Improvements to benefits data can enhance ePrescribing and the patient experience

ePrescribing offers numerous benefits to providers, payers and patients alike. Eligibility and formulary & benefit (F&B) transactions have long informed prescribers about a patient’s prescription insurance plan coverage, and which medications are covered under the patient’s formulary.  

Continuous improvements from stakeholders involved in the eligibility and F&B transaction have led to advancements in the ability to match patients with their coverage and pharmacy benefit information at the point of care. These advances are critical to improving medication adherence and, in turn, better patient outcomes and improved patient, provider and Pharmacy Benefit Manager (PBM)/health plan satisfaction in the ePrescribing process.   

Eligibility is foundational to the presentation of F&B information. It is also the building block for several newer, downstream ePrescribing-related transactions such as Real-Time Benefit Check (RTBC), electronic prior authorization (ePA) and specialty enrollment. These new transactions, when supported by complete and accurate eligibility data, can help patients get on therapy more quickly by avoiding unwelcome surprises at the pharmacy and help providers and pharmacy staff avoid manual work and rework. 

For an average practice, PBM/health plan eligibility can be determined for approximately 7 out of 10 patients. Missing patient information or a response of “patient not found” when running an eligibility check can elevate a provider’s lack of trust in the data and impact subsequent F&B related transactions. For example, when a provider prescribes a medication with no eligibility information found, the patient is categorized as self-pay, whether that be the case or not, and the provider is unable to ascertain any potential medication coverage restrictions. 

In addition to complete eligibility files, accurate and complete data in the F&B files is also imperative for the value of these transactions to be recognized. Research among providers and staff revealed that perceived lack of accuracy of F&B information is the number one reason why providers do not look at the data in the EHR when prescribing a medication. Yet, studies have shown that utilization of this information was positively associated with increased medication adherence and improvements for first-fill and subsequent fills. 

In addition, a recent Surescripts report shows that when a when a single PBM increased population of the PA indicator field in its eligibility response by only 16%, the number of ePAs it received completed increased by 40%¹.

Accurate and comprehensive F&B information can positively impact adherence in two ways. The first is provider adherence with a patient’s formulary when prescribing, and the second is the impact to patient adherence when a formulary is referenced in the ePrescribing workflow.

Provider Adherence - Recent research has shown the impact of F&B on helping providers choose a lower cost medication. In one study, when providers had access to formulary and drug cost information, there were greater savings in 30-day supply drugs over a 2-year period². In this study, improving providers’ access to F&B information was associated with lower increases in yearly total (health plan) drug costs averaging $208 per patient.

Patient Adherence - Recently released data show first-fill adherence increased by an additional 2.7 percent when eligibility was checked and validated¹.

An EHR vendors’ goal is to display F&B information accurately and effectively, easily understandable and actionable, with fewer clicks. F&B has been a part of ePrescribing for decades and there has been little reason for vendors to upgrade the functionality, until now. Version 5 of the National Council for Prescription Programs (NCPDP) F&B standard includes a wide variety of enhancements which will yield benefits to all stakeholders in the ePrescribing process. Mandatory compliance is still a few years away, but the improvements are worthy of consideration and innovation before they become required. In particular, enhancements in file structure and date stamping will reduce file size and decrease outdated information, and enhancements to the data fields and data content will enable more useful and actionable information to be displayed to the providers.

Recent improvements from stakeholders involved in the eligibility and F&B processes have led to enhancements in the data providers can access at the point of care. All stakeholders have a role to play to continue to enhance, improve, and support advancement in the quality, completeness, timeliness, and use of the transactions and associated data.

The value proposition of these transactions is clear, and advancements in these areas can improve patient care.  To learn more, download this free report. 
 

Michael Burger is a senior healthcare information technology consultant specializing in both clinical and administrative systems and processes with specific expertise in EHR implementation & optimization.