Point-of-Care Partners Comments on CMS Efforts to Enable Real-Time Pharmacy Benefit Checks for Medicare Beneficiaries

Proposed Rule Requires Part D Plan Sponsor to Implement Real-Time Pharmacy Benefit Check by January 1, 2020

Point-of-Care Partners (POCP) submitted comments to the Centers for Medicare & Medicaid Services (CMS) concerning the agency’s draft rule, Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses, CMS-4180-P

POCP expressed support for and provided further input on Section 2 of the draft rule, “E-prescribing and the Part D Prescription Drug Program; Updating Part D e-prescribing Standards.” In this section, the rule proposes requiring Part D plan sponsors to implement an electronic real-time benefit “tool” (RTBT) capable of integrating with prescribers' ePrescribing and electronic medical record (EMR) systems no later than Jan. 1, 2020.

“POCP’s comments focus on how best to integrate real-time pharmacy benefit check (RTPBC) with provider work flow, leveraging industry standards to deliver robust data that enable providers to make better informed medication choices at the point of prescribing and helps connect patients with the costs of their care,” said POCP CEO Anthony Schueth, MS. “We appreciate CMS’ clear recognition of the value that RTPBC brings to all healthcare stakeholders and this opportunity to share additional input from the healthcare information technology perspective.”

Summary of POCP’s major comments on the proposed regulation.  

·        Implementation date. We believe the proposed implementation date may be too aggressive for many electronic health record (EHR) vendors. We recommended that CMS consider moving back the implementation date to give EHR vendors a chance to build to the standard.

·        Name of the transaction. The proposed rule references a Real-Time Benefit Tool. POCP recommended that CMS adopt the term Real-Time Pharmacy Benefit Check (RTPBC) to prevent confusion and eliminate the need for additional nomenclature changes when the Real-Time Medical Benefit is under consideration for use by Part B in the near-term horizon.

·        Use of standards. The proposed rule is agnostic in terms of a standard to be used for the RTPBC, even though there are several under consideration by the industry. Because we believe that a single standard will hasten adoption of RTPBC, we recommended that CMS require use of a single standards-based RTPBC transaction that is deemed most appropriate by NCPDP.

·        Address the relationship with formulary and benefit files. The proposed rule does not address the interaction between RTPBC and the formulary and benefit (F&B) standard. POCP recommended that CMS should require payers to provide a minimum mandatory data set to populate F&B files inclusive of the prior authorization field and that the RTPBC does not replace the eligibility-informed F&B check.

Comments related to implementations of RTPBC to make it more useful, accurate and complete in addressing price transparency and patients’ out-of-pocket financial obligations.

·        Establish a uniform patient out-of-pocket cost model. Because of the way RTPBC has evolved, there are varying models for patient out-of-pocket costs. We recommend that CMS collaborate with the industry to create a uniform patient out-of-pocket cost model.

·        Address the prescription rework challenge. To ensure broad adoption and sustained use of RTPBC, POCP recommended that CMS address interoperability between the EHR system’s ePrescribing system and RTPBC application to eliminate clinician rework.

·        Integrate additional cost/access information. To address data gaps affecting patients’ potential out-of-pocket liability, POCP recommended that CMS should require RTPBC to provide lower-cost alternatives and restrictions and additionally encourage industry to provide relevant information on payment assistance programs.

·     Enable RTPBC access for patients. To give patients full visibility into their and family members’ medication costs, alternatives, restrictions (eg, prior authorization), assistance programs and pharmacy options, POCP recommended that CMS should consider including patient-facing implementations of RTPBC for payers.

“POCP looks forward to working with industry stakeholders and standards organizations on the implementation of these important policy changes,” Schueth said.

Point-of-Care Partners is a health IT management consulting firm with in-depth expertise in ePrescribing, eMedication management, health information exchange, population health management and multi-stakeholder initiatives. To learn more about how Point-of-Care Partners can help your company understand the changing healthcare landscape and implement effective strategies, contact info@pocp.com


Source: Point-of-Care Partners

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Point-of-Care Partners (POCP) is a leading health IT management consulting firm assisting healthcare organizations across the healthcare ecosystem in the evaluation, development & implementation of winning health information management strategies in a rapidly evolving digital world.

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