Copay at the Point of Care

Payers can use existing formulary data and EHR capabilities to satisfy physician and patient demand for timely copay information today. Upgrading formulary data to include better information enables physicians to make treatment decisions that patients can afford and are more likely to follow. Developing a plan for providing the right formulary and copay information is clear-cut and provides a long-term return on investment by boosting preferred prescription and pharmacy utilization rates.


Lack of Copay Information at the Time of Prescribing Negatively Impacts Patients

While EHRs have the capability to display formulary preferences, copays, and other data, many payers do not provide physicians with the information they need at the time they need it to develop effective treatment plans. “Doctors are largely unaware of copays although they may have an idea of the cash price. But variation in insurance coverage is far too wide for them to have reliable, accurate information for each patient,” writes Adam Rubenfire.

When payers don’t provide access to accurate copay and formulary information, doctors often prescribe drugs patients cannot afford. “For many patients...the price of filling a prescription is largely unknown until they get to the pharmacy. That can leave some patients shocked at the register, sometimes unable or unwilling to pay,” writes Rubenfire. Nonadherence, often linked to prescription affordability, is responsible for an estimated $100-$300 billion in avoidable healthcare costs annually.

Without access to formulary data that includes copay information, physicians may prescribe a nonpreferred drug for the ailment treated. The administrative burden of determining insurance copay information is steep. A Medical Group Management Association study estimated that physicians spend 1.3 hours per week and nursing staff spend 3.6 hours per week sorting out formulary issues with payers. The cost of physician interaction with insurers totaled $21-$31 billion per year. This study “doesn't include the countless hours physicians and staff spend discussing these issues with patients, who often are left to call back the doctor to figure out an alternative prescription,” notes Rubenfire.


Access to More Specific Information Enhances Treatment Planning

Payers that provide more specific copay and formulary information within the EHR enable the physician and patient to develop an effective treatment plan during the visit. “Patients can have a conversation with their doctors about price before leaving the office. If they're unhappy then, a new prescription can be written on the spot, avoiding the back-and-forth conversations that can come from patients who need to change prescriptions over the phone with nursing staff or pharmacies,” writes Rubenfire.

The good news for payers is that the mechanism for providing copay and formulary information to prescribers can be set up quickly and easily using existing EHR technology. Once in place, physicians can see patient-specific prescription benefit details, empowering them to make therapeutically appropriate and cost-effective decisions.


How Benmedica Can Help

Bruce Wilkinson, the founder and CEO of Benmedica, has leveraged technology to facilitate healthcare since the birth of electronic prescribing and physician connectivity in 2002. Bruce has extensive industry experience with Accenture, Express Scripts, ZixCorp, and CVS Health and continues to lead the development of healthcare standards through NCPDP. You can connect with Bruce on his LinkedIn page.