Real-Time Benefit Tools for Drug Prices

Direct-to-Consumer Drug Company Pharmacies

The recent launch of direct-to-consumer pharmacy LillyDirect prompts the author of this Viewpoint to consider why it was created and also to raise concerns about allowing manufacturers to sell their drugs directly to patients.

Quality of Medication Cost Conversations and Interest in Future Cost Conversations Among Older Adults

BACKGROUND

Medication cost conversations occur less frequently than patients prefer, and it is unclear whether patients have positive experiences with them when they do occur.

OBJECTIVE

To describe patients' experiences discussing their medication costs with their health care team.

DESIGN

Cross-sectional survey.

SETTING

Nationally representative survey fielded in the United States in 2022 (response rate = 48.5%).

PATIENTS

1020 adults over age 65.

MEASUREMENTS

Primary measures were adapted from Clinician and Group Consumer Assessment of Healthcare Providers Survey visit survey v4.0 and captured patients' experiences of medication cost conversations. Additional measures captured patients' interest in future cost conversations, the type of clinicians with whom they would be comfortable discussing costs, and sociodemographic characteristics.

RESULTS

Among 1020 respondents who discussed medication prices with their health care team, 39.3% were 75 or older and 78.6% were non-Hispanic White. Forty-three percent of respondents indicated that their prior medication cost conversation was not easy to understand; 3% indicated their health care team was not respectful and 26% indicated their health care team was somewhat respectful during their last conversation; 48% indicated that there was not enough time. Those reporting that their prior discussion was not easy to understand or that their clinician was not definitely respectful were less likely to be interested in future discussions. Only 6% and 10% of respondents indicated being comfortable discussing medication prices with financial counselors or social workers, respectively. Few differences in responses were observed by survey participant characteristics.

LIMITATIONS

This cross-sectional survey of prior experiences may be subject to recall bias.

CONCLUSION

Among older adults who engaged in prior medication cost conversations, many report that these conversations are not easy to understand and that almost one-third of clinicians were somewhat or not respectful. Efforts to increase the frequency of medication cost conversations should consider parallel interventions to ensure the discussions are effective at informing prescribing decisions and reducing cost-related medication nonadherence.

Associations between the use of a real-time benefit tool and measures related to prescription obtainment found in order type subgroups

BACKGROUND

The use of real-time benefit tool (RTBT) may help increase transparency of patients' out-of-pocket (OOP) costs, thereby reducing patients' OOP spend and increasing prescription obtainment.

OBJECTIVE

We have previously reported on the potential benefit of RTBT in electronic health records at a large health system. We explore the benefit of RTBT by subgroups of prescriptions (i.e., order types).

METHODS

In a retrospective cohort, we reviewed orders generated with and without RTBT use. We compared the 2 groups on key metrics related to prescription obtainment (fill rate, modification rate, cancellation rate, time to ready, time to sold, abandonment rate, and cancellation and transfer rate). Subgroup analysis included orders without over-the-counter (OTC) medications, orders without specialty medications, and orders without OTC and specialty medications.

RESULTS

Fill rate, cancellation rate, time to ready, time to sold, abandonment rate, and cancellation and transfer rate were statistically significantly different between the RTBT and non-RTBT groups, favoring the RTBT group (all, P < 0.01). Differences in modification rates were not statistically significant between the 2 groups.

CONCLUSION

RTBTs have the potential to increase prescription obtainment. A consistent difference in key outcome measures between the RTBT and the non-RTBT groups was apparent among prescription orders regardless of whether OTC and specialty medications were included in the analysis.

Impact of a Standardized, Pharmacist-Initiated "Test-Claim" Workflow for Anticipating Barriers to Accessing Discharge Antimicrobials

Background: Inability to access and afford discharge oral antimicrobials may delay discharges or result in therapeutic failure. "Test-claims" have the potential to identify such barriers. Objective: This study evaluated discharge antimicrobial access and patient outcomes after implementation of a standardized, inpatient pharmacist-initiated antimicrobial discharge medication cost inquiry (aDMCI) process. Methods: This was an Institutional Review Board (IRB)-approved, pilot retrospective cohort study that included adults admitted for ≥72 hours from November 1, 2018, to February 28, 2019, and discharged on oral antimicrobials. Patients with a cost inquiry (aDMCI group) were compared with those without (standard-of-care, SOC, group). Primary endpoint was discharge delay. Secondary endpoints included percentage of patients discharged on suboptimal antimicrobials and medication errors from aDMCI. Results: 84 patients were included: 43 in SOC and 41 in aDMCI. Seventy-five antimicrobial cost inquiries were evaluated among 41 patients. There were no discharge delays or medication errors associated with the standardized "test-claim" (aDMCI) workflow. Patients in the SOC group had a greater Charlson Comorbidity Index (4 [2-6] vs 2 [1-4], P =0.004), were more likely to be immunosuppressed (24, 56% vs 12, 29%; P =0.014), and had longer hospitalization (8 [5-15] vs 6 [5-9] days, P =0.026). Primary access barriers were prior-authorization (8, 11%) and associated with linezolid and moxifloxacin cost inquiries. Most aDMCIs results were available in <24 hours (66, 88%). Conclusions: The aDMCI process is safe and offers an actionable transition of care tool that can identify barriers to accessing discharge medications while insulating patients from surprise out-of-pocket cost.

