The practice manager’s impetus for a real-time prescription benefit standard

Insight Article - August 14, 2019

Electronic Health Records

HIT Regulations

Lee Ann Stember
As of 2017, nearly 9 in 10 (86%) of office-based physicians had adopted any EHR, and nearly 4 in 5 (80%) had adopted a certified EHR. Since 2008, office-based physician adoption of any EHRs has more than doubled, up from 42%.1 However physicians today encounter a key obstacle when prescribing medications: the lack of visibility on and access to real-time, patient-specific electronic formulary and drug benefit information.
All of that is about to change. The new Real-Time Prescription Benefit Standard was presented earlier in the month at NCPDP’s August Work Group Meetings in Philadelphia. NCPDP members took an important step in bringing the industry-wide transaction forward. At the work group meeting, members approved the BETA version of the Standard, which will be balloted for industry review, comments and feedback in September. Widespread adoption of the Standard will standardize the availability of every patient’s real-time prescription drug information at the point of care in the patient’s journey, regardless of the insurer — all within providers’ workflows.
The Centers for Medicare & Medicaid Services (CMS) recognizes the importance of national adoption of the real-time prescription benefit transactions. Specifically, CMS rules mandate that each Part D plan adopt one or more real-time benefit tools that are capable of integrating with at least one prescriber’s ePrescribing system or EHR, no later than Jan. 1, 2021.
Through the EDvocacy initiative, NCPDP has earned the trust and respect of policymakers, serving as a resource and sharing education and knowledge about the complexities of the healthcare system with federal and state government officials, including CMS. The cost of prescription drugs is a top priority for both the current Administration and Congress. In fact, three Congressional Committees focusing on cost transparency measures have reached out to NCPDP as a resource and expert on real-time benefit tools.
In essence, NCPDP’s standard will breathe new life into the EHR, providing a new level of transparency and visibility that is unprecedented and not exclusively based on one drug manufacturer’s formulary or one payer’s benefit coverage.
Consider the key methods in which the national standard benefits both providers and patients:
Strengthens provider-patient relationship: For physicians, the NCPDP standard is positive news on many fronts. The standardized transactions pave the way for anyone with prescribing authority to have higher quality and more informed, meaningful conversations with patients about the medications their insurance covers and the cost — helping patients avoid “sticker shock” and prescription abandonment at the pharmacy.
The ability to provide cost transparency at the point of care enhances the provider-patient relationship and builds trust. Physicians can talk with patients to make the best medication choices and recommend alternatives, if needed, based on the individual.
Provides instant drug cost and prior-authorization information: Access to real-time prescription drug information will streamline and speed up the prior-authorization process. Physicians will have access to patients’ up-to-date prescription information instantly, allowing them to identify medications that require prior authorization so they can initiate that process electronically. By the time the patient arrives at the pharmacy, the prescribed drug is ready for dispensing.
Improves medication adherence: The universality of NCPDP’s transaction is expected to dramatically increase a patient’s prescription drug adherence, which results in improved care quality and health outcomes and less spending on drugs that are not actually used.
Engaging in treatment conversations with patients presents a higher degree of certainty that patients will take their prescribed medications. Understanding their choices and costs upfront, patients are more likely to pick up and take the prescribed drugs from their local pharmacy instead of abandoning them.
Improved adherence rates can also support physicians who participate in pay-for-performance initiatives. Physician-led medication adherence is a strong predictor of patient health and should be considered as a measure of physician quality.

Supports complex ePrescribing claims: The transaction standard will support the growing complexity of claims adjudication, largely attributed to the growth in specialty drugs. The healthcare industry is seeing a seismic shift in drug spending, with specialty pharmaceuticals outpacing traditional pharmaceutical growth. By 2021, the specialty market is expected to make up 50% of total pharmaceutical spend, or $285 billion.

Conforms to physician workflows and drives interoperability: Many forward-thinking health plans have introduced prescription benefit tools in recent years to assist their in-network physicians. However, the challenge is that these tools are primarily point-to-point solutions —each payer’s specific patient prescription drug information is delivered via a flat file, portal or other mechanism to a practice’s EHR or ePrescribing system. While some health plans offer to provide visibility to drug benefit and pre-authorization, doctors must rely on multiple tools which in turn bring workflow challenges to the prescribing process.
Among the benefits of NCPDP’s national standard is improved interoperability, a challenge that plagues the U.S. healthcare system. The standard will also provide workflow efficiencies and leverage the success of other standards named in HIPAA (NCPDP Telecommunication Standard) and MMA (NCPDP’s SCRIPT and Formulary and Benefit Standards) regulations. In short, any physician will be able to easily and freely access a patient’s prescription data at the point of prescribing, in real time from any plan and from any flat file, portal or other mechanism.  
System vendor representatives who have participated in the development of the standard will be equipped with the knowledge to incorporate it into their company tools with minimal disruption and minor modifications.

NCPDP standards development process

NCPDP, a not-for-profit, ANSI-accredited Standards Development Organization (SDO), is developing the standard collaboratively with experts across the pharmacy industry. The end goal is to develop a standard that supports better informed clinical decision for the ultimate benefit of patients.
To achieve this, NCPDP is deliberately inclusive of all industry participants affected by an issue, and we are careful to develop standards and solutions for the common good, using our collaborative, consensus-building process. At the end of the day, we unite around patients to improve the healthcare experience.
NCPDP members come from every corner of the industry, driven by their personal passion for their work. We encourage physicians, practice administrators and other MGMA members to become involved in NCPDP to improve healthcare from both a business standpoint and for patients.
Your perspectives, knowledge and expertise are critical to the standards development process. Check out the NCPDP work groups, or sign up to participate in one of our task groups.  NCPDP work groups meet quarterly, in-person, at locations across the country. These face-to-face meetings are important and fundamental to the consensus-building process. Task group calls are open to NCPDP members and non-members, and you may join a task group at any time.


  1. Office of the National Coordinator for Health Information Technology. “Office-based Physician Electronic Health Record Adoption,” Health IT Quick-Stat #50. January 2019. Available from:

About the Author

Lee Ann Stember
President and CEO NCPDP

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