This long overdue action could substantially lower the number of Americans forced into bankruptcy by outrageous and unexpected medical bills.
Unfortunately, little has been done to prevent the much more common problem of unexpectedly high prices for medications, which can lead to prescription abandonment and dire consequences for patients. According to the Food and Drug Administration, up to 30 percent of medication prescriptions are never filled by patients. Cost is the number one culprit. A study in the Annals of Internal Medicine found a direct correlation between the amount of a patient’s out-of-pocket co-pay and the likelihood that they will abandon the prescription. Patients with $50 co-pays were nearly four times more likely to abandon a prescription at the pharmacy than patients paying $10.
Buyer Beware: A Difficult Choice at the Pharmacy
At a time when consumers can comparison shop for virtually anything online, the price of medications is still largely shrouded in mystery. Patients rarely know the cost of the medications they’ve been prescribed before they reach the check-out line at the pharmacy. Many who are surprised by a high price end up abandoning their prescriptions and, in the process, endangering their health.
Multiple studies have linked failure to take or adhere to prescribed medications with the increased likelihood of disease progression as well as avoidable doctor visits, trips to the Emergency Department, and hospitalizations. Prescribers understand this, but until recently, they had little, if any, information about the out-of-pocket costs of the drugs they prescribe to share with their patients. Fortunately, that is changing. New tools are delivering essential information to clinicians on pharmacy drug costs at the point-of-prescribing. Sharing this information with patients encourages shared decision making that can discourage prescription abandonment, encourage adherence to medication therapy, and lead to safe, effective, and affordable patient care.
Before we look at what’s possible, though, let’s review how we got to this point.
Drug costs missing in action
Historically, clinicians’ access to drug prices has been limited largely to what their electronic health records (EHRs) reveal. But the electronic prescribing applications in the majority of EHRs do not incorporate costs into the prescribing process. Instead, the software reveals only static, payer-supplied medication formularies, which lack patient- and drug-specific pricing. Murkier still is the varying cost of a particular medication at various pharmacies. What’s more, even if they knew the cost of a medication, prescribers would lack the additional information they need to suggest a lower-cost, therapeutically-equivalent, alternative drug.
A primary cause of the drug price mystery is that providers’ EHRs don’t share information with the IT systems used by pharmacy benefit managers (PBM)—the middlemen between pharmaceutical manufacturers and pharmacies. Without access to PBM data, prescribers lack the necessary details to reveal out-of-pocket medication costs at the point of encounter. This critical information includes complete and current insurance coverage information, coverage restrictions, therapeutic class guidelines, individual deductibles and copays, and related facts that impact medication selection, adherence, and the likelihood of prescription abandonment.
Revealing prescription drug benefits in real-time
So that’s how we got to a point where 1 in 4 patients simply abandon their prescribed medications, because they often cannot or will not pay exorbitant prices. Fortunately for clinicians and patients alike, new alternative approaches are lifting the veil of secrecy from medication pricing during the prescribing process. Enhanced drug transparency tools available today can significantly improve providers’ ability to drive medication adherence, formulary compliance and cost savings for patients by sharing drug costs with them. That’s good news for patients but also for health systems, self-insured employers, and risk-bearing entities like ACOs that realize better price transparency can help control costs, reduce prescription abandonment and improve adherence.
The key to accomplishing these goals lies in a prescriber’s ability to check a patient’s prescription drug benefit in real-time. Unlike the traditional formulary and benefit files within EHRs, real-time benefit checks are patient-specific, accurate and based on a pre-adjudication of benefits by the payer/PBM for that individual patient’s coverage. By transferring the adjudication process from the pharmacy to the point of encounter, real-time drug benefit checking improves price transparency, removes unnecessary friction from the prescribing process, and enables more streamlined medication management.
Real-time benefit checks also give prescribers point-of-prescribing information on therapeutic alternatives, which lets them discuss the pros and cons of lower-cost medications while the patient is still in the room. The technology also lets prescribers view guidance on different pharmacy options and advise patients of the expected out-of-pocket costs for each medication alternative.
Transparency is a win for everyone
Real-time prescription benefit checking can drive cost savings for patients and help physicians achieve value-based care goals. The tool can also help payers improve their bottom lines. With better price transparency, prescribers are more likely to replace high-cost and non-covered drugs with lower cost alternatives. Similarly, patients are more inclined to use lower-cost and preferred pharmacy channels. Moreover, the need for time-consuming prior authorizations is diminished because physicians are more likely to prescribe a preferred medication over higher priced alternatives.
Perhaps most significantly, when patients participate in determining the cost of the medications they take, they are less likely to abandon prescriptions due to sticker shock. Less abandonment and better medication adherence – that’s a goal we can all get behind.
