Blog, The Hospital Finance Podcast®

Achieving point-of-care price transparency [PODCAST]

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The Hospital Finance Podcast

In this episode, we are joined by Carm Huntress, CEO of RxRevu, to discuss how prescription price transparency at the point-of-care benefits both patients and providers.          

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Highlights of this episode include:

  • Background on price transparency and how it can impact a healthcare system’s bottom line.
  • What healthcare systems can do to ensure they’re providing accurate price transparency at the point-of-care.
  • How a healthcare system’s pharmacy could impact the overall growth of the system.
  • Why many systems are struggling to provide accurate prices under different coverages.
  • What interoperability and price transparency regulations mean for the industry.
  • And more…

Mike Passanante: Hi, this is Mike Passanante and welcome back to the award-winning Hospital Finance Podcast®. Price transparency in health care is something that is getting a lot of attention especially now that CMS price transparency requirements are in effect for hospitals. Prescription price transparency at the point of care can provide benefits for both patients and providers. To talk with us about this, I’m joined by Carm Huntress, CEO of RxRevu. Carm is an entrepreneur and strategic leader with over 20 years of experience in health care IT and interoperability as well as startup growth and technology. Carm, welcome to the show.

Carm Huntress: Thanks so much for having me. Great to be here.

Mike: So Carm, for folks who may not be familiar with RxRevu, why don’t you tell us a little bit about what you do there?

Carm: Absolutely. We’ve been around for about eight years. And our core focus today is really around bringing real-time cost coverage and benefit information around prescription drugs to the point of care to help doctors make more informed decisions and help patients get on sort of the most cost-effective and convenient drug based on their plan and insurance.

Mike: Excellent. So let’s start at a high level with this concept of price transparency. And tell us how price transparency can impact a health system’s bottom line.

Carm: Yeah. It’s a really interesting state of affairs today when you think about outpatient pharmacy. And most providers today are pretty blind to what the cost is going to be for their patients, what drugs are covered, what drugs are not covered. And pharmacy benefits for most individuals have become a pretty complex thing. There’s now coinsurance. There’s sort of narrow network pharmacy options or restrictions for patients where they have to fill in a specific pharmacy. So our job as a company is to really work with the insurance companies and the pharmacy benefit managers or the PBMs to in real-time as the providers making a prescription decision show this information so they know the cost, they know the coverage and/or restrictions on the drug they’re trying to prescribe as well as the therapeutic alternatives and make an intelligent decision and have a conversation right then and there with the patient to have the best choice for them and what they can afford. And so when you think about the benefits here, there’s a lot of really great things that come out of having this data in real-time to providers. The first thing is just patient satisfaction and experience. If you look at sort of the one– the top one, two, or three things patients complain about, it is the pharmacy experience. It’s very confusing. You have no idea what you’re going to pay. And then you show up at the pharmacy counter and the drugs are not covered. And you’ve got to pay full cash. And you’re at the wrong pharmacy. It’s a real mess. And it’s a big area of patient dissatisfaction that we can fix. And so that’s a big reason. The second and third thing are really around helping the provider with the administrative burden of pharmacy issues today. It costs health systems about $15,000 per doctor per year in administrative pharmacy issues, so pharmacy callbacks, prior authorizations. And clinical staff now spending about 20 hours per week doing pharmacy administrative tasks. And our job is really to bring all that information forward, so help them understand, “This drug is covered, let’s get you on a– going from a not-covered to covered drug. And so you’re not going to get a pharmacy call back.” Or, “This drug has a prior authorization, let’s move to this drug that doesn’t.” And all of that administrative savings is extremely impactful. We’ve saved doctors– for every prior off avoided, we’re saving about 50 minutes of time for them in their clinical staff. And so that’s a lot when you think about a provider’s day or week, and the issues they have to deal outside of trying to just get patient care.

Mike: Carm, what should a health system do to make sure that they’re providing accurate price transparency at the point of care?

Carm: Well, the big thing is, go to your electronic health record vendor. We work today with Epic, Cerner and Athena are three big partners that we provide this information for. And ask questions about, “Is this integrated and then turned down on?” Obviously, they can go to our website and reach out to us directly. But the key thing is, they’ve got to ensure that this capability has been turned on in their electronic health record and it’s available to their providers at their prescribing. And the other big part is that you want to make sure that you have good coverage across all your payers. So we do have some very unique and somewhat exclusive relationships with some payers that you’ve got to connect to our network to get access to cost transparency for their members. So it’s really important you look at your payer mix and understand which vendors you need to work with to get this information accurately at the point of care across all the insurance companies that you work with.

