Payers, Providers and PBMs: Embrace Data Liquidity to Improve Medication Adherence

To help patients access their prescribed medications during office closures due to the pandemic, many health plans relaxed or waived medication regulations, such as prior authorization (PA) and refill-too-soon orders.

Despite this temporary relief, many patients still experienced delays getting their prescriptions filled.

Solutions such as real-time prescription benefit (RTPB), electronic prior authorization (ePA) and intelligent pharmacy workflows can help reduce administrative and benefit barriers contributing to these delays – and improve medication adherence along the way.

RTPB technology enables providers, pharmacies, and payers to quickly exchange patient benefit coverage and out-of-pocket cost information. Relevant data can be surfaced within a single healthcare workflow that provides accurate data right from the source and can help more patients access their medications.

When providers used an RTPB solution, patients were 19 percent more adherent to picking up their medications.1

Direct connections with payers and pharmacy benefit managers (PBMs) through EHRs and pharmacy systems can also provide time-sensitive answers at critical points along the patient journey. Providers can spend less time searching for benefit information and more time holding productive and timely conversations with patients, especially those who need affordability game plans. Data liquidity within healthcare IT can help surface patient-specific affordability and access information to inform and elevate these discussions before patients reach the pharmacy counter.

Having this kind of information at the point of prescribing can also remove silos between providers and pharmacies. In a recent survey of physician satisfaction with health plans, respondents gave pharmacy and provider relations the lowest satisfaction scores of all plan characteristics. 2

What’s more, fewer than one in five providers said they started PA requests at the point of prescribing and less than 40 percent had visibility into alternative options when a PA was required.3 A robust ePA solution can help care team members head off PA requests before patients get to the pharmacy.

“Anything that minimizes interruptions and streamlines processes would be helpful – less phone calls, less time on hold, better communication tools and more accurate and detailed information sent back from the insurances on rejects,” said one independent retail pharmacist from Pennsylvania in the survey. “So many times we get ‘drug not covered/not on formulary,’ but they don’t populate the covered alternative fields… These simple changes would make a day in the life of a pharmacist so much easier.”4

Many solutions can deploy real-time, accurate data, but healthcare regulations may make sourcing the necessary information challenging. Legislation at the state level aims to change this, with several active bills seeking to require commercial PBMs and payers to share patient benefit and eligibility information with providers.

Health plans that can make this kind of data easily available through simple, intuitive interfaces will be the ones to earn providers’ and pharmacists’ trust.

Whether it’s driven by Centers for Medicare & Medicaid Services’ mandates or calls from payers, providers and PBMs demanding data liquidity across the healthcare ecosystem, data sharing at the point of prescription is the necessary future for prescription decision support.

To learn more about technology’s role in connecting providers with actionable data at the point of care, download Medication Access Report: Healthcare Technology.


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