With actionable insights at the point of prescribing, doctors and patients can work together to understand their options and make better-informed prescribing decisions. Doing so will ensure that patients receive the most affordable prescription that meets their therapeutic need. It sounds simple enough, but it represents a major leap forward from the current scenario.
Prescription price transparency tools are available today, and they are having a direct, immediate and positive impact on both healthcare cost and quality. We’re measuring this impact in a number of ways, including increased rates of prescribers changing their original selections and the related cost savings driven by actionable insights at the point of prescribing.
When prescribing a medication requiring a prior authorization and presented an alternative without a prior authorization, prescribers switched the drug 24 percent of the time—altogether preventing the need for what can be a time consuming and costly manual process. Considering the fact that 40 percent of patients abandon treatment when a prior authorization is required, this behavior change can have a significant impact on time savings and medication adherence.
In a real-world example, the prescriber uses their EHR to select an appropriate medication as well as the patient’s preferred pharmacy. Using a prescription price transparency tool integrated in their EHR, the prescriber can see that the medication will cost the patient $1,361.40, based on input from the patient’s pharmacy benefit manager (PBM). The prescriber also sees that a generic alternative medication is available through the patient’s pharmacy benefit plan for just $4.00. As a result, the prescriber changes the order and saves the patient $1,357.40. Other similar examples have occurred in doctor’s offices nationwide. In fact, in September, one prescriber using a prescription price transparency tool at the point of care saved their patient $8,032 on a single prescription.
However, even more modest savings can really add up and impact patient outcomes, especially given that a 10-dollar difference in a copay increases the likelihood that a prescription will be abandoned by 10 percent, which is one form of medication non-adherence.
The Features of an Effective Prescription Price Transparency Tool
In order to truly make a positive impact, prescription price transparency should occur during the office visit at the point of prescription decision-making. Further, the data that informs these conversations should be:
• Delivered at the right time: This data must be readily available at the “point of care,” before a prescription reaches the pharmacy. This is because prescription price transparency conversations that take place after a prescription has been sent to the pharmacy can result not only in a swirl of phone calls and faxes, but also in patient frustration if they find lower-cost alternatives on their own after picking up and paying for the original prescription.
• Delivered in the EHR workflow: Prescription price information should be automatically and intuitively delivered into the physician’s EHR software during the prescribing workflow so they can access the information with minimal effort. In other words, prescription price transparency shouldn’t represent a burdensome extra step for patients or providers. Access to this information within the EHR can prompt a discussion and shared decision-making between the physician and patient.
• Precise, accurate and on-formulary: Determining the actual out-of-pocket cost of a prescription drug requires information about the:
o Drug (e.g. name, dose, strength, days supply, etc.)
o Patient (e.g. benefit design, deductible, copay or coinsurance)
o Pharmacy (e.g. name, contact information, etc.)
A price transparency tool should provide cost information that is up to date and relevant based on the patient’s specific benefit details, and precise, patient-specific information on any formulary restrictions or utilization management criteria. Additionally, the tool should protect the prescriber’s freedom to choose an appropriate therapy, and the patient’s freedom to choose a pharmacy.
• Actionable: An effective prescription price transparency tool should include not just cost information for one desired prescription, but an actionable list of lower-cost therapeutic alternatives—both brand and generic—that are covered by the patient’s health benefit. For maintenance drugs prescribed to treat chronic diseases, the transparency tool should provide information on whether there is a 90-day-supply benefit option via retail or mail. These options may be more affordable and convenient, both of which can help promote medication adherence. Further, a tool that includes visibility to utilization management requirements should also help prescribers electronically initiate additional approvals or prior authorizations for medicines when necessary to help avoid delays in the patient starting a therapy.
The Link Between High Drug Costs and Compromised Patient Care
According to the Centers for Medicare and Medicaid Services (CMS), national health expenditure growth is expected to average 5.5 percent annually between 2017 and 2026, while prescription spending growth is projected to average 6.3 percent.
The aging population is impacted by the absence of prescription price transparency whether insured or not. Among insured 65-year-old American seniors, 14 percent report cutting pills in half or skipping doses (i.e. “medication non-adherence”) and 19 percent have not filled a prescription because of cost (i.e. “prescription abandonment”), according to a December 2016 poll from the Henry J. Kaiser Family Foundation.
In addition to cost-related medication non-adherence, patients who are made to wait for their medications due to manual prior authorization delays may also abandon treatment. According to a recent American Medical Association survey, 64 percent of physicians report waiting an average of at least one business day for prior authorization decisions, and 30 percent report waiting up to three business days for a prior authorization response. Almost all physicians surveyed—92 percent—feel that the prior authorization process delays access to necessary care for some of their patients, and 78 percent say that it causes some of their patients to abandon treatment.
Prescription Price Transparency Should be a Collaborative Effort
The fact is that most prescribers have little to no information about what a medication will cost their patient at the pharmacy. This is the root cause of a big problem with pain points all around. For instance, a common obstacle for prescribers is that the generic formulary information can be vague and unhelpful. They end up having to ignore irrelevant formulary alerts in their electronic health record (EHR). And outside of the EHR workflow, where cost-related prescription issues are generally handled and often protracted, prescribers and pharmacists alike are plagued by a steady stream of phone calls to find lower cost options or resolve prior authorization delays.
For patients, the pain comes in finding out too late what they will be expected to pay out of pocket for their medication. They find that that their healthcare providers don’t have information on lower-cost medications, so they’re frustrated and surprised by high costs and delays at the pharmacy. Again, this often prompts patients to abandon treatment altogether, which can make existing problems worse or give rise to new ones.
This breakdown in the prescribing process and the manual interventions that result cost time and money while undermining care quality, patient and provider satisfaction and, most importantly, medication adherence. In fact, 10 percent of patients who abandon medication do so because of cost, according to the Truven Health Analytics®-NPR Health Poll. And two-thirds of medication-related hospital admissions in the U.S. stem from medication non-adherence at a cost of $100 billion per year, according to The New England Journal of Medicine.
When a patient is surprised at the pharmacy, either because the cost is too high or an authorization has not been completed, the friction for the prescriber, pharmacist and patient is real and immediate. Everyone involved must divert to secondary workflows, including multiple phone calls and faxes to get the right medication at the right cost the second or third time around—e.g. after the original prescription was submitted. But doing so is only effective if the patient waits out the process failure and successfully picks up their medication once it’s available.
The root cause, the problems that result and the solution are well known to those on the front lines of healthcare. Most prescribers—86 percent—believe that it’s important to have out-of-pocket costs available when prescribing. And nearly all prescribers—97 percent—believe it’s important to have cost-effective medication alternatives when prescribing.
Prescription price transparency tools are gaining traction with the promise of helping consumers reduce out-of-pocket drug costs and unpleasant surprises at the pharmacy. These tools can also help prescribers and pharmacists better engage with their patients and deliver higher quality and safer care at a lower cost. And the potential macro impact of price transparency tools, especially as payment models evolve from volume to value—provided the tools are widely adopted and utilized, could revolutionize the prescribing experience for patients and healthcare professionals alike.
Tom Skelton is the chief executive officer of Surescripts, the nation’s leading health information network. Surescripts’ solutions deliver real-time, patient-specific prescription price transparency information plus therapeutic alternatives to the point of care, which is critical to lowering patients’ out-of-pocket costs and improving medication adherence and patient safety.