Implementing real-time prescription benefit tools: Early experiences from 5 academic medical centers

BACKGROUND

Medication price transparency tools are increasingly available, but data on their use, and their potential effects on prescribing behavior, patient out of pocket (OOP) costs, and clinician workflow integration, is limited.

OBJECTIVE

To describe the implementation experiences with real-time prescription benefit (RTPB) tools at 5 large academic medical centers and their early impact on prescription ordering.

DESIGN

and Participants: In this cross-sectional study, we systematically collected information on the characteristics of RTPB tools through discussions with key stakeholders at each of the five organizations. Quantitative encounter data, prescriptions written, and RTPB alerts/estimates and prescription adjustment rates were obtained at each organization in the first three months after "go-live" of the RTPB system(s) between 2019 and 2020.

MAIN MEASURES

Implementation characteristics, prescription orders, cost estimate retrieval rates, and prescription adjustment rates.

KEY RESULTS

Differences were noted with respect to implementation characteristics related to RTPB tools. All of the organizations with the exception of one chose to display OOP cost estimates and suggested alternative prescriptions automatically. Differences were also noted with respect to a patient cost threshold for automatic display. In the first three months after "go-live," RTPB estimate retrieval rates varied greatly across the five organizations, ranging from 8% to 60% of outpatient prescriptions. The prescription adjustment rate was lower, ranging from 0.1% to 4.9% of all prescriptions ordered.

CONCLUSIONS

In this study reporting on the early experiences with RTPB tools across five academic medical centers, we found variability in implementation characteristics and population coverage. In addition RTPB estimate retrieval rates were highly variable across the five organizations, while rates of prescription adjustment ranged from low to modest.

Financial Toxicity in Cancer Care: Implications for Clinical Care and Potential Practice Solutions

Patients with cancer face an array of financial consequences as a result of their diagnosis and treatment, collectively referred to as financial toxicity (FT). In the past 10 years, the body of literature on this subject has grown tremendously, with a recent focus on interventions and mitigation strategies. In this review, we will briefly summarize the FT literature, focusing on the contributing factors and downstream consequences on patient outcomes. In addition, we will put FT into context with our emerging understanding of the role of social determinants of health and provide a framework for understanding FT across the cancer care continuum. We will then discuss the role of the oncology community in addressing FT and outline potential strategies that oncologists and health systems can implement to reduce this undue burden on patients with cancer and their families.

Where Do Real-Time Prescription Benefit Tools Fit in the Landscape of High US Prescription Medication Costs? A Narrative Review

The problem of unaffordable prescription medications in the United States is complex and can result in poor patient adherence to therapy, worse clinical outcomes, and high costs to the healthcare system. While providers are aware of the financial burden of healthcare for patients, there is a lack of actionable price transparency at the point of prescribing. Real-time prescription benefit (RTPB) tools are new electronic clinical decision support tools that retrieve patient- and medication-specific out-of-pocket cost information and display it to clinicians at the point of prescribing. The rise in US healthcare costs has been a major driver for efforts to increase medication price transparency, and mandates from the Centers for Medicare & Medicaid Services for Medicare Part D sponsors to adopt RTPB tools may spur integration of such tools into electronic health records. Although multiple factors affect the implementation of RTPB tools, there is limited evidence on outcomes. Further research will be needed to understand the impact of RTPB tools on end results such as prescribing behavior, out-of-pocket medication costs for patients, and adherence to pharmacologic treatment. We review the terminology and concepts essential in understanding the landscape of RTPB tools, implementation considerations, barriers to adoption, and directions for future research that will be important to patients, prescribers, health systems, and insurers.

Costs and Utilization of New-to-Market Neurologic Medications

BACKGROUND AND OBJECTIVES

The objective of this study was to compare the utilization and costs (total and out-of-pocket) of new-to-market neurologic medications with existing guideline-supported neurologic medications over time.

