It Costs What? Sticker Shock Can be a Health Hazard

By Colin Banas, M.D., M.H.A., Chief Medical Officer of DrFirst

Healthcare providers and patients are often in the dark when it comes to 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, it’s only when patients show up later in the Emergency Department with serious complications that they acknowledge, “Doc, I couldn’t afford the medicine.”

Sticker Shock Can Be a Health Hazard

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 have 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 do adhere to their treatment plans.

It’s frustrating to me that patients are forced to make life-and-death decisions between their daily expenses and the medications they need to stay healthy. If we as 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 that therapy.

Solving the Mystery of Prescription Pricing

While affordability is top of mind for some patients, cost isn’t always considered by providers. 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:

Make real-time data available in the EHR workflow. 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 disjointed, friction-filled process to gather that data. It’s essential that the provider can see not only that a certain drug isn’t covered, but also which two or three appropriate alternatives are covered and what the patients’ true out-of-pocket costs will be, not just an estimate or a preferred tier of coverage.

Offer cost-saving options at the time of prescribing. 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’m going to 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 are now able to see cost-saving coupons within the prescription workflow, or see that using mail order is less expensive, or that ordering 90 pills instead of 30 will lower the patient’s out-of-pocket costs.

Mirror consumer models to customize the patient experience. 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.

Let’s Not Wait for Mandates

New rules are coming from the Centers for Medicare & Medicaid Services (CMS) and other government agencies that will mandate EHRs and Part D plans 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 continue to wait for price transparency mandates, let’s get them the information they need now.

#HealthcareTechnology #HealthcareIT #PatientExperience

Colin Banas, M.D., M.H.A., is Chief Medical Officer of DrFirst, and former Internal Medicine Hospitalist and former Chief Medical Information Officer for VCU Health System in Richmond, Virginia.