Exploring Implementation of The Medicare Price Transparency Rule (2025-2026)
Background
Half of the adults in the United States cannot afford their medication leading 31% of adults to skip doses in an effort to save money. This rationing has serious consequences including faster disease progression, more frequent hospitalizations and earlier death.
Clinicians have historically been unable to predict the costs of prescriptions, limiting their ability to choose lower-cost and equally effective treatment options for their patients. Strategies to navigate costs and connect patients to affordable medications are desperately needed.
In 2019, Medicare issued a regulation requiring Part D plans and pharmacy benefit managers (organizations that help manage prescription drug benefits, negotiating prices and ensuring cost-effective access to medications) to provide clinicians with out-of-pocket cost estimates for prescribed medications at the point-of-care, via real-time benefit tools (RTBTs) embedded in electronic health records (EHRs).
RTBTs can reduce out-of-pocket costs by suggesting lower-cost medications or pharmacies and are a unique innovation that has the potential to improve value in the healthcare system by increasing medication access and affordability. RTBTs have shown promise so far; however, adoption and implementation by healthcare organizations has been suboptimal. A third of healthcare organizations do not have RTBTs in their electronic health records, and even at institutions that do have RTBTs, clinician use remains low. For the Medicare regulation to accomplish its goal of improving medication affordability and access, RTBT use must increase. Therefore, more must be known about the facilitators and barriers to RTBT adoption and implementation at the health system level.
Project Description
This project team will investigate the experiences, facilitators and barriers to adoption and implementation of real-time benefit tools from the perspective of healthcare delivery organizations and pharmacy benefit managers.
Team members will conduct semi-structured interviews with approximately 20 leaders of healthcare delivery organizations who have participated in decision-making around RTBT adoption and/or implementation. Participants will be identified through snowball sampling, beginning with leaders from Duke Health, Brigham and Women’s Hospital, Northwestern University, University of Colorado Health, Geisinger Health, Atrium Health.
Team members develop an interview guide, carry out interviews, create codebooks, and analyze interview data. The team will also have the opportunity to prepare a manuscript describing the study findings.
Anticipated Outputs
Interview data and analysis; publications in a health policy journal; presentations to federal policy groups and agencies; grant for further research
Student Opportunities
Ideally, this project team will include 3 graduate students and 3 undergraduate students with backgrounds and interests in healthcare, health policy, business and the science of decision-making. Ideally, this project will include graduate students with experience using qualitative research methods.
Team members will have the opportunity to learn about the U.S. health policy landscape, current price transparency regulations, the intricacies of RTBT implementation, the financial barriers to care faced by many U.S. patients, project implementation, qualitative methods and qualitative manuscript writing.
A graduate student with skills in qualitative research methods will be selected to serve as a project manager.
In Fall 2025, the team will meet on Mondays from 9-10 a.m. Meetings will be divided into two 30-minutes sections. In the first half of each meeting, the team will discuss action items due that day, any roadblocks to completion of tasks, next steps and approaches to remedying roadblocks. The second half of the meeting will be dedicated to education and training in health policy, RTBT implementation, qualitative research, and manuscript writing.
An optional part-time summer opportunity will be available for team members, requiring 5-10 hours per week beginning in early July 2025.
Timing
Summer 2025 – Summer 2026
- Summer 2025 (optional): Finalize interview guides based on pilot interviews conducted in spring 2025; conduct participant recruitment; begin iterative development of codebooks
- Fall 2025: Double code all interviews transcripts; reconcile any discrepancies in coding and refine the codebooks
- Spring 2026: Analyze all codes; discuss major concepts and themes that are emerging; begin manuscript writing
- Summer 2026 (optional): Finalize manuscripts for submission
Crediting
Academic credit available for fall and spring semesters; summer funding available