As seen on HIStalk.
Tell me about yourself and the company.
I’m CEO of the recently minted Arrive Health, which until a few days ago was known as RxRevu. I’m part of the original team and have been with the company for almost eight years. We have built a network that delivers cost and coverage information into the e-prescribing or ordering workflows of providers and advocate for real-time, patient-specific, location-specific, moment-in-time-specific insights to help connect effectively marketplace information with clinical decision-making at a high level.
We can all share stories about inconvenience and aggravation due to prior authorizations, prescription coverage and cost surprises, and the increased difficulty in shopping prescription prices with the move away from paper prescriptions, none of which can be easily measured except indirectly on provider satisfaction surveys. How do you think that frustration manifests itself?
There are absolutely mountains of anecdotal evidence. The way that we have structurally arranged the system is that on one end, healthcare providers make decisions based on what they perceive, how they have been trained, the clinical guidelines that exist, and maybe some influence based on the system that employs them. On the other end, health plans and PBMs have developed rules that are intended to guide the right decision to a best-cost decision. Those best-cost decisions are usually behind a curtain, to some degree. There’s a lot of mystery or maybe unique intellectual property in how those things happen and are derived.
The net of that is there are rules on one end developed by health plans, there are rules on the other end being adhered to by clinicians, and those two sets of rules are entirely disconnected. We connect those two things into one experience, because in today’s state, it’s up to the patient to manage the in-between. They have to advocate for themselves with their health plan. They have to advocate for themselves with their provider. Ultimately, their trust is with the provider. If you have a question about something that’s health related, if you’ve got a question post-visit about something or you’ve got a question about a med you’ve been prescribed, your first instinct is to pick up the phone and call the clinic where you went, where the decision originated. We are empowering that provider who already has the trust and the leveraged relationship to drive the right decisions, to ultimately take the preferences of that individual’s health plan and put it into the hands of a decision-maker who is already making that decision.
As far asmeasuring the impact and maybe even the size of the problem, we are finding about 20% of the time when we present other options, providers are adhering to that. That’s just with the workflow intervention. That’s not with a care team or a patient intervention. Just by providing this information in a relatively passive way in workflow, providers are accepting those options about 20% of the time, which is meaningful. That means that one out of five patients aren’t having to show up at the pharmacy counter and realize that their claims have been denied. They aren’t having to call their PBM or their health plan to understand if there’s a prior auth required, and if so, how they resolve that prior auth. They aren’t having to call back the clinic and say, “I can’t afford that medication.” All of those things are resolved in that moment in time.
The way the world is moving, there’s just not a future where providers are not going to be considering cost. High-deductible health plans are ubiquitous now, and patients are bearing a price for healthcare that was never intended for them. The in-network negotiated rate was used in a calculation before, but now patients are faced directly with that out-of-pocket expense, first dollar. Clinical decision-making and cost and coverage decision-making are now one and the same. They have to become integrated, clearly not emphasizing cost and coverage over the right clinical choice, but making sure that the clinical choices that you are making are the things the patients can access and afford. Patients are demanding that.
How much inefficiency is involved with the provider making a clinically appropriate decision and then having to redo that decision without compensation for cost reasons, through no fault of their own?
I think the number I saw in a Health Affairs article years ago was 65 million calls a year to provider offices to resolve exactly what you just described. There are three therapeutically equivalent drugs. You chose A, we wanted you to choose C. The provider doesn’t necessarily have a strong opinion on one of those three options. They just don’t have the information they need to understand that choice and how the health plan is contracted to derive that preference. There’s an absolutely strong efficiency argument for provider offices in general. Making the right decision the first time prevents reworking many of them.
Have you seen a comparison of patient satisfaction with the provider when their prescription process goes without a hitch versus when the patient is bounced around as the middleman?
We are just starting to look at that. Our focus to this point has been primarily on provider adoption, because in our belief, everything starts there. If we can’t compel a provider to use the tool consistently and to influence their behavior in an appropriate direction as a result of this intervention, then everything downstream of that becomes impossible. Most of our focus has been on the behavior change aspect of the tool.
That’s where that 20% or so number that I mentioned earlier is really important. It is many times higher than most of the other things happening in the industry. Multiple times higher than other behavior change measures in the industry. It has been a huge part of our focus, and the key to our value is understanding provider engagement and how and why they use the tool. That comes from being an organization that was incubated within the University of Colorado health system and having intentionally worked with health systems as strategic partners to better understand their world, to better understand the problems they’re trying to solve, to better understand how our solution can impact those problems.
Transparency would ordinarily create a more competitive market, perhaps among insurers, PBMs, or pharmacies. Are you seeing an effect on the pharma supply side of having patients know upfront where to get their prescription filed or what alternatives are available?
Real-time benefit is a mechanism to communicate the supply-side negotiations that have already happened. PBM and manufacturer have decided on formulary placement and what tier and what reimbursement is appropriate. Real-time benefits allow the mystery that was happening in the background to be provided in a way that makes sense to an end user, to a provider trying to make that decision. It will be some time before having that information at the point of care starts to influence, well downstream, the supply-side negotiations. Because in a lot of ways, we are just communicating something that has already happened between the risk-bearing entity and manufacturers.
But I do think that over time, the fact that this is happening at the point of decision is a massive opportunity to think about these things differently. Maybe future-state thinking about other forms of affordability being communicated at the point of care and maybe even directly to patients. That’s the key to all of this, starting to expand our purview beyond just the point of care, but also to care teams and also to the patient themselves. Making sure that we are leveraging our network — which is focused on driving the right decision the first time, whether that’s a med or something beyond a med — to influence point-of-care decision making, care team decision-making, and patient decision-making, all from a common source of information and one source of truth.
