Real Time Benefits Check: Improving the Patient Experience and Reducing Costs

Congress is focused on increasing transparency in drug pricing and lowering health care costs for consumers. There’s a great tool—commonly referred to as Real Time Benefits Check (RTBC)—in use by payers that does both, but it is underutilized by physicians and prescribers. The tool also puts patients and prescribers at the forefront of health care decisions.

RTBC is an electronic prescription decision support tool that enables prescribers to choose therapies to help lower out-of-pocket costs for their patients. The tool integrates with electronic health record (EHR) systems to present clinicians with real-time, patient-specific medication coverage information, including out of pocket costs (copays, coinsurance, etc.), formulary status and therapeutic alternatives. This enables patients to work with prescribers to consider cost-effective alternatives regarding their medication choices.

A recent study found RTBC recommendations lead to lower patient out-of-pocket costs, with the largest savings—typically around 40%—occurring for high-cost medications, especially when therapeutically appropriate, lower-cost alternatives exist.¹ In addition, RTBC recommendations were made for only a small percentage of prescriptions, presenting opportunities for improved access to affordable prescription drugs.¹

One in five patients experience some cost-related barrier to medication adherence, according to a recent JAMA Network Open report, meaning their drugs are often too expensive for them to take as prescribed. This same study also found nearly 90% of patients indicated they wanted their clinicians to use RTBC tools.²

Informed patients can actively participate in the decision-making process, leading to improved patient satisfaction and treatment outcomes. RTBC facilitates conversations between patients and providers about medication options, costs and therapeutic alternatives. Another advantage of the tool is that providers can reduce administrative burdens associated with manual insurance verification processes. Increased efficiency across the health care pathway can lead to time savings and decreased health care costs for both patients and providers. Successful implementation of RTBC requires collaboration between EHR vendors, payers—including pharmacy benefit managers (PBMs)—pharmacies and prescribers.

Path to requirement of RTBC

In May 2019, Centers for Medicaid & Medicare Services (CMS) published a Medicare Advantage and Part D rule that requires Part D plan sponsors to implement RTBC. The rule applies to plans offering Part D coverage, but there’s no requirement prescribers use RTBC. The rule states that a plan sponsor’s RTBC must be capable of integration with at least one prescriber electronic prescribing (eRx) system or EHR. The final rule took effect on Jan. 1, 2021, and many payers and PBMs also have deployed RTBC elsewhere in the commercial market, where it’s not mandated.

Additionally, a provision mandating RTBC utilization was included in the Consolidated Appropriations Act, passed in December 2021. At the end of 2022, Health and Human Services (HHS) issued a proposed rule that started the implementation of a standard promulgated by the National Council for Prescription Drug Programs (NCPDP), a nonprofit standards development organization that represents most sectors of the U.S. pharmacy services industry. CMS has mandated beneficiary RTBC for Medicare Parts C and D as of Jan. 1, 2023. The Office of the National Coordinator (ONC) for Health Information Technology—also part of HHS—issued a request for information on RTBC.

Current adoption 

Prescriber adoption of RTBCs is low, and we face four key challenges:

1. prescriber education, which my organization, Prime Therapeutics/MagellanRx Management, and our clients are tackling
2. prescriber acquisition of the tool
3. consistent use of the tool by prescribers, which requires direct integration and implementation into a provider’s existing workflow
4. the current user interface for providers varies by electronic medical records system, and in some cases, doesn’t easily display therapeutic alternatives or impacts to patient cost

Horizon Blue Cross Blue Shield of New Jersey (Horizon), which has partnered with Prime to provide RTBC since 2018, has made significant investments in education and outreach. Horizon, which also is the largest health insurer in New Jersey, has even conducted chair-side visits with providers to demonstrate the tool and piloted member awareness campaigns urging members to ask their doctors about lower-cost alternatives. The next challenge is to achieve widespread adoption of the tool.

Kunal Patel, a clinical pharmacist at Horizon who has played a central role in driving awareness and adoption of RTBC offered the following assessment: “Reducing the total cost of care and our members’ out-of-pocket costs by identifying lower cost, clinically effective alternatives is a win-win-win. All of us—prescribers included—have to put the physical, mental, and financial well-being of the patients we serve at the center of what we do. By providing prescribers with access to RTBC and giving them the information needed to use this simple tool, Horizon is working to help our network doctors improve affordability for their patients who rely on prescription drugs to achieve their best health.”

Horizon has observed that in the last 12 months of using RTBC, each time a prescriber has used the tool, the average annual member savings was $385 per prescription.

Solutioning for a successful future  

It’s critical that all stakeholders help to ensure RTBC tools are included into EHRs and that those tools integrate as seamlessly as possible with prescribers’ prescription drug order entry systems. One such tool is the Office of the National Coordinator for Health Information Technology Health IT Certification Program, which catalyzes the inclusion of cost transparency and disclosure requirements into federal, state, and private health programs.

CMS’s Center for Medicare and Medicaid Innovation (CMMI) should conduct a demonstration that incentivizes providers who use RTBC and choose therapeutically appropriate, lower-cost alternatives. CMMI also should expand its limited “rewards and incentives” (R&I) reach for beneficiaries (R&I is currently only available in one Medicare Advantage model) to better evaluate patient behavior in this demonstration. CMMI should then analyze improvements in medication adherence resulting from the use of lower-cost drugs, as well as improvements in total spend and consumer cost-savings resulting from guiding and incentivizing prescriber choices.

RTBC enables cost savings and improved efficiency for all players—patients, prescribers, pharmacists and payers. By increasing providers’ familiarity and understanding, and ultimately their use of the tool in e-prescribing, RTBC can not only improve the e-prescribing process, but also the e-prescribing experience for all.