research shows that patients who do not take their medication are more likely to be hospitalized, which is significantly more expensive than ambulatory patient care. Over $105 billion of avoidable healthcare costs have been attributed to non-adherence in the U.S. annually.  

Fortunately, technological advancements can help alleviate both of these issues. Here are three ways health plans can reduce administrative burdens and help improve medication adherence.

Eliminate Faxes and Phone Calls

Medication prior authorization without automation and modern technology is a burdensome and costly process. Doctors and staff waste valuable time tracking down information, filling out forms, and responding to requests via phone calls and faxes. A 2019 American Medical Association data brief found almost 30% of physicians and their staff wait at least three business days for a prior authorization decision from health plans.

This complicated manual process has an impact on health providers and also on patients—who must wait (and wait) for their medication. In fact, in a survey earlier this year, we found that nearly one-third of all patients reported not taking medication because it took too long to fill.

The opportunity to automate the medication prior authorization process is well known. In a recent poll by America's Health Insurance Plans (AHIP), 84% of health plans identified automating the prior authorization process as one of the most significant opportunities for improvement.

Electronic Prior Authorization integrates directly with prescribers' and specialty pharmacists' electronic workflows, enabling them to quickly and easily obtain prior authorizations so patients can start on their medications sooner. Providers can do rapid prior authorization approvals while patients are still in the office, which allows them to have more time for meaningful patient engagement and eliminates surprises for patients at the pharmacy. And a vast majority of health plans have found positive impacts from prior authorization programs on quality of care, affordability and safety.

Boost Medication Adherence

Health plans have sophisticated tools to understand and analyze medication adherence, yet the real challenge has been informing physicians of this information in a timely manner within their workflow. Socio-economic factors like income, transportation difficulties and health illiteracy are among the myriad reasons for patient non-adherence.

Being able to identify adherence issues and gaps in care is critical for getting the best outcome possible. By using tools like Surescripts Insights for Medication Adherence, clinicians can be informed about potential patient non-adherence and gaps in care at the point of care. Specifically, it provides patient-specific medication real-time messages from pharmacy benefit managers (PBMs) and health plans within clinicians' electronic health records workflow.

Clinicians can use this information to talk to their patients and get to the root cause of medication non-adherence, whether it is due to unpleasant side effects or difficulty paying high out-of-pocket costs at the pharmacy. And it can help inform physicians about the most important gaps in care that impact quality and outcomes for their patients.

Increase Medication Affordability

Over half of patients have poor medication adherence because their prescriptions are too expensive. Finding a more affordable alternative has historically been a time consuming and frustrating process. Care providers had to search the internet, read PDF files, or use apps on their phones to try to find the lowest cost medication for their patients.

But with technology available today, like Surescripts Real-Time Prescription Benefit, prescribers and pharmacists have access to patient-specific cost of medications based on their plan, deductible and out of pocket spending for the year. Additionally, the tool shows physicians and pharmacists alternative medications and the cost of these alternatives. This allows them to work together with their patients to identify and remove price barriers so patients can get the medicine they need.

Health plans that implement a real time benefit tool now will be in compliance with the new Centers for Medicare & Medicaid Services (CMS) rule, which requires Medicare Part D health plans to adopt real time benefit tools that are capable of integrating with at least one prescriber's electronic health record. This new CMS rule that takes effect on January 1, 2021, will help patients get the necessary medications at an affordable cost.

In an increasingly value-based world, health plans need tools that streamline administrative healthcare processes and boost medication adherence. This will not only help drive down costs but also help improve patient outcomes more than ever before.

Visit Surescripts Intelligence in Action page to learn more about these tools and other actionable insights.