Making the task of understanding pharmacy benefits easy and transparent has never been a strong suit for pharmacy managers, creating challenges for self-insured employers seeking to properly work with their employees. But Transparent has a vision for how it can change that by simplifying the experience so users don’t have to navigate the existing system. In an interview, Transcarent COO Snezhana Mahon provided an overview of how businesses are looking to embed price transparency and drug information to provide a digital pharmacy benefits experience that allows self-insured employers and their staff to more informed choice.
Mahon explained that Transcarent’s approach is based on four principles. Price is a crucial issue when it comes to pharmacy benefits. Such are the form and the possibility of receiving discounts from pharmaceutical manufacturers.
“Transparency governs everything we do as an organization, both transparency with members and employers. Whether that’s providing full access to discounts that employers are eligible to receive, or unlimited access to view information about available drugs, reimbursement information and ultimately what members pay.” Mahon said.
Transcarent has rejected traditional pharmacy benefit management approaches built on outdated legacy technology and claims adjudication systems. Instead, Transcarent uses open, API-based, cloud-based technology that allows users to see real-time information that is related to their benefits. Transcarent members can also proactively receive lower cost referrals at the time of prescription, then use the Transcarent platform to make smart decisions in collaboration with their doctors in real-time, something no other pharmacy solution does can provide today. They can also see how much a drug costs both prospectively and retrospectively if they shop for drugs.
Employers can use Transcarent to build a high-end pharmacy service that allows them to choose a formulary design for how drug benefits are administered. It adds flexibility to use retail pharmacies near where their employees live, as well as specialty or mail order pharmacies.
The goal is to empower users.
“The number one problem in healthcare today is that consumers don’t trust the current ecosystem,” Mahon said. “So how do we give them the right tools, accurate information and reliable guidance so they can make better decisions about their care? We can help them look for alternative medicines and cheaper alternatives. We can be fully transparent and provide easy access to care to drive greater adherence, better clinical outcomes and better choices about the health care decisions they make and the medications they take.”
Solving the conundrum of treatment adherence is critical to reducing healthcare costs and helping people manage their conditions. While there are many personal reasons why people do not pick up their medication from the pharmacy, one of the most common is that they cannot afford it. Analysis of National Opinion Research Center (NORC) at the University of Chicago showed that one in four Americans who struggle to take their medications are from disproportionately lower-income households. But that doesn’t tell the whole story. Poor treatment adherence can affect even people who have well-paid jobs. Some drug costs are astronomical, regardless of personal income level. This is why consumer empowerment is such a critical part of Transcarent’s approach.
If you think about the average number of medications people take, even saving $10 to $15 can make a significant difference. For some members, they can save $50 to $60. It accumulates over the course of a year. If the average member can save $500 to $600 per year through guidance and awareness of lower cost options available to them, it can have a huge impact.
Another component to improving adherence is improving health literacy through education, counseling, and guidance. When patients do not understand how to take a medication correctly, or know what side effects to expect, or how to look for this information, it can lead to unwanted surprises and resistance to taking a medication. Transcarent provides guidance and support to its members, providing direct access to a pharmacist who can talk about the short- and long-term benefits of adherence. Symptom Checker in Transcarent’s digital experience allows members to enter symptoms so they can find out what side effects to expect from their medications. It can also prompt a follow-up appointment with a provider to ensure patients are prescribed the correct medications, which can provide them with a better quality of life and help protect against adverse effects. The goal is not only to arm patients with transparency tools to access lower-cost medications, but also to help members stay on top of their medications and stay committed to their care plan.
Biosimilars also play a role in Transcarent’s drive to improve the digital pharmacy experience. They offer the prospect of cheaper alternatives to prescription biologics. The ability to show and educate patients about the price differences of biosimilars compared to branded biologics will give people the kind of information and insight that allows patients and their families to make more informed choices. This information and guidance is necessary for self-insured employers to reduce their costs.
According to Mahon, there are several key drugs and biologics that are losing exclusivity in 2023. HUMIRA is key, and there are several others that will be able to provide more options when brand exclusivity expires in 2023.
“There are currently over 7,000 products in the FDA’s specialty drug and biologics pipeline. Most of these drugs are specialty drugs that will be approved sometime between 2023 and 2025,” Mahon said.
By providing these tools, employers are able to provide and shape the future of benefit and incentive designs that consumers can engage with and be more empowered to take better care of themselves and their families.
Transcarent is also transforming the pre-approval process. Typically, prior authorization is based on the benefits design in the form the employer chooses, according to Mahon.
“I would say that on roughly every formulary in the country for most employers, maybe 20 to 30 percent of the drugs have either clinical prior authorization, step therapy, or a cap on the amount that is administered. In this scenario, for customers who choose us to be their claims adjudicator as well, we not only provide a superior pharmacy experience, but also adjudicate the claim on behalf of the employer,” said Mahon. “It will still trigger the associated quantity level restrictions at the prior authorization stage that may be associated with this drug, but we are able to connect with the provider, get the patient to receive their drug in a very quick time, using the information available to us. But with our prior authorization process, it may never even have to happen retroactively because you’ve already turned to drug alternatives, lower-cost options at the point of care versus the point of sale at the pharmacy counter , where we don’t even need to get to that point and be able to support both fronts.”
Transcarent wants to bring the long-term holistic pharmacy experience to health and care and empower consumers in the decision-making process so that they can be a critical driver in the delivery and consumption of care.
photo: Who I am, Getty Images