Real Time Benefit Tools (RTBT) are so promising, why haven’t they taken over the market yet?
On the surface, RTBT allows physicians to access drug pricing and patient benefit information at the point of care, so they can prescribe the lowest-cost medications and avoid the embarrassing, painful sticker rush at the pharmacy. The technology is mandated by the 21st Century Cures Act, passed in 2016.
Every health plan must utilize RTBT to connect to at least one health organization, which can be anything from a large health system to a single physician practice in a rural setting. But it turns out that RTBT isn’t delivering on the promised savings for several reasons.
First, the point of care is not the best place to intervene during an office visit. The workflow in a doctor’s office is rigid and sacrosanct: patient enters office, paperwork is done, called to exam room, nurse does intake, doctor or PA comes in, brief conversation, doctor/PA prescribes, says goodbye, A nurse schedules a follow-up visit. If the intervention disrupts this workflow, it is unlikely to happen.
Doctors’ time is already very limited, and patients are scheduled to the minute. Adding another layer of work to the clinic’s time can hinder adoption. Also, RTBT adds too many hits. This functionality is in the EHR, but not in the traditional workflow. Physicians must enter a new section in an electronic prescription request or EHR to study drug costs and a member’s formulary. This requires a significant increase in time and clicks, taking doctors away from their usual procedures.
It is thought that RTBT will track the adoption of electronic prescribing by doctors. This did not happen because RTBT is still an unwieldy add-on to the workflow and is not an integral part of the electronic prescribing process. Historically, physicians have embraced new technologies for two reasons: to save money and time. If neither, the technology will not be adopted at scale. This is the unfortunate case of RTBT. These tools do not generate any revenue and take more time.
To make matters worse, doctors may have multiple RTBTs in their EHR. If one RTBT takes doctors beyond their normal workflow, then two or more RTBTs are like Christmas decorations on the 4th of July. They’re colorful and bright, but not really the right thing at the moment.
Physicians using RTBT have raised serious questions about its accuracy, which makes sense given the significant data confidentiality concerns. There is an inherent competition issue with accessing drug cost data because of who owns the data. PBM is highly competitive and protects its negotiated drug costs and does not share this information with competitors. For example, Surescripts offers RTBT, but it doesn’t have Optum cost data because Surescripts is partly owned by Optum’s main competitor, Express Scripts.
I understand the complexities behind integrating drug cost and patient benefit data. To say it was a challenge would be an understatement.To be effective, RTBT must provide up-to-date information from various PBMs, health plans, and patient records and provide real time Electronic health records to the clinic.
Transmitting accurate pricing information to physicians in real time requires integrating data from a variety of sources, including thousands of peer-to-peer digital connections. Each of these interfaces requires regular updates, version control, and technical support. To date, no single RTBT has achieved this, which explains doctors’ accusations that the data in RTBT is inaccurate, so they don’t trust it. The reality is that for doctors, these tools create more work and provide a dubious benefit.
RTBT is designed to prevent high prescription costs, but fails to catch “leakage.” For example, after a patient is prescribed a drug to treat a chronic disease, the drug rarely changes even though the price of the drug and member prescriptions change frequently. This means that patients are likely to be refilled with the same medication even if there are new, lower-cost options. RTBT has no cost savings in refilling the space. With leakage accounting for the majority of cost overruns, the overall savings potential of RTBT is limited.
RTBTs face an uphill battle as they require a structural shift in the behavior of PBMs, health plans, clinics and prescribers. Changing behavior is by far the hardest thing to do in any field, even when the benefits of change are obvious.
Before Congress enacted the Economic and Clinical Health Information Technology Act (the HITECH Act in the American Recovery and Reinvestment Act of 2009), physicians were slow to adopt EHRs because it disrupted their usual workflow. Congress understands the scale of the effort and has committed $19 billion to the transition, with many incentives for doctors and penalties if they fail.
The Cure Act has no carrots or sticks to push doctors to use RTBT, so the tool won’t be widely adopted. RTBTs are a good idea, but they are limited by design. To achieve real savings without getting caught in a battle over pricing data and disrupting already strained workflows within clinics, Congress should consider and support other solutions.
Over the next 5 to 10 years, RTBT adoption will likely increase with better integration and automation of workflows. In its current state, RTBT may be more effective if combined with other applications for traceability conversion of drugs. This will create a more complete solution to catch more leaks obtained via RTBT.
photo: z wei, Getty Images
