Prescription Cost Estimation System for Point-of-Care
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Solution Overview
Problem
Healthcare providers face challenges in obtaining accurate and timely information on medication costs during patient prescriptions due to evolving benefit coverage structures and varying prices between pharmacies, leading to patient non-adherence when costs are unforeseen.
Innovation Solution
A computer-implemented method that receives a prescription benefit coverage inquiry, transmits it to a pharmacy claims processor, and if a response is not received or insufficient, determines an estimated cost range using historical data and identifies available incentives, providing real-time or near-real-time estimated costs and targeted out-of-pocket costs to prescribers.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Measurement precision
If a response is obtained from a pharmacy claims processor, then accurate prescription cost information is provided, but the process time increases and may exceed the point-of-prescribing window
Solution Approach 1:
The system performs preliminary actions by sending the prescription benefit coverage inquiry to the pharmacy claims processor in advance and simultaneously preparing fallback cost estimation logic. This allows the system to wait for the accurate response while having a ready backup plan, thus not increasing the overall process time beyond the point-of-prescribing window.
Solution Approach 2:
The service provider computer acts as an intermediary between the prescriber computer and the pharmacy claims processor. It manages the communication flow, handles timing constraints, and coordinates between the accurate but slow claims processor and the time-sensitive prescriber interface, resolving the timing conflict.
2Reliability
If real-time cost information is provided to prescribers, then patient adherence improves, but system complexity increases due to multiple data sources and fallback mechanisms
Solution Approach 1:
The system segments the cost information provision into two independent modules: (1) the primary module that obtains accurate costs from the pharmacy claims processor, and (2) the fallback module that estimates costs using historical data. This segmentation allows each module to be independently managed and maintained, reducing overall system complexity while ensuring reliability through the fallback mechanism.
Solution Approach 2:
The system changes the parameter of cost information from a single static value to a dynamic range estimation when accurate data is unavailable. By transitioning from exact cost (when unknown) to estimated cost range based on historical transactions, the system maintains reliability for patient adherence decisions without requiring complex real-time data from multiple sources.
3Loss of time
If estimated cost ranges are provided instead of exact costs, then information is available at point of prescribing, but measurement precision decreases
Solution Approach 1:
The system implements a dynamic cost information provision mechanism that adapts its precision based on data availability. When exact cost data is available from the pharmacy claims processor, it provides precise information. When unavailable, it dynamically switches to providing estimated cost ranges with confidence intervals, thus maintaining time efficiency while adjusting precision to match the available data quality.
Solution Approach 2:
The system uses feedback from the pharmacy claims processor response status to determine the appropriate level of precision to provide. If the processor returns accurate cost information, the system feeds this back to the prescriber with high precision. If the response is delayed or unavailable, the system feeds back the historical estimation with appropriate uncertainty indicators, managing expectations while providing timely information.
Data Source
AI summary
A method, apparatus and computer program product are provided for providing a patient with prescribed medication cost information at a point of prescribing. A prescription benefit coverage inquiry is received and provided to a claims processor for processing. Historical data associated with prior prescription transactions is utilized to determine an estimated cost range of a prescribed medication in the event of an insufficient or absent response from a benefits manager. The estimated cost range is then provided to a prescriber to share with a patient. A targeted out-of-pocket cost according to incentives, such as vouchers and drug manufacturer rebates may also be provided.