The rising price of prescription drugs has triggered problems for patients and their physicians: high out-of-pocket costs can lead individuals to skip or ration their medications, and questions about insurance coverage can require medical office staff to spend hours on the phone negotiating with pharmacies.
Plus, for doctors participating in value-based care arrangements with insurance companies — in which good outcomes and low costs are rewarded — high expenses within the practice can make it harder to meet savings goals outlined in their contract.
To help healthcare providers get a better handle on these costs, Horizon Blue Cross Blue Shield — New Jersey’s largest health insurance company — has developed a software tool that enables prescribers to get quick access to a list of lower-cost drug options tailored to address a patient’s unique needs and definitively covered by their specific prescription drug plan.
Horizon worked with Gemini Health, a national company that uses technology to tackle drug-pricing issues, to develop its own version of a so-called drug-cost-decision-support prescribing tool. The insurer launched a pilot project in April and its use has since spread to some 5,000 prescribers, Horizon said, and they hope to roughly double that usage by the end of 2019.
“Drugs are becoming more and more costly and a bigger part of the premium dollar. (This software) allows everybody to have tools to better manage it,” said David Gambino, Horizon’s vice president and chief pharmacy officer. Already the tool is creating an estimated 1,600 opportunities for prescription savings daily, he said.
‘Administrative burden’ and costs
“It addresses the administrative burden, the back and forth (between medical providers and pharmacists), and it addresses the cost from the member (or patient) perspective,” Gambino added. Roughly 20 percent of the prescriptions doctors write (without using this type of tool) require follow-up from office staff when patients encounter problems at the pharmacy related to availability, insurance coverage, or other issues, he explained.
The Gemini tool is built to interface automatically with the most common system of electronic health records — and the software these use — to create prescription records, Gambino explained. When clinicians type in the name of the drug they want to prescribe, the system will produce within seconds a list of up to three lower-cost options that are also medically appropriate to treat their patient.
In addition, the software is designed to sort through hundreds of health insurance policies, and the myriad prescription plans and formularies that these can involve, to ensure its recommendations are covered by that patient’s insurance. Physicians are not required to act on the information — and can still prescribe whichever medication they believe is the best fit — but it presents choices and helps them demystify prescription coverage questions for their patients, Horizon said.
“It allows doctors to better engage (with their patients) and everybody will be happier because there will be less surprises,” Gambino said. “The decision is still in the hands of the provider,” he stressed.
Price of drugs affecting patient behavior
Prescription drugs make up a relatively small portion of the nation’s overall healthcare costs, but their pricing has been more volatile and is escalating quickly, experts have found. An analysis of healthcare claims data from 2012 to 2016, commissioned by the New Jersey Health Care Quality Institute, showed that while overall healthcare spending rose 18 percent in New Jersey — outpacing the national rise of 15 percent — drug costs here jumped 27 percent during those four years.
Research also suggests that this increase is having a measurable impact on patient behavior. A Kaiser Family Foundation poll published in February showed nearly one quarter of Americans said they had difficulty affording their medications (the figure is much higher for senior citizens, according to other data.) Kaiser found close to 60 percent of respondents said they spent more than $100 a month on these drugs and nearly three in 10 admitted they had at times avoided filling a prescription, cut pills in half, or substituted over-the-counter options to save money.
Prescription prices have attracted attention from national policymakers, including several members of New Jersey’s federal delegation, as well as Garden State officials. New Jersey Attorney General Gurbir Grewal joined a multi-state lawsuit charging generic drugmakers with inflating prices on certain products, and state legislators have proposed several ideas to help boost competition among drugmakers, including a call for the state to develop a public price list for drugs sold here.
Dr. Gregory Herman, the chief medical information officer with Inspira Health Network, which includes three hospitals and hundreds of providers in South Jersey, said that physicians had not traditionally concerned themselves much with the price of care. But he said that approach is evolving with the growth of healthcare models like Inspira’s accountable-care organization, which seeks to raise quality and control spending — and take cost-effectiveness into consideration.
“I was trained in a system where we did not give one rat’s ass about cost,” Herman said. “I think that needs to change.”
To support this shift, Inspira — a partner in Horizon’s OMNIA network, a system of value-based contracts and collaborations — will soon be integrating the Gemini tool into some of its practices, Herman said. They plan to train prescribers, create a tip sheet and short video, but Herman said the system is easy to use and there is little downside to activating it right away.
Getting doctors to change their ways
“It won’t interfere with their workflow,” or take extra time, he said, and the way the cost savings are displayed is immediately evident.
The bigger challenge, Herman acknowledged, will be getting doctors to change their patterns and make use of the information Gemini presents — a process that could take some time. Inspira will be tracking the results and plans to present these findings — including any savings numbers — to the prescribers after a few months, a strategy Herman hopes will help convince them of the value.
Even practices that are not participating in savings-oriented contracts could also benefit from the tool, Herman said. Doctors may not realize that their patients aren’t taking their medications as prescribed, for cost or other reasons, and that they remain vulnerable to the effects of their disease or condition. Having less expensive options easily available could increase the chance patients would comply with their treatment, a positive development for all involved.
In addition, Herman said many doctors are already frustrated with calls from the pharmacy about drugs that are not covered by a patient’s plan. More information up front means less hassles with the pharmacy, he said. “This way, everybody wins.”