"This is a much-needed conversation, at the point of care," says plan executive Martin Burruano.
Editor's note: This Q&A is part of HealthLeaders' Mind the Gap series, a three-part exploration of how healthcare is bringing information, patients, care, and payment closer together. Gaps abound in healthcare: in data, coverage, and equity. There are equally fundamental spaces between information and patients, patients and care, and care and reimbursement. The degrees of separation between these elements are often excessive and unnecessary. Payers and their partners are helping to close these gaps—and ensuring the value in healthcare's value chain is linked throughout. Read the other articles on automated prior authorizations and hospital-at-home care.
Independent Health is one of many health plans gearing up to offer real-time prescription benefits checks for patients at point of care, following a January 2021 final rule from the Centers for Medicare & Medicaid Services (CMS) requiring Part D plans to provide this information to enrollees.
HealthLeaders spoke with Martin Burruano, vice president of pharmacy services at Western New York's Independent Health, about how smaller, regional plans are implementing real-time benefits checks.
HealthLeaders: What does Independent Health's tool include?
Martin Burruano: The myBenefitCheck solution from DrFirst will include up-to-date, patient-specific drug coverage information for nearly 400,000 members, including required prior authorizations and out-of-pocket costs for prescribed medications and therapeutically appropriate alternatives.
HealthLeaders: How long has Independent Health been working on this, and what impact did the CMS requirement have?
Burruano: While implementing a real-time prescription benefits check is CMS-driven, Independent Health had been looking at cost transparency as a part of our business plans for a long time, as well as improving member and provider experience.
It's hard for prescribers. They deal with multiple plans, PBMs, and dozens of formularies, drug coverage criteria, and polices. And clarity around member cost share is especially important given the growing number of high-deductible plans. This is a much-needed conversation, at the point of care that includes lower-cost alternatives, prior authorization, quantity limits.
It was one of those welcome requirements. What currently happens is that a claim rejects from the PBM at the pharmacy and slows things down. Efficiency in the system, up front, is better administratively and for the member and provider. CMS recognized the need, including for interoperability of platforms. It's a win-win for providers, members, and the health plan.
HealthLeaders: What are the unique implementation challenges and opportunities for regional plans?
Burruano: Really, all plans are kind of in the same place. It may even be easier for regional plans because we have strong relationships and mutual trust with our providers already. This is giving them another tool in their toolbox, which makes adoption easier.
HealthLeaders: How are you rolling this out to your physicians?
Educating providers on the benefits of what this means for their total cost of care and greater member satisfaction is huge. Most of our PCPs are in value-based models, so total cost of care really matters. Specialists are included also and there is just less administrative burden for everyone.
HealthLeaders: What is the scale of your rollout?
Burruano: This will be one big bang for all lines of business at once. There's no real advantage to pilot in this situation, even leading up to a CMS requirement. Physicians don’t practice by lines of business and at point of care, they may not even know who the patient's specific payer is.
HealthLeaders: What role did your PBM play?
Burruano: We own and operate our own PBM, Pharmacy Benefit Dimensions, and they were part of the implementation process from day one. It makes designing for flexibility much easier.
About its final rule, which is effective January 1, 2023, CMS stated: "With this tool, enrollees will be better able to know what they will need to pay before they are standing at the pharmacy counter." Independent Health is one of many plans working toward full implementation by that date to improve member and provider experience.
Laura Beerman is a contributing writer for HealthLeaders.