According to an article in the Permanente Journal, “as many as 40% to 50% of patients who are prescribed medications for management of chronic conditions” don’t take their medications properly, or perhaps at all. The study attributes at least 100,000 preventable deaths each year to this problem. The Permanente Journal article suggests the cost is $100 billion dollars per year, but another study estimates the cost at more than $528 billion, or 20% of US health care spending. Note that the higher estimate encompasses all “nonoptimized medication therapy,” a broad term that covers problems besides lack of adherence.
Another alarming statistic cited by Dr. Michael Wiener, medical director of strategy and planning at Babylon Health, is that one out of five prescriptions waiting at the pharmacy don’t get picked up. Going even further, Bryan Hill, VP of digital health and innovation at Cognizant, says that only 25% of patients are “even mostly adherent.”
In this series of articles, I’ll look at the problems with prescribing medication from a wide perspective.
If you think about the consequences of not taking critical meds, the high costs cited here won’t be surprising. For instance, Jason Rose, CEO of AdhereHealth, points to a study finding that an epileptic seizure can cost the health care system up to $50,000. Add up the ER visits, hospitalizations, and especially long-term care facility placements for patients whose conditions aren’t treated, and you reach the astronomical figures cited above.
Additionally, a recent study found that female patients often reject blood pressure medication, perhaps because they think it’s a man’s problem or are more afraid of side effects.
I decided to look into the causes and possible fixes for this problem, which leads not only to deteriorations and deaths but enormous cost burdens. And in this series of articles, I’ll look at the problems with prescribing medication from a wide perspective.
Finding Cheaper Medications
In the United States, cost is clearly the most urgent concern in access to medication, generating front-page news stories about various political proposals I won’t go into here. Some patients, particularly in rural areas, run up against other barriers to access too. What’s interesting for this article is that IT can help connect doctors and their patients to cheaper and more convenient sources of medicine.
According to Dr. Colin Banas, chief medical officer of DrFirst, adherence plummets once out-of-pocket costs for a medication exceed $50, and patients cut their prescribed dose in half 20% of the time to make the medications last longer. But patients can take advantage of alternative sources for medications—if they know about them.
Prices often vary greatly between pharmacies, even those that the patient can drive to. Sometimes a cheaper alternative will work just as well as the medicine prescribed by the physician. Some companies offer discount coupons. There are even private organizations that subsidize costs for needy patients (and for some drugs, “neediness” extends well into the middle class).
These alternatives are publicized, but scattered through many sources of information. Some of the companies whose managers I talked to pull together all the options, the way a travel site pulls together all the options for air travel or hotels. The sites present the options to the doctor prescribing the medicine, so that the doctor and patient together can choose the optimal solution for that patient. Some of the vendors offering this service include Babylon, DrFirst, and athenahealth, which I’ll use as an example of such services for the rest of this article
The Technology of Medication Pricing
athenahealth provides real-time prescription benefit checking by combining information from third-party aggregators (Surescripts, Arrivehealth, and CoverMyMeds) with data from payers and pharmacy benefit managers. The athenahealth service gives the physician a cost estimate for the selected prescription and pharmacy location. This estimate also includes alternatives (30-day versus 90-day supply, local pharmacy versus mail order, alternate drug recommendation), allowing the patient and physician to work out the best choice instead of leaving the patient to be surprised when arriving at the pharmacy.
Dr. Nele Jessel, chief medical officer of athenahealth, said that it would also be very helpful for prescribers to obtain real-time in-stock information before the prescription is sent to the pharmacy. Such communication could eliminate delays in therapy, because the physician could change the medication to an equivalent that is in stock, or find an alternate pharmacy. Unfortunately, such data is not yet available, but athenahealth advocates for it.
athenahealth can also adddress access problems. If the patient has physical problems getting to a pharmacy, athenahealth provides the cost for a long-term mail order supply.
A dilemma is presented when pharmacies offer low-price generics for cash. Patients can sometimes save money by buying the drug out of pocket instead of charging the insurer and paying a copay. (That seems strange, but exemplifies the arbitrary structure of the U.S. medication market.) But paying without telling the payer creates another problem: the payer thinks the patient hasn’t taken the drug at all, and may penalize the patient or physician. It also distorts the physician’s view of the patient, and may even lead the physician to prescribe a drug that interacts negatively with the one the patient is taken.
Thus, pharmacies have to communicate better with physicians and payers when patients pay out of pocket. Banas says DrFirst wants to “arm” physicians with data so they have “less friction” around finding sources of medication.
Sensitivity on the doctor’s part is required to help a patient find an affordable drug. Many doctors don’t even ask patients whether they have trouble affording medication. Such inquiries must be done delicately, with attention to the patient’s pride and state of mind. Dealing with critical issue of affordability might take up time the busy doctor would rather spend on clinical issues.
Transparent Pricing Has Ripple Effects
In conclusion, the market for medications in the United States is broad, confusing, and often arbitrary.
Information gaps open the market to manipulative direct-to-consumer advertising by pharmaceutical companies. Perhaps the services described in this article could undermine the appeal for drugs that appear on major TV channels. If you’re told that the premium medication you’ve been sold on TV is essentially no better than a generic, you can save yourself and your insurer a lot of money.
It’s daunting to pull together all the public sources of help, but well-designed technology can do it fast enough to help doctors and patients find cheaper solutions during a clinical visit. However, many gaps exist that could be filled with better real-time sources of information.
This article has focused on cost and access, two tangible and pressing issues in medication adherence later articles will look at a range of other issues. Do patients know how to take their medication, and why it’s important? Are they searching for alternative treatments? Do they need a closer and more trusting relationship with health care providers?