METHODS

We used a healthcare pharmaceutical claims database (from 2001 to 2019) to identify patients with both a diagnosis of 1 of 11 separate neurologic conditions and either a new-to-market medication or an existing guideline-supported medication for that condition. Neurologic conditions included orthostatic hypotension, spinal muscular atrophy, Duchenne disease, Parkinson disease, multiple sclerosis, amyotrophic lateral sclerosis, myasthenia gravis, Huntington disease, tardive dyskinesia, transthyretin amyloidosis, and migraine. New-to-market medications were defined as all neurologic medications approved by the US Food and Drug Administration (FDA) between 2014 and 2018. In each year, we determined the median out-of-pocket and standardized total costs for a 30-day supply of each medication. We also measured the proportion of patients receiving new-to-market medications compared with all medications specific for the relevant condition.

RESULTS

We found that the utilization of most new-to-market medications was small (<20% in all but 1 condition), compared with existing, guideline-supported medications. The out-of-pocket and standardized total costs were substantially larger for new-to-market medications. The median (25th percentile, 75th percentile) out-of-pocket costs for a 30-day supply in 2019 were largest for edaravone ($712.8 [$59.8-$802.0]) and eculizumab ($91.1 [$3.0-$3,216.4]). For new-to-market medications, the distribution of out-of-pocket costs was highly variable and the trends over time were unpredictable compared with existing guideline-supported medications.

DISCUSSION

Despite the increasing number of FDA-approved neurologic medications, utilization of newly approved medications in the privately insured population remains small. Given the high costs and similar efficacy for most of the new medications, limited utilization may be appropriate. However, for new medications with greater efficacy, future studies are needed to determine whether high costs are a barrier to utilization.

Demand for and Occurrence of Medication Cost Conversations: A Narrative Review

High medication prices can create a financial burden for patients and reduce medication initiation. To improve decision making, public policy is supporting development of tools to provide real-time prescription drug prices. We reviewed the literature on medication cost conversations to characterize the context in which these tools may be used. Our review included 42 articles: a median of 84% of patients across four clinical specialties reported a desire for cost conversations (n = 7 articles) but only 23% reported having held a cost conversation across six specialties (n = 16 articles). Non-White and older patients were less likely to report having held a cost conversation than White and younger patients in 9 of 13 and 5 of 9 articles, respectively, examining these associations. Our review indicates that tools providing price information may not result in improved decision making without complementary interventions that increase the frequency of cost conversations with a focus on protected groups.

"Worth it if you could afford it": Patient perspectives on integrating real-time benefit tools into drug cost conversations

BACKGROUND

Medication costs can lead to financial burdens for patients, creating barriers to effective medication use. Health care provider use of real-time benefit tools (RTBTs) may facilitate cost conversations with patients. We sought to explicate patient views on how RTBTs could be used to improve cost considerations in prescribing decisions.

METHODS

We conducted focus groups to characterize patient perspectives on holding cost conversations with their physicians and to identify factors that would influence the value of RTBTs. We focused on adults aged 50+ who reported trouble paying for their prescriptions. Three groups included patients with conditions requiring high-cost treatments and one group included lower-income patients independent of their medical conditions. Focus groups were recorded, transcribed, coded, and categorized to salient themes employing inductive and deductive approaches using the Health Equity Implementation Framework.

RESULTS

Focus groups were conducted from 09/2020-12/2020 including 18 participants representing cancer (n = 6), diabetes (n = 6), rheumatoid arthritis (n = 3), and lower income (n = 3). Participants were between 50-74, eight self-identified as Black, 10 as White, and eight reported earning <$50,000/year. We identified five themes regarding cost conversations (medication cost importance, past experiences with cost/cost conversations, perception of physician's role and knowledge, knowledge of existing resources, and influence on decision-making) and four RTBT-use-specific themes (advantages/disadvantages, perceived relevance, data quality concerns, and implementation considerations).

CONCLUSION

Approaches that envision RTBTs as one-size-fits-all technological interventions may underestimate the complexity of incorporating price information into prescribing decisions. Nevertheless, patients highlighted the potential value of accurate, real-time information on medication costs to inform decision-making.

The least costly pharmacy for cancer supportive care medications over time: the logistic toxicity of playing catch up

PURPOSE

No single pharmacy in an urban zip code is consistently the least expensive across medications. If medication prices change differently across pharmacies, patients and clinicians will face challenges accessing affordable medications when refilling medications. This is especially pertinent to people with cancer with multiple fills of supportive care medications over time. We evaluated if the lowest-priced pharmacy for a formulation remains the lowest-priced over time.

