Dynamic Copay Adjustment System for Prescription Adherence
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Solution Overview
Problem
Pharmaceutical manufacturers face challenges in maintaining customer adherence to prescription drugs due to increasing out-of-pocket costs, leading to potential customer switching or discontinuation, and existing subsidies are costly to maintain.
Innovation Solution
A computer-implemented method and system for copay adjustments based on historical transaction records, where if a customer's current copay amount exceeds their prior copay amount, the system reduces the copay to the prior amount, enhancing customer adherence while controlling subsidy costs.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If pharmaceutical manufacturers provide subsidies to reduce out-of-pocket costs for customers, then customer adherence to prescription drugs is improved, but subsidy costs increase
Solution Approach 1:
The copay amount is made dynamic by adjusting it based on historical transaction data. The system compares current copay amounts with prior copay amounts for the same customer and drug, and adjusts the copay accordingly. This dynamic adjustment allows the subsidy level to vary over time based on actual customer behavior and historical patterns, rather than remaining fixed at a high level that would be costly to maintain.
Solution Approach 2:
The system implements feedback by continuously monitoring historical claim transaction records and using this information to adjust copay amounts. The feedback loop compares current copay data with historical data, identifies patterns in customer adherence behavior, and uses this information to determine optimal copay adjustments. This feedback mechanism ensures that subsidies are adjusted based on actual customer response and adherence patterns.
2Reliability
If copay amounts are reduced to maintain customer loyalty, then customer adherence is improved, but out-of-pocket costs for the manufacturer increase
Solution Approach 1:
The system changes the parameter of copay amount based on historical transaction data. By analyzing past copay amounts and customer responses, the system determines optimal copay adjustments that maintain customer loyalty without excessive expenditure. The parameter adjustment is data-driven, using historical patterns to identify the minimum effective copay level that maintains adherence.
Solution Approach 2:
The system uses historical transaction data to automatically determine appropriate copay adjustments without requiring continuous manual intervention or excessive subsidy expenditure. The historical records themselves provide the information needed to self-adjust copay amounts, allowing the system to maintain customer loyalty using past performance data rather than requiring continuous high-level subsidies.
Data Source
AI summary
Systems and methods may provide for copay adjustment. The systems and methods may include receiving a claim request from a pharmacy computer, where the claim request may be associated with a product requested by a customer, transmitting the claim request to a claims processor for adjudication, and receiving, from the claims processor, a first claim response for the claim request, where the first claim response may include a current copay amount payable by the customer. The systems and methods may also include determining, based upon a historical claim transaction record associated with the customer, that a prior copay amount for the drug is less than the current copay amount, and transmitting a second claim response to the pharmacy computer with a new copay amount lower than the current copay amount of the first claim response.