Drug prices remain high and many patients abandon their treatment because they no longer can afford it, so adopting tools to help physicians tell patients how much they will be paying out of pocket is very important. Still, as NPR recently covered in one of their stories, progress is rather slow.
The high cost of drugs has been the focus of a growing national debate about revolutionizing the U.S. healthcare system.
The U.S. spends nearly $334 billion a year on prescription drugs. In 1990, the share the nation spent for pharmaceuticals accounted for 5.6% of total health care spending, but grew to nearly 10% in 2017.
The elevated price of prescription drugs is a problem that has managed to convince Congress to find common ground; passing legislation on the connected issues of patent reform and price transparency has bipartisan appeal. According to NPR, at a hearing last month, Sen. Martha McSally (R-Ariz) pressed a top Trump administration health official about why many patients are not granted access to information on prescription drug prices at their doctor’s office.
“This is America. Why can’t we have this tool available now?” she asked. “The data is out there; the information is out there. What is it going to take to make this happen?”
The increased cost of prescription drugs can cause the inability of some patients to afford critical medicines. Patients are skipping doses of medications, splitting pills, or simply abandoning a treatment altogether because they can’t afford it. Studies show these practices can jeopardize their health and often lead to higher medical costs down the road.
Physicians and patients don’t receive any explanation as to why drug prices fluctuate year after year even when the ingredients used to make them remain the same.
Taking all this into consideration, finding solutions to avoid patient shock related to prices is very important. As patient Mary Kay Gilbert noted in the story covered by NPR, she was very surprised when her doctor informed her the antibiotic cream she needed would cost her $30 on her Blue Cross Blues Shield insurance plan. Gilbert, 54, a nurse and health consultant, told her doctor in Edina, Minnesota, it was “pretty cool” he knew that price.
The reason behind it was Allina Health, the large Minnesota-based hospital network to which Gilbert’s doctor belongs, is providing physicians with real-time drug pricing information, so they can avoid causing their patients’ price related shock. The pricing tool is embedded in each physician’s electronic health records and prescribing system. It calculates, based on their insurance plan and what pharmacy they go to, how much patients would be paying out of pocket to fill their prescriptions.
The tool is otherwise useful, by allowing the physician to find a cheaper alternative, if possible, and demand an authorization for a drug, if the insurer requires that.
Since patients are facing increasing copayments and higher deductibles, learning their options from the doctor’s office is key to their subsequent treatment going smoothly.
Such a tool is therefore increasingly important. Unfortunately, doctors did not rush to adopt it on a larger scale. One of their concerns is being involved in long talks about the price of drugs, a discussion they cannot easily avoid when face-to-face with the patient. Humana, for example, introduced its drug pricing tool to its network of doctors in 2015. Today, fewer than 10% are using it, according to Humana officials, which prompted the company to partner with Epic. Humana’s IntelligentRx will integrate with Epic’s e-prescribing workflow, allowing physicians to review a patient’s treatment options and cost information before prescribing medication.
Another reason doctors are reluctant to adopt these pricing tools refers to their limitations. Price negotiations among insurers, drugmakers and middlemen are secret because of high competition, so these tools often lack useful data for every patient.
Allina’s, for instance, NPR says, works for about half its patients, the reason being, according to the company, not all pharmacy benefit managers share data concerning health plan enrollee costs; even those that do, provide only part of the information.
“It’s a chicken-and-egg thing where doctors don’t use it because they don’t have the data for all their patients, and health plans don’t promote it to physicians because doctors don’t have the technology in place,” says Anthony Schueth, a health information technology consultant in Jacksonville, Fla. “It can be a powerful tool when it works, but at the moment the drivers are not there across the board for widespread adoption.”
Pharmacy Benefit Managers, or PBMs, are the ones providing the details about how much patients spend out of pocket for drugs. They are the middlemen between insurers and other medical providers and drug makers. PBMs negotiate prices with drugmakers, this is why any tool that does not include all PBMs in the listing is not going to be useful.
Basically, for the pricing tool to work properly, it should have access to all prices for all drugs, no matter who makes it and who sells it. For example, a drug pricing tool sold by Surescripts, partly owned by the PBMs CVS Caremark and Express Scripts, includes data from those companies, but not from PBM OptumRx, which belongs to insurance giant UnitedHealth. The OptumRx drug pricing tool includes Optum data but not information from Express Scripts and CVS.
Last month, pricing technology got a boost because the Centers for Medicare & Medicaid Services mandated that all Medicare drug plans embed such a tool in their doctors’ electronic prescribing system starting in 2021.
Demetrios Kouzoukas, who heads the Medicare program for CMS, says he hopes this initiative will encourage the industry to provide doctors and patients access to a standard pricing tool, regardless of their insurance. Whether this will actually happen and how soon it would be possible, remains to be seen.