METHODS

We compiled generic medications used to manage nausea/vomiting (14 formulations) and anorexia/cachexia (12 formulations). We extracted discounted prices in October 2021 and again in March 2022 for a typical fill at 8 pharmacies in Minneapolis, Minnesota, USA (zip code 55,414) using GoodRx.com. We examined how prices changed across formulations and pharmacies over time.

RESULTS

Data were available for all 208 possible pharmacy-formulation combinations (8 pharmacies × 26 formulations). For 172 (83%) of the 208 pharmacy-formulation combinations, the March 2022 price was within 20% of the October 2021 price. Across pharmacy-formulation combinations, the price change over time ranged from - 76 to + 292%. For 12 (46%) of the 26 formulations, at least one pharmacy with the lowest price in October 2021 no longer was the least costly in March 2022. For one formulation (dronabinol tablets), the least expensive pharmacy became the most expensive, with an absolute and relative price increase of a fill of $22 and 85%.

CONCLUSION

For almost half of formulations studied, at least one pharmacy with the lowest price was no longer the least costly a few months later. The lowest price for a formulation (across pharmacies) could also change considerably. Thus, even if a patient accesses the least expensive pharmacy for a medication, they may need to re-check prices across all pharmacies with each subsequent fill to access the lowest prices. In addition to safety concerns, directing medications to and accessing medications at multiple pharmacies can add time and logistic toxicity to patients with cancer, their care partners, prescribers, and pharmacy teams.

Defining the Role of the Modern Oncology Provider in Mitigating Financial Toxicity

Financial toxicity, the cumulative financial hardships resulting from cancer diagnosis and treatment, is a growing problem in the United States. With the proliferation of costly novel therapeutics and improved cancer survival, financial toxicity will remain a major issue in cancer care delivery. Frontline oncology providers serve as gatekeepers in the medical system and, as such, could play essential roles in recognizing and addressing financial toxicity. Providers and health systems could help mitigate financial toxicity through routine financial toxicity screening, financial navigation, and advocacy. Specific strategies include developing and implementing financial screening instruments that can be integrated in electronic medical records and establishing team-based financial navigation programs to help patients with out-of-pocket medical costs, nonmedical spending, and insurance optimization. Finally, providers should continue to advocate for policies and legislation that decrease cost and promote value-based care. In this review, we examine opportunities for provider engagement in these areas and highlight gaps for future research.

Effects of Real-time Prescription Benefit Recommendations on Patient Out-of-Pocket Costs: A Cluster Randomized Clinical Trial

Importance

Rising drug costs contribute to medication nonadherence and adverse health outcomes. Real-time prescription benefit (RTPB) systems present prescribers with patient-specific out-of-pocket cost estimates and recommend lower-cost, clinically appropriate alternatives at the point of prescribing.

Objective

To investigate whether RTPB recommendations lead to reduced patient out-of-pocket costs for medications.

Design, Setting, and Participants

In this cluster randomized trial, medical practices in a large, urban academic health system were randomly assigned to RTPB recommendations from January 13 to July 31, 2021. Participants were adult patients receiving outpatient prescriptions during the study period. The analysis was limited to prescriptions for which RTPB could recommend an available alternative. Electronic health record data were used to analyze the intervention's effects on prescribing. Data analyses were performed from August 20, 2021, to June 8, 2022.

Interventions

When a prescription was initiated in the electronic health record, the RTPB system recommended available lower-cost, clinically appropriate alternatives for a different medication, length of prescription, and/or choice of pharmacy. The prescriber could select either the initiated order or one of the recommended options.

Main Outcomes and Measures

Patient out-of-pocket cost for a prescription. Secondary outcomes were whether a mail-order prescription and a 90-day supply were ordered.

Results

Of 867 757 outpatient prescriptions at randomized practices, 36 419 (4.2%) met the inclusion criteria of having an available alternative. Out-of-pocket costs were $39.90 for a 30-day supply in the intervention group and $67.80 for a 30-day supply in the control group. The intervention led to an adjusted 11.2%; (95% CI, -15.7% to -6.4%) reduction in out-of-pocket costs. Mail-order pharmacy use was 9.6% and 7.6% in the intervention and control groups, respectively (adjusted 1.9 percentage point increase; 95% CI, 0.9 to 3.0). Rates of 90-day supply were not different. In high-cost drug classes, the intervention reduced out-of-pocket costs by 38.9%; 95% CI, -47.6% to -28.7%.

Conclusions and Relevance

This cluster randomized clinical trial showed that RTPB recommendations led to lower patient out-of-pocket costs, with the largest savings occurring for high-cost medications. However, RTPB recommendations were made for only a small percentage of prescriptions.

