Effects of Real-time Prescription Benefit Recommendations on Patient Out-of-Pocket Costs

Abstract

ImportanceRising drug costs contribute to medication nonadherence and adverse health outcomes. Real-time prescription benefit (RTPB) systems present prescribers with patient-specific out-of-pocket cost estimates and recommend lower-cost, clinically appropriate alternatives at the point of prescribing.ObjectiveTo investigate whether RTPB recommendations lead to reduced patient out-of-pocket costs for medications.Design, Setting, and ParticipantsIn this cluster randomized trial, medical practices in a large, urban academic health system were randomly assigned to RTPB recommendations from January 13 to July 31, 2021. Participants were adult patients receiving outpatient prescriptions during the study period. The analysis was limited to prescriptions for which RTPB could recommend an available alternative. Electronic health record data were used to analyze the intervention’s effects on prescribing. Data analyses were performed from August 20, 2021, to June 8, 2022.InterventionsWhen a prescription was initiated in the electronic health record, the RTPB system recommended available lower-cost, clinically appropriate alternatives for a different medication, length of prescription, and/or choice of pharmacy. The prescriber could select either the initiated order or one of the recommended options.Main Outcomes and MeasuresPatient out-of-pocket cost for a prescription. Secondary outcomes were whether a mail-order prescription and a 90-day supply were ordered.ResultsOf 867 757 outpatient prescriptions at randomized practices, 36 419 (4.2%) met the inclusion criteria of having an available alternative. Out-of-pocket costs were $39.90 for a 30-day supply in the intervention group and $67.80 for a 30-day supply in the control group. The intervention led to an adjusted 11.2%; (95% CI, −15.7% to −6.4%) reduction in out-of-pocket costs. Mail-order pharmacy use was 9.6% and 7.6% in the intervention and control groups, respectively (adjusted 1.9 percentage point increase; 95% CI, 0.9 to 3.0). Rates of 90-day supply were not different. In high-cost drug classes, the intervention reduced out-of-pocket costs by 38.9%; 95% CI, −47.6% to −28.7%.Conclusions and RelevanceThis cluster randomized clinical trial showed that RTPB recommendations led to lower patient out-of-pocket costs, with the largest savings occurring for high-cost medications. However, RTPB recommendations were made for only a small percentage of prescriptions.Trial RegistrationClinicalTrials.gov Identifier: NCT04940988; American Economic Association Registry: AEARCTR-0006909

Helping Patients With Chronic Conditions Overcome Challenges of High-Deductible Health Plans: Mixed Methods Study

“…Schiavoni et al [ 38 ] found that primary care physicians, when presented with patient-specific price information, were more likely to engage in conversations with patients to seek more affordable treatment options. Current real-time benefit tools, which display patient-specific OOP costs when a provider orders a medication, have been shown to generate savings for patients but only display lower-cost alternatives for a small proportion of prescriptions [ 39 ]. Such tools embedded into the provider’s workflow could be expanded to cover other costly services and further encourage patient-physician cost conversations.…”

Real-time Prescription Benefit Tools—The Promise and Peril

“…The study highlights some promising findings and some pitfalls associated with RTBTs. It was encouraging that patient out-of-pocket costs declined by 11% overall, and by close to 40% for patients using high-priced drugs.…”

“…As with many electronic health record (EHR)-based and other tools, there are important implementation considerations that influence the success of RTBTs in practice. 2 In this issue of the journal, Desai et al 3 present findings from a cluster randomized evaluation of one institution's experience with RTBTs. They found that RTBTs could be used for a small minority (4%) of prescription orders and their use was associated with an 11% reduction in out-of-pocket costs when prescribers were shown lowercost choices via the EHR.…”

“…We suspect that many pop-up alerts indicating potential savings were ignored or not acted on, often owing to fatigue with such alerts, and that some potential benefit remains. Similarly, although the authors reported the frequency of switching to a mail-order pharmacy, it was not clear whether the tools facilitated other cost-saving strategies such as steering patients to lower-priced pharmacies that are preferred by the patient’s plan.…”

“…One important area of concern for RTBTs, highlighted by Desai et al, is the very low proportion of orders for which RTBTs were relevant in the study. Specifically, the authors included only 4% of all prescription orders in the analysis.…”