Here are a number of ways physicians can work with their patients to best overcome cost barriers for their prescriptions.
Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions expressed here are that of the authors and not UBM / Medical Economics.
Healthcare costs are continually on the rise. Between 1995 and 2015, U.S. healthcare spending grew at an annual rate of 4 percent, which far outpaces the annual economic growth rate of about 2.4%. Of this increase, a large contributor is the rising cost of prescription medication.
The U.S. pharmaceutical market is unique in that the manufacturer is able to set their drug costs at any price. This is in contrast to other nations with a national healthcare service, where the government is able to negotiate price and reject certain drugs for the entire nation. From 2013 to 2015, prescription medication spending increased roughly 20 percent to about 310 billion dollars, comprising 17 percent of healthcare cost in the United States. As care becomes more expensive, insurance companies must continually increase their prices in order to maintain coverage for their members. Consequently, patients are increasingly being priced out of receiving quality healthcare.
Simply put, this is unpleasant, unhealthy, and inefficient. Starting in 2019, Medicare will be using its Merit-based Incentive Payment System (MIPS) to reimburse medical practices and individual providers for care. Among the incentives being measured are quality of care and clinical improvement. As patient adherence drops, so could quality of care, patient satisfaction and physician reimbursement.
So what can a physician do if a patient is non-adherent due to the cost of prescription medications? Here are a number of ways a physician can work with their patients to best overcome cost barriers, and different ways a practice can integrate these processes into their workflow.
Prescribing generics is the first way to help patients afford their medications. Walmart’s Four Dollar Generic List is a great resource for physicians to utilize. There are also apps for physicians that will allow them to compare effectiveness and side effects of generic medications to their name brand counterparts. Epocrates is a well-known application that has a feature enabling physicians to compare safety information and prescribing details for many name brand, OTC, and generic medicines.
Additionally, there are many apps that patients may find useful. Some of the top-rated apps available on computer and mobile devices are OneRX, GoodRX, and LowestMed. These apps help patients find discounts on their name brand or generic prescriptions, compare prices at different pharmacies, and will work to include their insurance plan so the user can see what the cost will be based off their coverage. These apps offer a lot of the same benefits, but GoodRX seems to be the app with the most features. It has reminders built in to refill prescriptions, shows where the $4 generics are, and can even find pharmacies that have some generics for free.
For patients who have a Medicare Advantage health plan or a Part D prescription plan, CMS offers medication therapy management in which patients receive one-on-one counselling sessions with a pharmacist at no cost. During these sessions the pharmacist reviews how to take each medication and checks for duplications or negative drug interactions.
Even with all of these resources, some patients may still not be able to pay for their medications. For them, a patient-assistance program (PAP) may be an additional option. Pharmaceutical companies have funded PAP programs to help cover patients’ copayments, coinsurance, and deductibles. Medicare.gov lists information for many of these programs, and each is specific to a certain medication.
If additional aid is necessary, state-funded and non-profit programs like NeedyMeds are available to help patients. It is important to remember that even an insured patient may still have trouble paying for medications. A situation that often arises with the Medicare Part D coverage gap.
Integration into practice workflow
The time commitment to integrate these tools into a practice’s workflow may seem daunting. Because of this, a model for where to spend time and effort is ideal so that prescription cost and clinician effort can both be minimized. Table 1 below shows a progression of intervention and how the steps can work with each other depending on how the patient is managing the cost of the prescription medication.
|Adherent||Generics when possible|
|Cost sensitive + adherent||Patient apps|
|Cost annoyance + non-adherent||Insurance council referral Clinicial apps|
First, generics should be used whenever possible. If a patient is adherent, but has a concern about the cost, directing the patient to the common apps they can use could be an easy, beneficial step. Up to this point, cost management has minimally impeded daily operations.
Physician and/or healthcare team efforts increase slightly when the patient becomes non-adherent due to a medication’s cost. This is because as soon as the patient is non-adherent, there is a drop in the quality of care. If it is available, a referral to someone within the clinic or a part of the hospital system to counsel the patient on their insurance coverage could help this patient’s adherence. At this stage, it is also necessary to analyze the patient’s prescription at a deeper level. Could the side effects of a different generic be tolerated for adherence? Having a patient-centered approach and discussing the risks and benefits, including cost, will increase patient adherence, quality of care and overall patient satisfaction.
The next level of involvement is a patient who is able to afford to buy the prescription some months, but not all the time. This is when the physician and/or the healthcare team can begin introducing the Patient Assistant Programs.
For everyone involved, it will take some time to become familiar with these programs. Just like a physician has a few drugs that they use consistently for hypertension, the same goes for PAP programs. Do not become overwhelmed with all of the possible options, simply pick a few drugs that are common budget breakers and understand their respective programs. The number of programs utilized can always be expanded over time. At this stage, also introduce the patient to state assistance programs that are available to them. Similar to the PAPs, make this simple and streamlined. Involving others in the healthcare team can also lighten the load and make this process more efficient.
The last level of cost management is a patient that is non-adherent due to complete inability to pay for medications. They can’t afford the prescription, they never could afford the prescription, and they won’t be able to afford it in the foreseeable future. These patients need everything in the toolbox. Engage the PAPs and state programs. Finally, see if the patient is a candidate for any assistance programs available through non-profit organizations.
An estimated 50 percent of medications for chronic disease are not adhered to as prescribed. Although this lack of adherence is not always a cost issue, the price of medications can be a heavy burden on patients. Segmenting the patient population according to their ability to afford their prescription medications allows for more affordable care and an increase in patient adherence, which increases the quality of care. The first few steps are easy and take very little time to put into action. The last few steps may require more time, but it doesn’t have to be just a one-person job. Splitting up the work among the healthcare team can accomplish the same outcomes.
The front desk personnel, social worker, nurses, and others can all contribute to this process of patient education and support. If the physician is the only one that knows about the programs and assistance methods, they are the only ones that can educate. The American Academy of Family Physicians suggests bringing on a weekly volunteer to assist in organizing the PAPs for the patients.
Being diligent in helping the patient population be adherent will not only improve the patient’s health, but their satisfaction. It will also decrease the overall burden on the healthcare system, lowering cost per capita, and stabilize physician reimbursement going forward.
Parker Adams, Megan Gage, and Colin Farritor, MBA, are first year osteopathic medical students at Kansas City University of Medicine and Biosciences in Joplin, Mo.
Janis Coffin, DO, FAAFP, FACMPE, is a professor in the department of family medicine at Kansas City University of Medicine and Biosciences in Joplin, Mo.
• Patient Apps:
• Insurance Questions:https://www.medicare.gov/find-a-plan/questions/home.aspx
• Medication Therapy Management:https://www.medicare.gov/part-d/coverage/medication-therapy-management/medication-therapy-programs.html
• State Programs and further assistance: