Nearly all insured Americans have prescription medication benefits.
So why are so many Americans struggling to afford those prescriptions?
Shouldn't these benefits cover the cost?
In this episode of CareTalk, David Williams speaks with Kyle Kiser, CEO of Arrive Health, to explore the factors driving the disconnect between consumer needs and prescription pricing, and how point-of-prescribing technology can serve as a patient-centered solution.
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Episode Transcript:
David Williams: Almost everyone has a drug benefit these days but many patients still struggle to pay for their prescriptions. Is there a solution to that problem? And how can point to prescribing technology help?
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That's BetterHelp, H E L P dot com slash CareTalk. Welcome to CareTalk, America's home for incisive debate about healthcare business and policy. I'm David Williams, President of Health Business Group. I'm looking forward to delving to these topics with today's guest, Arrive Health CEO, Kyle Kiser. Kyle Kiser, welcome to Care Talk.
Kyle Kiser: Glad to be here. I think I'd, I think I'd say a long-time listener, first-time caller if this was a radio show.
David Williams: Yeah, that sounds good. I think that's about, that's about right. And then they'd say, yeah, can you turn your radio down in the background so we don't hear it? And no, you're impressed with being on a sports talk or whatever we're doing.
But no, that's it's, it's great. Well, we're going to talk this way broadly about medication access. And, you know, as I mentioned in the intro, Everybody has health insurance and that health insurance generally includes prescription drug benefit. I mean, not just generally, and that's almost universally.
So why is medication access even an issue? I mean, what are we talking about here?
Kyle Kiser: Yeah. I mean, it really comes down to patient out-of-pocket costs. So to your point, drug benefits are nearly ubiquitous. We've done a great job of sort of access to insurance, I guess, as a problem to solve. But in doing so deductibles used to be hundreds of dollars.
They're now thousands of dollars. Out-of-pocket costs. For copays and coinsurance used to be fives and tens of dollars and now it's, you know, hundreds and thousands of dollars and in that context, almost everybody then is effectively a cash pair. And so, you know, that's, that's primarily why I think we feel with strain is there is absolutely this sort of confluence of that happening at the same time as the, you know, unit cost of meds going up because there's new meds and new technology, new brands.
But I think we were talking about it more and feeling it more acutely because ultimately the way patients are paying for medications has changed, that the burden has shifted to their shoulders more acutely.
David Williams: Got it. So it used to be you'd go in and you'd have like a 1 maybe 10 or maybe 50 if something's out, you know, out of, off the formula or whatever. But now, even though you've got some of these drugs that are very expensive and the insurance company is paying a lot from a consumer standpoint, it's still comparable to like a, a car payment or a monthly rent.
Kyle Kiser: So, and even in the less expensive cases that you're mentioning, the complexity is just gone way up, right?
It's just in a, in an effort to control their own cost of goods, health insurance companies negotiate specific deals based on specific types of meds in a category. And it ends up with a dynamic where something will be you know, a category of drugs might be generic and assumed to be nearly 0 or 0. But the out-of-pocket cost ends up being surprisingly high because the doc didn't know to pick.
You know, this specific form rather than this other specific form. And that's not a function of, you know, the overall cost of meds being higher. It's just a function of the complexity that's in front of that doc having to make that decision being kind of untenable or invisible to them in a lot of cases.
David Williams: Yeah. Yeah. Well, so I feel I'm lucky. I don't really take any medications. But back in the olden days, as you're saying, it's like, okay, that's a generic drug. So that's basically free. And then there might be a second branded one that's advertised and that may be expensive. Then there's something that maybe it's like pseudo cosmetic or they don't necessarily want you to have it.
And that's more, but it's gotten to the point where even if that, you know, it still generally carries the day because of the way the deal-making is done. I could have something that should be free. That actually ends up being pricey is what you're saying.
Kyle Kiser: Yeah. Yeah. We did, we did a study of our data recently and found that almost, almost half the time a doc prescribed something that was more than 50 out of pocket with the patient when a 0 option was available, that's just an information availability problem, it's just not, you know, getting the right option in front of the right person.
You know, decision in that case, so that's it's not an overall function of drug prices going up. It's just complexity.
David Williams: So one of the things that's been used for a while, but I think it's used even more now is prior authorization. And so, you know, my understanding is that you've got coverage, but then in order, so you know, to keep costs under control and make sure people using the proper product, there's prior authorization, which, which serves that function, but it's also puts a lot of friction in the system.
What's the state of prior authorization these days?
