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2021 MIPS IA_BE_25: Drug Cost Transparency

Activity ID

IA_BE_25

Activity Weighting

High

Subcategory Name

Beneficiary Engagement

Activity Description

To receive credit for this improvement activity, MIPS eligible clinicians must attest that their practice provides counseling to patients and/or their caregivers about the costs of drugs and the patients’ out-of-pocket costs for the drugs. If appropriate, the clinician must also explore with their patients the availability of alternative drugs and patients’ eligibility for patient assistance programs that provide free medications to people who cannot afford to buy their medicine. One source of information for pricing of pharmaceuticals could be a real-time benefit tool (RTBT), which provides to the prescriber, real-time patient-specific formulary and benefit information for drugs, including cost-sharing for a beneficiary. (CMS finalized in the Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out of Pocket Expenses final rule (84 FR 23832, 23883) that beginning January 1, 2021 Medicare Part D plans will be required to implement one or more RTBT(s).)

Objective

Help patients navigate the stress and risks associated with paying for healthcare—with particular attention to out-of-pocket costs on medication; when relevant, help them explore alternative options that address their holistic needs.

Suggested Documentation

Documented provision of counseling to patients and/or their caregivers regarding the cost of drugs and patients’ out-of-pocket expenses for their prescribed medications. Include at least one of the following elements:

1) Counseling on drug costs provided – Documentation could include an electronic health record (EHR) note that the eligible clinician provided counseling to patients and/or caregivers about the costs of drugs including the patient’s out-of-pocket costs for the drugs; OR
2) Use of Real-Time Benefit Tool (RTBT) – Evidence of RTBT* used in practice (e.g., workflow diagram, screenshot of tool) to provide real-time patient-specific formulary and benefit information for drugs including cost-sharing for a beneficiary; OR
3) Discussion of alternative drugs and assistance programs – Documentation (e.g., EHR or medical record note) of discussion/counseling with patients when applicable about the availability of alternative drugs and the patients’ eligibility for patient assistance programs that provide free medications for patients who are unable to afford to buy their medicine. For this activity, patient assistance programs pertain to patients who require assistance to purchase necessary medications, e.g., www.rxassist.org/providers.

Example/Information

Real-time benefit tool (RTBT) www.covermymeds.com/main/insights/rtbc-scorecard/

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