Patients Need More Tools To Gauge Drug Costs
According to the Department of Health & Human Services (HHS), Americans spent $457 billion on prescription drugs in 2015, which represents nearly 17% of the total amount spent on healthcare. By 2018, that number is expected to soar to $535 billion.
Soaring prices alone would be bad news. But couple it with rising deductibles (and other out-of-pocket health insurance costs) and a largely stagnant economy, and you have the makings of a full-fledged crisis.
Financial pressures are leading many of those who need prescription drugs the most (especially the one in four Americans with multiple chronic conditions) to forego adherence as-prescribed in favor of paying the rent or meeting other expenses. Yet the short-term financial benefit is often quickly offset by increased hospital utilization and other medical expenses. Not to mention members generally experiencing poorer health. And all this at a time when the healthcare industry is focusing on outcomes and long-term health as the key metrics for success.
Clearly, this is an unsustainable model. While there are several factors that drive non-adherence, helping to bring the cost of prescription drugs under control is one of the most significant ways payers and pharmacy benefit managers (PBMs) can create a change for the better.
Tight formularies and mandatory mail order programs for drugs that treat chronic conditions, are a start. Utilization management programs such as quantity limits and step therapies, also help. But one of the most important contribution payers and PBMs can offer is to make the process of prescription drug selection and use more transparent to and easier for members – so the member can be an agent of savings.
Current efforts toward consumer-directed cost control have had limited success because members haven’t had the tools to be effective. That is now changing, however.
The first thing members need is a tool that allows them to easily compare the costs of different drugs in order to make more-informed financial decisions. Many members don’t realize costs can differ because they only see their own co-pay, or they always go to the same pharmacy for everything. Understanding cost differences can help them find more affordable alternatives.
Secondly, we need to focus specifically on helping members with chronic conditions find a way to make medications more affordable in order to encourage adherence over the long term. It should go beyond straight one-for-one generic substitutions to include options such as generic alternatives, over the counter (OTC) medications with the same level of effectiveness, alternative dosages, and drugs that stay in the system longer so they don’t have to be taken every day. These options have the effect of making medications more affordable while achieving comparable outcomes.
Finally, payers and PBMs need tools to help them engage more effectively with members – not just during enrollment periods but throughout the year. Members are being asked to shoulder a larger share of drug costs, in part to incentivize them to find ways to save. But if they’re not provided with tools to evaluate the cost, safety, and efficacy of alternatives they simply become frustrated and non-adherent. Tools that show them where the best prices are for each drug in their location, whether the pharmacy is in-network, if it has preferred coverage, and a comparison of the cost versus mail order are also helpful in building the trusted relationship.
Ensuring adherence is vital to the success of value-based care. But it is challenging in the face of skyrocketing costs.
Giving members the tools to take an active role in bringing costs under control solves both issues.
Matt Parker is Vice President of Consumer Engagement at Connecture, Inc.