Kyle Kiser: I would say that it's utilization is higher, right? Like, the, the actual experience of prior authorization probably feels like more friction than ever before. And I think if you wanted to hear this description from an insurance company or PBM perspective, I think they would describe that as a quality program, the goal being reviewing decisions that are being made to ensure that the right patients are getting the right meds and the wrong patients aren't getting those meds too.
Because there's a, yeah. There's a function of, you know, auditing that decision-making behavior to some degree. That's probably an indelicate way to describe that, but you get the point. And I think that what's been challenging is faced with that barrier. For the most part, providers just submit everything and see what happens.
And so, you know, what I think creates an opportunity is, is to really start to apply new types of technologies to turn decision support better. Capabilities into more real-time prior off decisions for capabilities, which some of the things we're working on, because there's it's got to kind of turn into a guidance system, not just a no machine, which is kind of how it functions today, right?
Instead of submitting everything, see what you get knows for then tackling appeals or making a different choice. Can we get the decision right the 1st time? And that's largely what we spent time on is how do you. How do you guide around formulary decision-making? How do you guide around prior authorization and get the right patient on the right bed the 1st time rather than.
So having to rework everything multiple times, which is often the case these days.
David Williams: So, you know, when you've got a process, there used to be the, the physician or other prescriber, usually physician would, would write out the prescription on a pad. You bring it to the drug store, they'd fill it. And sometimes they'd have to call the doctor to say, Hey, this is expensive or we don't have it or whatever.
And that was the process. And that was kind of slow because you wouldn't necessarily get the, the physician, the pharmacist is busy. You're not taking everything into account. And yeah. And you'd think in a way that electronic prescribing, it's tied in with the electronic medical record. And also that's the same system that the offices was using for billing.
Like it should all just sort of tie together in a straightforward way. So like, it sounds like there's more electronics where if I go to Amazon, I could just do one click and there's a lot of complexity in the background, you know, relating to payments and pricing and logistics, that all seems to happen.
And it, but it seems like it's gone the other way when we deal with prescribing.
Kyle Kiser: I think you're right. This is in my view, the only time in in my knowledge of our economy where we adopted an electronic process and consumer choice was constrained. You know, you had a paper script if you felt so inclined, you could go shop that anywhere you wanted at the corner pharmacy and we adopted the prescribing in the early 2000s and what changed is that script got routed directly from EMR to directly to pharmacy and then, you know, someone else made a purchasing decision on your behalf and neither of you knew what it cost until you're asked to show up and pay for it.
And so. Our mission for for many years now has been how do you reintroduce consumer choice into that clinical decision-making process and throughout the patient experience to then start to to do exactly what you just described is how do we make how do we make that selection process and that purchasing process feel a lot more like the other ways that we experience purchasing in our economy rather than being this great mystery that you sort of have to Now,
David Williams: I think based on this discussion, it's starting to come into focus now you use a term on your, on your website on Arrive Health.
It talks about patient-centered, provider-friendly technology. Just unpack that for me a little bit. What does it mean to be patient-centered and, and why provider friendly?
Kyle Kiser: Yeah, absolutely. I think patient-centered, I would almost be more specific than that. The part of what changed when we move from a generic formulary benefit data to what's now real-time benefit data.
Is that it's patient specified. It's not it's not that the prior office required generically for that plan. It's that this prior office required specifically for this patient that they haven't satisfied it already that it's not pending. There's a sort of patient-specified insight in what we do. Yeah, what we're doing millions of times a month now.
So that's 1 aspect of patient center. It's also taking into account pharmacy selection in a really specific way. So, as I know, you know, the prices at pharmacies very widely. And that's very widely for a minute-to-minute or day-to-day, or even location-to-location, right? But, you know, the right aid in the, in the pharmacy across the street may have very different prices, depending on your formulary and their negotiations.
And so being able to provide a really specific insight into that pharmacy selection process is also quite patient-centered and those things are taking into account benefit design and specific patient benefit design, not generically group and plan level design. So that's sort of patient-centered. We'll set aside provider friendly is you know, we've, we've really not done a great job as an industry of designing things that are with provider user experience in mind.
We've, we've had the benefit of being incubated inside of the Care Innovation Center at UCHealth in Colorado. And that gave us this provider-centric, centric view on how we design solutions. And how do we, how do we make things that are, that's easier, not harder, that's fewer clicks, not more clicks, that's, that's right reliably and something that providers can trust and rely on to make decisions.
And that's, that led us down this path where we took, What was a new transaction emerging in the form of real-time benefit, which is a real-time patient-specific moment in time-specific price insight into the prescribing workflow and what was required to make that reliable every time and provider-friendly is that we had to take the intelligence of the pharmacist and embed it into the technology.
