Transparency Within Health Care

AMCP supports efforts to encourage transparency within health care. Healthcare decision makers (payors, providers) and patients rely on transparent and complete information to make informed health care resource decisions. Patients and providers should have access to information including explaining the reasons behind health care coverage decisions. Transparency enables health care decision makers and patients to make informed decisions regarding health care choices, including decisions regarding the use of prescription drugs. AMCP recognizes that certain information, such as negotiated drug prices and net costs, need to remain confidential to maintain a competitive marketplace. This statement focuses on how transparency applies to the use of prescription information, drug costs and communication. Each section discusses the role of transparency between healthcare decision makers and patients. It also addresses the need for transparency in communication with pharmaceutical manufacturers regarding emerging therapies and with patients to assure they clearly understand their pharmacy benefits.

The Transparency of Prescription Information 
The sharing of prescription information is a powerful tool that can help protect patient safety, provide transparency into cost effective and quality treatments, leading to lowering both prescription drug spending and overall health costs. AMCP supports the ability of healthcare decision makers to responsibly use and share prescription information, whether it is identifiable by patient, or provider or aggregated.

• Safety: The availability of patient‐identifiable prescription information enables a payer to work with individual patients to protect against inappropriate medication use, evaluate a patient’s drug therapy needs, identify, and prevent adverse drug reactions and medication errors, manage disease and drug therapy cost effectively, and ensure appropriate follow‐up.
• Fraud and Abuse:  Prescriber‐identifiable information is useful to monitor for fraud, waste and abuse and to coordinate care.
• Quality and Affordability:  The ability of healthcare decision makers to use de‐identified prescription utilization information can also encourage the use of health promotion and wellness programs and can help lower overall health care spending to maintain the affordability of the prescription drug benefit. 

The Transparency of Drug Costs
Patients and providers often have difficulty discerning the actual costs of drugs.  AMCP supports efforts to ensure that providers and patients know estimated cost‐sharing associated with drugs to promote appropriate and cost-effective prescribing. Providers may use drug cost information and effectiveness data to inform treatment recommendations. Empowering patients with cost information can encourage discussions with health care providers on the total cost of care when developing treatment plans and help reduce wasteful health care spending.  It is important that costs associated with the dispensing and administration of treatment are available for patients and their prescribers to consider when selecting treatment options. 

Examples of empowering patients include:

• Offering multiple communication tools and online resources to inform patients of the drug cost.
• Offering total drug treatment costs, which may vary by several fold depending on the delivery channels used such as administration by health care providers in a hospital facility or office setting.
• Offering clear explanations of which benefit of coverage is relevant to the billing for a specific treatment (i.e., medical benefit or pharmacy benefit) and which cost-sharing requirements apply.  

While AMCP supports making transparency tools available to the patient and healthcare decision maker, in a competitive marketplace where payors are negotiating discounts on behalf of membership, it is necessary that certain discounts on pricing remain confidential. In instances where there are multiple, clinically comparable therapeutic options available for a certain disease state, negotiating lower net costs and discounts are important tools used by payers, to help lower prescription drug costs and maintain affordability for the patient. Lower net costs can be contingent on overall utilization by a plan’s members or placement of a manufacturer’s product on a specific formulary tier. Because lower net costs, purchase discounts and other price concessions are negotiated it is essential that they remain confidential to preserve the competitive nature of the negotiation process. 

The Transparency of Communications with Patients and Prescribers 
AMCP supports efforts to improve patient health literacy. This includes enhancing patient understanding of their prescription benefit, formularies, utilization management programs, and drug costs. AMCP also supports efforts to identify best practices in communications between all stakeholders involved in the health care delivery system including:

• Readily retrievable information about formularies and utilization management programs and their impact on patient cost-share.
• Patient-centered communication that is culturally sensitive and is in the patient’s preferred language.
• Optimal the use of healthcare information technology (e.g., real time benefit check, pharmacy point of sale messages, text messaging, email) for delivery of real time information that helps educate patients about their pharmacy benefits and can impact the affordability of the benefit as a whole. 
• Simplified drug cost information that is consumer-friendly and provides quality and cost comparisons to help make informed decisions.  Often, it is assumed that a higher‐priced treatment option is superior to a comparable, lower‐ cost option, even if the two treatments have similar expected outcomes. Providing patients with access to information showing similar expected clinical outcomes can help guide making a decision that is based on more than just cost alone.
• Supports shared decision-making support tools enabling assessment of medication value compared to alternatives. (e.g., National Comprehensive Cancer Network Scale)
• Continual education on certain characteristics of the prescription drug marketplace (e.g. generics are therapeutically equivalent to their brand‐name counterparts, biosimilars) that can help guide patient purchasing decisions. 

The Transparency of Communications with Manufacturers about Emerging Therapies 
AMCP supports the participation of manufacturers in providing cost, safety, and efficacy information for medications in development.  Moreover, AMCP believes that flexibility is needed to support manufacturers to make available pharmacoeconomic analyses and epidemiologic information that describe the risks and benefits of the emerging drug, future cost offsets for the patient and payer and price considerations of similar medications. AMCP supports flexibility with various alternative budget impact models such as outcome-based contracting or indication-based contracting.

Conclusion
AMCP supports efforts to promote transparency within the health care system. Health care decisions made based on information shared among healthcare decision makers and patients can help promote improved health outcomes, improve safety, and maintain the affordability of the prescription drug benefit.

See also:

AMCP’s position statement on Appropriate Uses of Prescription Information by Managed Care Organizations, Competitive Marketplace, Government Regulation of Prescription Drug Prices, and Regulation of the Prescription Drug Benefit

AMCP Where We Stand series: https://www.amcp.org/policy-advocacy/policy-advocacy-focus-areas/where-we-stand-position-statements

Revised by the AMCP Board of Directors, March 2022