Healthcare providers and patients are often in the dark regarding the cost of prescription drugs. That’s more than a simple inconvenience—it also affects whether patients adhere to their treatment plans when they discover that prescribed medications are too costly.
Many physicians choose an appropriate medication during an office or telehealth visit, hit the send button, and assume the patient has picked it up at the pharmacy. Unfortunately, when patients show up later in the Emergency Department with serious complications, they acknowledge, “Doc, I couldn’t afford the medicine.”
When the high price of prescription drugs causes “sticker shock” at the pharmacy counter, patients might not purchase their medications or may ration them by taking less than the recommended dosage. In a recent survey of American consumers, half said they had abandoned a prescription at the pharmacy in the past few years because it was too expensive.
For some patients, especially those with chronic conditions like diabetes, heart disease, and COPD, non-adherence to prescribed therapies can lead to serious health problems and hospital readmissions. A study by the American Heart Association found that people with hypertension who don’t take their medications as prescribed are five times more likely to be hospitalized than patients who adhere to their treatment plans.
It’s frustrating that patients are forced to make life-and-death decisions between their daily expenses and the medications they need to stay healthy. If healthcare providers had a better understanding of our patients’ out-of-pocket costs, we could make more informed choices to get them on therapy and keep them on track.
While affordability is top of mind for some patients, providers don’t always consider the cost. That’s not because we don’t care; it’s due to the complexities inherent in each patient’s prescription drug coverage, including medication formularies and pricing structures that vary based on insurance benefits. Here are some ways we can support better prescription price transparency at the point of care:
With the average patient visit lasting no more than 15 minutes, it’s not feasible for a provider to jump into different applications or websites to look up formulary information. Even when a modern EHR can show potential tiers of coverage within the system (often with icons or color changes in picklists), this no longer goes far enough. To truly change the equation and benefit our patients, we need to make coverage and true cost information available in the EHR workflow so providers don’t have to navigate a confusing, friction-filled process to gather that data. It’s essential that the provider can see not only that a particular drug isn’t covered, but also which two or three appropriate alternatives are covered. Additionally, the provider needs to see what the patients’ actual out-of-pocket costs will be, not just an estimate or a preferred tier of coverage.
Up-to-date benefits information should reflect whether patients have hit their annual deductible, so costs are real instead of theoretical. It’s no longer adequate or appropriate to deal with estimates. When I have real-time information while the patient is in front of me, I can see that one medication will cost $100 and one will cost $5. If the drugs are clinically equivalent, I will have a conversation with the patient and make that choice right there and then. With many high-deductible plans, it might be more cost-effective for patients to pay for their prescriptions with cash and a coupon from the pharmaceutical company. Too often, patients don’t know these discounts are available. Providers can now see cost-saving coupons within the prescription workflow, that using mail orders is less expensive, or that ordering 90 pills instead of 30 will lower the patient’s out-of-pocket costs.
In industries, from banking to aviation to shopping, customized consumer experiences are a decade or more ahead of healthcare. If our booksellers and airlines, and clothing retailers can create seamless digital transactions for consumers, shouldn’t healthcare providers be able to meet patient expectations for efficient healthcare experiences? Our industry needs to leverage lessons from the consumer market to improve the patient experience in ways that increase loyalty and support better outcomes.
New rules from the Centers for Medicare & Medicaid Services (CMS) and other government agencies will mandate EHRs and Part D plans to offer real-time benefits comparison tools so providers and patients can view medication pricing information. We know the mandates are coming and solutions already exist. Rather than making patients wait for price transparency mandates, let’s get them the information they need now.
Read this Innovation Spotlight with Magnolia Regional Health Center and learn how they used price transparency and medication history tools to:
Colin Banas, M.D., M.H.A., is Chief Medical Officer of DrFirst, and former Internal Medicine Hospitalist, and the former Chief Medical Information Officer for VCU Health System in Richmond, Virginia.