We had to make sure that. You know, if there's an NDC mismatch or there's a quantity unit mismatch, or if there's some, you know, some mishandling of that transaction programmatically that the system could fix it so that it could be right more often because pharmacists were solving invisible problems at the point of sale that providers never saw.
And if we don't sort of marry those 2 processes into 1 real-time process, then you don't create a user experience that providers can rely on, which I think a lot of providers had that experience sort of in the initial launch of real-time benefit with some of those early. Early solutions and where we, I think we've, we've really built something that's market-leading is that now we have a tool that you can rely on consistently and it handles a lot of that complexity and those things matter most in the more expensive meds.
It's in self-administered meds and self-injectable pens and the creams and the inhalers and all the things that are in those more complicated units where that stuff matters the most and that's where the highest value is for all stakeholders that are using our solutions.
David Williams: You know, one of the things about the introduction of the electronic medical record is that on the one hand, it's great to have all the records in one place on the other hand, it took the physician's job and made sort of more of these administrative tasks that could have previously been done by.
Someone without all that training and it was expensive to kind of put it on to the doctor. And what I think what you're suggesting here was the e-prescribing side of it. Also, the, the physician ended up doing some of the pharmacist tasks, things that they weren't necessarily aware of, or not just in the e-prescribing, but in the whole, the whole process that you're, that you're talking about.
So I think certainly patients are, are familiar with the providers struggling, you know, with the, with the computer while they're in front of them. So there's that part of it. So that's, Well understood now, and you've added an extra element there when you talk about the interaction with the pharmacy. I wanted to ask you a little bit more about the patient-centered part of it.
So you said before, you know, I could take my script and it used to go wherever I was. Maybe I'd if I was at work downtown, I'd take it to the, you know, the pharmacy there. If I was near my home, I might, I might do that. Or if it's a place like shopping for groceries. And now it's more or less, what's your preferred pharmacy?
And they have that in there. Are you saying that, that I shouldn't have a preferred pharmacy, but that I should vary it based on like what I'm specifically being prescribed?
Kyle Kiser: In some cases, yeah. That is you know, the rooming process is always going to have that question of what's your preferred pharmacy, but it's so arbitrary at that point in the visit that there's no knowledge of what you're going to be prescribed or you know, what access or affordability barriers might be ahead of you.
And so, yeah, I think that one of the things that's valuable and inherent in real time benefit is the. We're, we're bringing back alternatives around pharmacies. So let's say you start with pharmacy a, and it's at a network we can then suggest in a network pharmacy. That's the best cost. In that case.
Let's say you're being prescribed a branded med that may have some patient support programs associated with it. We might be able to provide some insight into the right paths for you to take down a medication access path. And those things can happen at the point of care and connected into a patient message that's, that's really tightly coordinated with the point of care transaction.
Which, you know, driving up patient engagement, driving up sort of patients acceptance of this information and hopefully adherence in our goals to, you know, help people manage their conditions more, more effectively because of those things.
David Williams: Let's talk about the pharma support here and how that plays in, you know, it back in the, in the olden days, it was, you know, some people didn't have insurance or they were, you know, low income.
And then there were certain programs that you could essentially get free medication, you get some, some help with it. But it was sort of the same way you think about, you know, being on food stamps or, or welfare that that's not for people above a certain, you know, the income or, you know, if you have insurance, you certainly wouldn't wouldn't be looking for free care and so on.
But I think the world has evolved, and when you talk about you know, people having hundreds or thousands of dollars in co pays, then that, that, that affects, you know, everybody, at least 90 percent probably of patients there. How have the pharma support programs evolved, and are these, are they just for low-income people these days, or what's, like, what's the, how, what does the environment look like, and how does it play into what you do?
Kyle Kiser: Yeah, it is a team sport for sure, in this case. And I think, you know, we think about patient support mostly in the context of access teams inside of health systems, just because of where we sit and who we work with more often. And so there are, you know, teams of dozens, sometimes hundreds of people inside of health systems that are doing nothing but trying to.
Resolve prior and then find affordability options for patients. And that's that's largely because that problem we identified at the beginning of the conversation. It's just the thousands of dollars of out-of-pocket cost is just something that doesn't work for the vast majority of Americans. And so, in response to that, copay assistance has come in a variety of forms.
There's commercial copay. Programs that will buy down the out-of-pocket costs for the patient for some period of time. There's the, you know, the more philanthropic aid type category that you were describing, where maybe that's a free drug program or a disease-based, you know, some disease-based association that's providing support for specific disease categories.
