How many times do you think this happens? After thoughtful deliberation and discussion, a physician prescribes a medication that they think will be a good option to help their patient with their current medical condition. But, when the patient arrives at the pharmacy, he or she is surprised — the medication is far more expensive than anticipated. The patient has to make a choice: walk away, call the prescriber back for an alternative, or simply pay for the costly medication, even though those dollars may have been earmarked for other essentials like groceries or gas.

On a related note, 75 percent of doctor visits involve medication therapy, making medication adherence critical to patient safety and outcomes. Yet one-third to one-half of U.S. patients do not take their medication as prescribed, and two-thirds of medication-related hospital admissions are due to non-adherence, costing our healthcare system $100 billion a year.

There are many causes of prescription non-adherence. For instance:

  • The patient has concerns about side effects
  • The patient is worried they’re taking too many medications
  • There is a perceived lack of need
  • The patient simply forgets to pick them up

But the number one offender? Patient out-of-pocket costs. Compared to a prescription with a $0 co-payment, patients are 3.4 times more likely to abandon a medication with a $40-$50 co-pay and 4.68 times more likely to do so when the copay is more than $50. And as U.S. healthcare embraces value-based care, physicians are also being held accountable for patient adherence, outcomes, and total cost of care — all of which are at risk the moment the patient walks away from an unaffordable medication at the pharmacy.

Non-adherence isn’t the only downside of surprise medication costs at the pharmacy; it also leads to additional phone calls, rework, and frustration at the physician’s office. When the pharmacy or patient calls the office back to ask for an alternative, the physician has to remember the context of the original medication, try to identify a lower-cost alternative, and then notify the pharmacy and patient about the change. At a time when practices are overwhelmed with administrative burdens, this is yet another phone call and task that is best avoided altogether by ensuring the patient can afford the medication at the time of prescribing. 

Until recently, there was no way for a physician to determine the patient’s out of pocket cost. While formulary information displayed in an EHR can be directional and provide relative pricing for different therapies, the patient’s specific cost could only be determined by the insurance company in real-time based on a number of factors: the medication, how many days supply, the patient’s chosen pharmacy, out-of-pocket spend for the year, deductible, and whether the drug requires a co-pay versus co-insurance. And even when a medication was known to be expensive, it was always difficult to find a lower-cost alternative that could achieve the same outcome.

Today there are tools that are native to most electronic health records (EHRs) that give the physician a clear view of costs as well as alternative options, in real-time, at the point of care. During the visit, after the doctor has entered the prescription details, the EHR displays the precise out of pocket patient cost, along with lower-cost alternatives — within just a couple seconds. Alternatives options to save the patient money could include selecting a different therapy, switching to a mail-order benefit, or simply ordering a 90-day supply instead of 30-day. The physician can also see if there are alternative options that do not require prior authorization.

With just one click the physician can quickly change to a better alternative. The extra few seconds to review this information can save minutes or hours of rework down the road while improving the patient’s adherence and overall experience with their doctor. I’ve had physicians tell me how this tool makes them feel like a stronger patient advocate, and those feelings are echoed by patients after they engage in discussions with their physician and make a decision together to change to a lower-cost therapy.

Most physicians have not had any formal training about how or when to have financial conversations with their patients. And while 70 percent of Americans want to talk about the costs of care with their health care providers, only 28 percent report doing so. Studies show that, with the introduction of new tools, these conversations often take less than one minute and have a positive impact on adherence and, therefore, patient outcomes.

The good news is most EHRs have the ability today to show patients real-time, patient-specific prescription out of pocket costs and less expensive alternatives. The future is filled with exciting advancements in healthcare information technology. Mobile apps, smart pill bottles, microchips, smart pills with sensors…we’ll get there someday. But for now — today — we can start with the basics: can your patient afford the medication? If not, nothing else matters.

Photo: Devrimb, Getty Images


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