Mike: Let’s talk about the impact of pharmacy on the business. And I’m curious how a health care system’s pharmacy could impact the overall growth of the system.

Carm: Yeah, so a lot of what we– we work closely with a lot of large academic integrated delivery networks, a lot of large IDNs. And I would say a lot of these large IDNs are really interested in, they have started their own pharmacies. They do specialty. And we’re really starting to help them better around that patient experience and doing fulfillment at their own pharmacies. And we can be really helpful in that because we can say, “Hey, is the health system on pharmacy and network? Do they have a relationship with the plan? And is it okay for the patient to fill at that pharmacy?” And that really helps opposed to – they send the patients in a facility where they have a pharmacy and it’s not covered on their plan, for instance. So then you’re sending a patient through a pharmacy they can’t even get the drug out, or they’re going to have to pay full cash. And so we’re really helping a lot of those internal pharmacy teams out, large health systems, sort of use our data to help them figure out where’s the best place to send the script. And maybe it’s a specialty script and it needs to go to the patients’ plans specialty pharmacy, so we make sure it gets routed there. Or can it be filled at the health system. So in some cases we’re kind of a router to sort of route the drug to the right point of fulfillment that’s going to be best for the patient and have the best patient experience, right, and sort of a continuation of care. And as you think about health systems moving into value. This is the big opportunity for them where the most important thing or one of the most important things they can do is, one, make sure the patient fulfills their drug and to make sure the patient stays on the drug. And a lot of that has to do with convenience on fulfillment in that first bill. And our payers have told us when we get the costs right for a patient and they use our technology, there’s about a 23% lift in first bills, which is a big deal if you think about getting that patient to get on that drug and stay on that drug. And cost is such a big factor in making sure that that happens. And that’s one of the biggest things as we talk to health systems that are moving into ACO or risk-based models, adherence is just one of the number one things they can do to help keep that patient out of coming back into the hospital and readmitting and costing the health system a lot of money in those risk-based contracts. So we really see part of our conversation with health systems today is as you think about moving into risk-based contracts with your payor partners, this is essential data that providers need to make to really make informed, cost-effective decisions for your patients that are not only going to make the drug affordable but really drive adherence so you can thrive in those risk-based models with your payor partners.

Mike: Can you talk to us about what a real-time prescription benefit is and how doctors are using it?

Carm: Yeah, sure. So if you think about a prescribers’ workflow, they typically started in counter and they work in the electronic health record. They’ll figure out the diagnosis and what the patient needs. And then they go into their ordering system and they say, “Okay. I want to order you a particular drug to treat this condition.” And when they go and pick that drug and they usually put it in a pending status inside the electronic health record– so let’s say they just pick Humira, as an example. They would say, “Hey, I want Humira at this dose, this duration,” and they would pend that drug to be ordered. And then they would go ahead and sign that order and it will be routed out to the pharmacy. When they pend that drug in their electronic health record, behind the scenes, we look at the patient’s insurance and then route that to the particular PDM to price the drug at the patient’s preferred pharmacy and get back benefit coverage and cost information as well as therapeutic alternatives. So Humira might come back and they might say, “Well, Humira is very expensive on your plan. It has a prior authorization. And it looks like there’s a therapeutic alternative here that’s less expensive, that’s covered, and doesn’t have a prior auth.” We’ll show that information to the doctor in real-time right after they pend the medication and they can simply select the alternative and then the order’s updated. And they’ve really just prevented a huge amount of administrative waste and overhead and a lot of dissatisfaction potentially from the patient in having to go down that path where that drug was not covered by their plan. And so it updates in the EHR and then they just signed the order and it’s routed out to whatever pharmacy may be best. And that’s another thing we’ll look at. We’ll look at, “Hey, is mail order better here? Is this a chronic drug that they’re going to be on for a long time? And is a 90-day better than a 30-day fill at their retail pharmacy?” And there’s a lot of savings to be had by routing it to a mail-order or a pharmacy. And so those are different things we’re looking at to kind of figure out what’s the most cost effective and convenient option for the patient, and so we do that all inside the electronic health record. And what’s great about this is this isn’t a portal, right? I think the history of these solutions is sort of forcing the doctor to go out of their workflow into a portal or another way of doing it. We think it’s so essential to try to minimize the clicks and minimize the disruption to the provider’s workflow, and so we’ve really focused on being tightly integrated into the electronic health record into the point of decision at the point of order to help the provider make that most informed decision with this data. And so that’s essentially how it works today and how we integrate with the provider’s workflow to help them make these decisions.

Mike: Carm, what is being done with medical benefits, solutions, and price transparency, knowing that those prices all fall under different coverage? Why are so many struggling to get accurate prices and what are you doing in that space?