Trial Registration

ClinicalTrials.gov Identifier: NCT04940988; American Economic Association Registry: AEARCTR-0006909.

Health informatics interventions to minimize out-of-pocket medication costs for patients: what providers want

Objective

To explore diverse provider perspectives on: strategies for addressing patient medication cost barriers; patient medication cost information gaps; current medication cost-related informatics tools; and design features for future tool development.

Materials and Methods

We conducted 38 semistructured interviews with providers (physicians, nurses, pharmacists, social workers, and administrators) in a Midwestern health system in the United States. We used 3 rounds of qualitative coding to identify themes.

Results

Providers lacked access to information about: patients’ ability to pay for medications; true costs of full medication regimens; and cost impacts of patient insurance changes. Some providers said that while existing cost-related tools were helpful, they contained unclear insurance information and several questioned the information’s quality. Cost-related information was not available to everyone who needed it and was not always available when needed. Fragmentation of information across sources made cost-alleviation information difficult to access. Providers desired future tools to compare medication costs more directly; provide quick references on costs to facilitate clinical conversations; streamline medication resource referrals; and provide centrally accessible visual summaries of patient affordability challenges.

Discussion

These findings can inform the next generation of informatics tools for minimizing patients’ out-of-pocket costs. Future tools should support the work of a wider range of providers and situations and use cases than current tools do. Such tools would have the potential to improve prescribing decisions and better link patients to resources.

Conclusion

Results identified opportunities to fill multidisciplinary providers’ information gaps and ways in which new tools could better support medication affordability for patients.

Almost a quarter of Americans taking prescription medications have difficulty affording them. We asked 38 healthcare providers what they do to help patients get affordable medications. They try to reduce the number of medications that patients take, choose more affordable medication options, and connect them to free medications or financial help. But it is hard for providers to do these things because they don’t always know which patients have financial challenges, and they may not know how much medications cost patients. Healthcare providers use digital tools like ordering systems to pick medications for patients, but they do not always have clear price information and they do not help outside of healthcare visits with prescribers. It is also hard for healthcare providers to get information about what patients have difficulty affording medications, and about resources to help them. Healthcare providers want new and improved digital tools to help them choose medications, and to be able to compare exact medication price differences. They also want a visual sign for patients with financial challenges, and centralized information about cost reduction resources. Finally, they desire tools to help them talk to patients about mediation prices, and medication price reports for patients themselves.

Financial Burden of Drugs Prescribed for Cancer-Associated Symptoms

PURPOSE

The financial toxicity of anticancer drugs is well-documented, but little is known about the costs of drugs used to manage cancer-associated symptoms.

METHODS

We reviewed relevant guidelines and compiled drugs used to manage seven cancer-associated symptoms (anorexia and cachexia, chemotherapy-induced peripheral neuropathy, constipation, diarrhea, exocrine pancreatic insufficiency, cancer-associated fatigue, and chemotherapy-induced nausea and vomiting). Using GoodRx website, we identified the retail price (cash price at retail pharmacies) and lowest price (discounted, best-case scenario of out-of-pocket costs) for patients without insurance for each drug or formulation for a typical fill. We describe lowest prices here.

RESULTS

For anorexia and cachexia, costs ranged from $5 US dollars (USD; generic olanzapine or mirtazapine tablets) to $1,156 USD (brand-name dronabinol solution) and varied widely by formulation of the same drug or dosage: for olanzapine 5 mg, $5 USD (generic tablet) to $239 USD (brand-name orally disintegrating tablet). For chemotherapy-induced peripheral neuropathy, costs of duloxetine varied from $12 USD (generic) to $529 USD (brand-name). For constipation, the cost of sennosides or polyethylene glycol was <$15 USD, whereas newer agents such as methylnaltrexone were expensive ($1,001 USD). For diarrhea, the cost of generic loperamide or diphenoxylate-atropine tablets was <$15 USD. For exocrine pancreatic insufficiency, only brand-name formulations were available, range of cost, $1,072 USD-$1,514 USD. For cancer-associated fatigue, the cost of generic dexamethasone or dexmethylphenidate was <$15 USD, whereas brand-name modafinil was more costly ($1,284 USD). For a 4-drug nausea and vomiting prophylaxis regimen, costs ranged from $181 USD to $1,430 USD.

CONCLUSION

We highlight the high costs of many symptom control drugs and the wide variation in the costs of these drugs. These findings can guide patient-clinician discussions about cost-effectively managing symptoms, while promoting the use of less expensive formulations when possible.