And, and really the challenge exists now that it is, you know, the state of the art of where to find those things is usually. 20 to 40 sticky notes over the monitor of somebody inside of a health system. And so we're, we're trying to rationalize some of that and in tying that point of care encounter directly to a patient message that we can then sort of help move forward the appropriate enrollment based on what we know about that patient.
It's, there's a, there's definitely a much more coordinated dance between insurance benefits and other types of payment and, and even cash pay. I think just as importantly these days. And probably at a higher volume from a transaction perspective, that cash pays a real part of how people are paying for benefits.
And those, you know, the integrated cash coupon programs and are just the way of the world. Now, we work closely with several of the, you know, the air PBM-type folks that are providing those programs. And that's that just raises the level of complexity for doctors, right? Is that now in a clinical day, you maybe see 30 or 40 patients.
Those 30, 40 patients, you know, used to probably represent 5 to 15 different health plans and formularies. And I bet every 1 of them now has a different formulary, you know, and it's, it's an impossible scenario for provider to take on themselves and it's where, you know, direct connectivity, interoperability and automation can really be a important solution.
David Williams: We talk about a big driver of costs of medication being biologics. As you mentioned at the start of the show, a lot of new expensive medications being introduced. There's a countervailing effort though, to introduce biosimilars. And I'm wondering how that plays in broadly, is that helping to keep the cost of biologics down?
And I assume it does something also with the complexity of your choice now that you're not just choosing the specific biologic.
Kyle Kiser: Yeah, no, it's it's certainly. The answer to that question is different from pair to pair. For sure. Everybody seems to be negotiating their own specific deals. And again, we come at it from this provider-centric perspective, which means it's only a harder problem for the provider to solve.
And, you know, discerning, you know, pay or a, and their preferences from Bay or B, and their preferences becomes a challenge and. And the only way that by some of those are going to have a real impact is adoption. If we can't get adoption because the, the decision rubric for the provider is too complicated.
Then that's going to limit impact. So our goal is, how do you take that complexity, bring it to the point of care and make it easy to use for the provider so that, so that, you know, patient 1 through 10 that have a different answer than patient 11 through 25 is easy for that provider to adopt and for their care team to administer and overcome the prior off and those sorts of things.
It's bringing that into a decision support frame that I think is going to
David Williams: So, you know, this conversation we're having is actually fairly complicated and I can imagine a typical listener, if they've made it this far, is thinking, okay, I'm glad somebody else is, is dealing with that, but for the, someone who's made it to the end here and it's more of like a patient or is you know, responsible for the financial, let's say of a, of a dependent.
I mean, what would be the takeaway of like, what should a patient know as they interact with a system these days? I mean, I, I consider myself pretty well informed, but I, you know, there's a lot that I learned even, even from this, but like, what are, what takeaways for patients in this whole system?
Kyle Kiser: Let me, let me answer that question with a story.
So one of our co founders, a guy named Kevin O'Brien, he's a doctor in Denver, and part of what inspired the beginning of this company is Kevin wanting to help his mom. Kevin's mom approached him. She had an out-of-pocket cost that was a struggle. Kevin, being a physician, had the skills to do so.
He looked at her meds, found ways to save, looked for options that might have not been obvious to her, or found, you know, a generic med that could be broken into its, or a branded med that could be broken into generic parts. And cut her spend in half. And so we still have a mantra around the company that that's Lucy up.
And it's kind of our way to think about that problem. And so serving that one patient, it's because Kevin's mom's name is Lucy. And that to me is the that's the, that's the opportunity for every patient is that there's likely something in your encounter with that physician where engaging in a different way could make a huge difference.
And I think that providers desire this information. I think that's the biggest thing that we've proven over the years is that, you know, the first thing we had to prove was do providers care. And I think definitively, now we can say by the end of the year, we'll be doing. North of 20 million of these transactions a month and providers want to want this information.
These are the problems they want to solve for patients because they want you to be able to take your medication. And so I think, you know, the key takeaway if I'm a patient without diving into the health care data, nerdery that we spent most of the time on is, is just that your provider wants to help.
And in many cases, they now have the tools to do so. And that wasn't the case even a couple of years ago. So the adoption of these things has happened fast and there's an opportunity to really rely on that relationship. And to me, that's the biggest leverage point for change is that patient-provider relationship, the trust that exists in that's inherent in that relationship is the, is the best opportunity we have systemically to make things better.
David Williams: Well, that's it for yet another episode of Care Talk. I'm David Williams, president of Health Business Group. I've been speaking with Kyle Kiser, CEO of Arrive Health. Thank you, Kyle.
Kyle Kiser: Thanks, David.
David Williams: So if you like what you heard, or even if you didn't, please go ahead and subscribe on your favorite service.
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