Carm: Yeah. So we’ve had great success in pharmacy and built out this network. What started to happen over the last few years, and there’s some national things going around with The Da Vinci project and others, where payers have said, “Wow, we’ve had a lot of success in pharmacy. What else can we do to get other types of benefit coverage and cost information to the point of care that today is sort of, again, locked up in these portals that providers or patients really use?” And so we have been extending and adding to this with our ex-platform, which is Pharmacy and adding now medical benefit capabilities through the similar type mechanisms to basically take data from the electronic health records around labs, radiology, imaging, referrals, gaps in care, and do the similar types of transactions where we can show the benefit coverage and cost information for these services and bring them back into the point of care. And so if you really want to think, ultimately what we’re trying to be is that cost transparency and decision support layer for providers at the point of care across all types of orders and decisions that we’re making every day and getting that essential information at the point of care at the point of decision-making in their ordering workflow. The challenge, right – we kind of look at this internally – medical benefits capabilities today kind of look like pharmacy did a few years ago. They’re kind of immature. Most of the payers have their own way of doing this in very unique systems, and we’re tapping into a lot of the claim systems to do these types of transactions. And they’re pretty complex. And so we’ve started to build out that capability. We’ve launched so far in Cerner and we’re really excited about that partnership, and we’re expanding to other EHRs later this year as well as adding more payers into what’s called our medical benefits capability next to our pharmacy benefit is called SwiftRx. And so we’re really trying to be that complete platform for payers and PBMs to get this data to the point of care across our EHR footprint now which is over 200,000 doctors. So it’s a pretty ambitious goal, but we’re really excited about it because we really think we can dramatically impact the cost of care, the quality of care, by getting this information to doctors so they can just make better decisions and really start to bend the cost curve in healthcare which we so need to do. 

Mike: Carm, what do interoperability and price transparency regulations mean for your work?

Carm: What I would say is this is what healthcare– for our work and the mission here, we just think this is fundamentally what health care needs. Our mission is to help providers make better healthcare decisions. And the reason they’re not making great decisions today is they don’t have the information they need to make an informed decision. They definitely have a clinical picture and, that’s their core focus. But so much of healthcare is about, “What does my insurance enable me to do and get? And what type of care can I get with my insurance?” And rationalizing that for the patient in real-time is really what healthcare needs. If you think when we started the company and what we’ve seen over the last year is such a heavy focus on consumer-based solutions. But if you really think who’s making the decision in health care about your care, it’s your provider. It’s not you. And patients don’t have the clinical experience or understanding to really rationally make these decisions. And often, the opportunity to intervene, it’s too late. The provider’s already made the decision. They’ve already made the referral. They’ve already made the prescription decision. And so our goal is really to get upstream at that point of care and really dramatically change provider’s behavior so they have the data to make the most informed decision. And I think it’s an incredible vision of what health care can be, right, where we get rid of this administrative waste. We get rid of poor decision-making, which is so frustrating patients today because they don’t even understand, “If I had just been referred to this other doctor, I would have paid one-tenth the cost, and it would have been a much better experience with a lot less costs for me as a patient.” We have to really work to rationalize these decisions for providers. And we don’t sit here and think providers have an intent to do anything bad. They just don’t have the information. They have extremely busy days. They have very little time to spend with patients. But definitely, there’s clear opportunity in what we’ve been able to prove in pharmacy, if you get the information to them in the right ways, in their workflow as they’re making the decision and you try to reduce the number of clicks to get to this information and make it seamless for them, they adopt it. And they really do change their behavior. And that’s what’s so exciting and we’ve been able to prove that at RxRevu. And I think when we talk to providers and interview them, they’re incredibly excited about what we’re doing and the impact it has on patient care. And we’re grateful to be partners with them. And just I would say thank them for all the incredible work they do every day and the impact they’ve had, especially in this last year with the pandemic. And we just want to make their jobs easier, right. We want to get them back to being the great doctors that they set out to be in medical school and in residency by giving them tools that get them away from the administrative headaches of rationalizing a patient’s insurance and benefit information and to really being empathetic partners with patients that they so desire to be and really support the best and highest quality care for patients. So that’s really, for me, the underlying mission here and what we really want to do to change healthcare.

Mike: If someone wanted to find out more about RxRevu, where can they go?

Carm: Our website is www.rxrevu.com. You can use that same spelling to find us on Twitter and LinkedIn. You can reach out directly through our website and on Twitter and you can directly DM me if you have questions or want to learn more about what we do.

Mike: Carm Huntress, thanks so much for joining us today on the Hospital Finance podcast.

Carm: Thanks so much for having me. Really enjoyed the conversation.


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