Real-time prescription benefit tools in the electronic health record: working towards greater value for prescribers and patients

From the 2021 HVPAA National Conference

Brittany Tsou (Wilmer Eye Institute, Johns Hopkins University School of Medicine), Michael Fliotsos, Tanvi Mehta, Jeremy Epstein, Jessica Merrey, Erika Smith, Jeremy Schwartz, Bradley Crotty, Fasika Woreta

Background

In the United States (U.S.), prescription drug spending surpasses that of any other country in the world. Given the growth of high deductible health plans with higher patient out-of-pocket requirements, patients increasingly face high medication costs; patients frequently cite this financial burden as a reason for not filling medications at the pharmacy. To address this issue, the Centers for Medicare and Medicaid Services mandated that Medicare Advantage and stand-alone Part D plans adopt electronic real-time prescription benefit (RTPB) tools in electronic health records (EHRs) in 2019. Several commercial vendors now provide RTPB tools that display to prescribers both the patient’s out-of-pocket cost as well as any appropriate alternatives based on the patient’s insurance and pharmacy benefit manager (PBM), all before the prescription is sent to the pharmacy.

Objective

To describe the early implementation experiences and preliminary prescribing outcomes of RTPB tools at three U.S. academic medical centers.

Methods

This is a cross-sectional study assessing early RTPB tool implementation at Johns Hopkins Health System (JHHS), Yale New Haven Health (YNNH), and Froedtert and Medical College of Wisconsin (F&MCW). We analyzed the characteristics of RTPB tool rollout [FW1] at each institution such as EHR integration and RTPB vendor selection. We also analyzed rates of how often these tools were used as well as the types of prescription adjustments that occurred. We included all ambulatory encounters where a medication order was prescribed in the outpatient visit setting three months after implementation of RTPB tools at each site, including scheduled telemedicine visits. Inpatient or emergency department encounters with outpatient medication orders, encounters for medication refills by telephone, and EHR-portal refill requests were excluded. Data pertaining to RTPB requests associated with Epic outpatient encounters were extracted using R software and analyzed using SAS 9.4.

Results

Across the three sites, two RTPB tools by different vendors (A and B) were integrated into Epic. At two sites, the RTPB tools automatically displayed prescription costs and alternatives if available, and at one site RTPB tool displayed on-demand. All sites allowed providers to opt out of viewing RTPB tool results. One site implemented a minimum cost differential of $0.10 per day between the prescribed medication and alternative in order for the RTPB tool to fire, or retrieve a cost estimate from the PBM and insurer. Rates of RTPB tools firing and subsequent prescription adjustments are further detailed in the attached supplemental table.

Conclusions

RTPB tools were utilized at varying rates across institutions. Overall, the rate of prescription adjustment based on use of the tool was low across all three institutions. Future studies should examine reasons for low utilization.

Clinical Implications

The out-of-pocket cost of prescriptions is a main driver of medication non-adherence. RTPB tools can help increase price transparency for patients and providers. By reducing out-of-pocket costs and prior authorization requests, RTPB tools have the potential to improve medication adherence and downstream health outcomes for patients. Future work involves further characterization of RTPB utilization, exploration of factors associated with alternative prescribing, assessing the impact of these tools on patients and prescribers, and identifying barriers and facilitators to adoption of these tools by providers. This work will help improve the design and adoption of RTPB tools which can reduce the financial burden that patients face, improve medication adherence, and patient health outcomes.

Click here to register for the 2022 Architecture of High Value Health Care National Conference!

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPAA on Health Affairs Blog