That’s where we can start to change systemic decision-making, but it takes all three legs of that stool to do that well. The impact then will be some of the things you are driving at, which is ultimately that adherence will be massively impacted, the patient experience will be massively impacted, and even ultimately how some of these financial decisions around which med and why will be financially impacted. Because we will have the data end to end, from decision to fill, to understand those things, to identify the cohorts, and to understand outcomes. That’s the groundwork that we are laying, this decision network and then the access network.
How hard is it for prescribers to advise patients, using available electronic information, where their prescription will be cheapest given available pharmacies, manufacturer assistance programs, coupon programs such as GoodRx, and insurance coverage? In the paper prescription days, patients could visit multiple pharmacies for prices, then choose which one to fill it.
Today, that’s a tough thing to do at the point of care. I think your point around empowering consumers is the most relevant one. Ultimately we have to put some of this cost decision – specifically, the decision around location of fulfillment and what methods to drive affordability that patient needs — in the hands of the consumer. E-prescribing 1.0 really limited patients’ ability to have choice and patients’ ability to be an active and informed consumer.
Real-time benefit and price transparency, like the liquidity of price transparency information more broadly, absolutely represents an opportunity to return to that. We can put these types of insights into the hands of the care team that’s trying to support that patient and the patient themselves to potentially select the lowest-cost pharmacy, to select the lowest-cost path of care in general. For sure, that is the opportunity. That’s the turn we are making as an industry and we are making as a company.
Our transition from RxRevu to Arrive Health is part of that. We see our role expanding, both with stakeholders — so not providers alone, not prescribers alone, but care teams and patients — and also around the types of transactions and services that we are able to impact. It’s not just drugs any more, it’s labs and radiology and all of the shoppable things that are coming because of the No Surprises Act, price transparency regulations that have happened, and even the Cures Act to some degree, Patient data itself is more liquid and we are required by statute to engage patients with. All of those things net out to an environment where patients being empowered to make those decisions now is possible. The technology, for a number of reasons, wasn’t capable of doing it, and that has changed.
How will the lab, pharmacy, and radiology market, as well as the company itself, change once prescribers have access to cost and alternatives information during the ordering process?
Providers care a lot about patient out-of-pocket costs. The ability for a patient to actually afford care is usually motivating for a provider, because ultimately, they can only benefit from care that they can afford and access. In some of these more discrete medical benefit site services, the out-of-pocket impact is not quite the same as drugs. We lose some of the incentive for the provider to engage, because providers care a lot about patient out-of-pocket costs, but it’s much more difficult to get providers to pay attention to, or adhere to, plan cost requirements.
This is not a criticism of providers. It’s just that when you think about the way they are trying to make that decision, it’s ultimately doing the right thing for the patient. The right thing for the patient is, can they afford it? That’s where care teams become really important, the care teams that are doing access work, the care teams that are doing referrals, the care teams that are doing prior authorizations. That’s the opportunity that I see to influence some of that other medical benefit type decision-making that’s just more appropriate workflow. That’s where that work is happening and that’s where I think the value is, in concert with a direct patient outreach. Patients need to understand their options, but it’s heavily a care team utility in that case.
What will be most important to the company in the next few years?
The continued capability of health plans to expose price transparency information to their members is really, really important. Critical, even. The continued push for data liquidity as it relates to eligibility, the straight commodity stuff that you need to understand who the patient is. To me, pharmacy eligibility is a good example of that. That should flow freely, because ultimately all you do with pharmacy eligibility is you understand that I, Kyle Kiser, am a part of Health Plan A and Formulary A. That’s more or less like a user credentialing function.
If you think about an Amazon login, that’s just a ticket to the game. Making that flow freely and as liquid as possible, accessible to any patient who wants it, accessible to anybody working on behalf of that patient that the patient has given permission to. All those things that Cures promises — the progression of that is important because the restriction of that information is a rate limiter to innovation, period. Those two things, from an industry level, are important.
For us, as we look to the future as a company, it’s ultimately how we more tightly integrate point-of-care decision-making, care team decision-making, and the patient themselves making these decisions. How do we create as tight a feedback loop between those stakeholders as possible, so that everybody is informed in the right ways and in ways that drive the right decision the first time? That’s us spending a lot more time in how we are engaging patients and engaging patients in ways that add significant value to the decisions they are trying to make.
Creating a whole-patient experience for care team workflows. Those are highly fragmented tools right now. If you ask a member of an access team in any health system in America what they use, they’ll give you 30 answers. Really, the truth is those 30 answers are on sticky notes stuck to the monitor, all the websites they have to go to solve these problems — one for prior auth, one for medical benefit prior auth, one for affordabilities content, one for enrollment. Creating a more consistent workflow for that team has a huge amount of value and is low-hanging fruit in the industry.
Then ultimately, continued focus on point-of-care behavior change. What really drives decision-making in an appropriate way for providers? How do we continue to become value-add to their workflow? Not another alert, not another thing that burdens them, not another of the overwhelming amount of information that we tend to throw at them, but how do you start to drive decision-making in way that is effortless for them to engage with?
Ultimately patients are demanding, and will only continue to demand, that clinical decision-making and marketplace information are considered in one consistent workflow. How do we do that in a way that consistently drives provider engagement and behavior change, and how do we measure all of that? What is our ability to stitch together that complete patient journey from point of care to care team, to patient engagement, all the way to fulfillment? What is the underlying data that allows us to understand when that is working and understand when that is not working? That’s our future.