By Kyle Kiser
Achieving “price transparency” in healthcare feels more urgent today than ever. A recent Kaiser Family Foundation poll found out-of-pocket healthcare costs were a top concern for voters across political affiliations, with more than 40% worried that they will not be able to pay for their health insurance deductible or their prescription drug costs. While current price transparency legislation has made cost data more widely available, these rulings have not gone far enough, since simply transacting data does not bring affordability to patient care. We need to do more to reduce the cost of care. Price transparency must enable better decision making on behalf of patients, while providing visibility into lower-cost options.
Today, new technology platforms offer a complete view of prescription costs, restrictions, and availability, allowing patients to get the care they need at a price they can afford. In this way, price transparency tools can significantly increase patient access by mitigating surprise costs and creating the best care plan possible, resulting in increased adherence and better health outcomes. Government regulation combined with technology can achieve this goal – however, both need to work more cohesively to positively impact patients and providers.
The State of Price Transparency Today
New price transparency rules from the Centers for Medicare and Medicaid Services (CMS) will go into effect this year, mandating that insurers post pricing information for covered items and services – just as hospitals were obligated to do starting in 2021. CMS is aiming to create an ecosystem where patients have clarity around the cost of care and services, while simultaneously driving down pricing and helping patients “shop around” for the best options.
Unfortunately, those efforts have encountered obstacles. For one, discrepancies exist in the reported prices of items and services, which undermine the initiative. It can also be difficult for patients to digest the information provided to them, which can include technical language and may require a high degree of healthcare literacy. Patients still primarily rely on providers to select the best care options, but there is no single place to find all of this information and decipher it. Challenges remain in realizing price transparency for hospital services despite the rule going into effect in January 2021, and this experience forebodes similar delays in insurer pricing.
Today, the cost of prescriptions is still far too high and providers continue to struggle to understand each individual patient’s benefit details. In 2019 alone, U.S. citizens spent more than any other nation on medications, at an estimated $1,000 per person. These costs are unsustainable, and many patients are abandoning their medication regimen and allowing their health to suffer as a result.
As prescription price transparency mandates begin to take hold, providers are constantly searching for ways to optimize value and make the information understandable for their patients. The CDC published a report noting that increased drug costs negatively impact medication adherence and overall physical health, as patients are less likely to purchase medication that is more expensive than expected. While these policies are pushing for transparency and increased interoperability, legislation will not be enough to provide a successful result for patients and providers.
Technology Driving Price Transparency
Real-time prescription benefit (RTPB) technology has emerged as a tool that can give providers and patients complete access to data so that they can make informed decisions around their care. These data include cost and coverage information, prior authorization restrictions, quantity limits and step therapy alerts, among others. RTPB tools are also increasing efficiency by providing recommendations such as prescribing a different drug delivery mechanism (e.g. capsule vs pill) or pharmacy location to save patients time and money.
While RTPB tools have existed for years, many of these tools use historical data and only present a cost average. Patients and providers only benefit when looking at patient-specific pricing in real time. The newest RTPB systems do not require the heavy administrative work that characterized previous generations of price transparency tools and are contributing more meaningfully to a transparent healthcare ecosystem.
RTPB technology can also be combined with reporting tools to help reduce prescribing variability, provide a robust order history, and identify behavior change opportunities. Care teams can use these reporting tools to see what is working and what isn’t and make improvements to provide better overall care.
Improving Access to Care
One challenge in the prescribing space today is that RTPB transactions require real-time, up-to-date eligibility data. Currently, a lack of eligibility data prevents a significant portion of price transparency checks, restricting RTPB platforms from showing providers and their patients lower-cost options that may exist. We need to continue to push for eligibility requirements as well as a broader interoperability movement in which patients and providers have access to comprehensive coverage and cost data – not just for prescription benefit, but all medical services at large. Only then can patient access and understanding of care truly become a reachable goal.
Price transparency legislation that builds on existing initiatives from CMS, combined with innovative and interoperable technology, will help providers and their patients understand the cost of their care. By mandating eligibility data be present in prescribing workflows, CMS can foster innovation and empower RTPB platforms to increase access to therapy. With legislation and technology working in tandem, we can help patients find the lowest-cost options, resulting in fewer price surprises, higher adherence rates, and improved overall health outcomes.
Kyle Kiser is the CEO of RxRevu, a leading provider of integrated solutions that improve patient access to care.
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