Cost-of-living challenges highlight urgency for clinicians to prescribe affordable medications

Information gap

It is difficult for clinicians to know drug costs for individual patients because of insurance plan and drug pricing complexity. Prices for generic drugs on provincial and territorial formularies are governed by an agreement between the pan-Canadian Pharmaceutical Alliance and the Canadian Generic Pharmaceutical Association. Drug costs for Canadians with private plan coverage vary based on the existence of more than 100,000 individual plans.⁶ At the federal level, the Patented Medicine Prices Review Board sets a maximum introductory price for new patented drugs and limits price increases to roughly the rate of inflation. Provinces and territories strike confidential price-listing deals with drug companies that typically yield discounts between 25% and 30%.⁷

This complexity helps explain the observation that while clinicians almost universally inquire about patients’ drug allergies they often do not ask whether a prescribed drug is affordable, even though 20% of Canadians have inadequate or no drug coverage at all and must pay the full cost out of pocket.⁶

Physicians, nurse practitioners, and pharmacists are the final arbiters in deciding which medications are prescribed and dispensed. Yet, of the 3, only pharmacists can directly access the cost of a patient’s medication, and even they are only partially aware of what patients ultimately pay because out-of-pocket costs are based on patients’ specific drug plans, whether private or public.

Real-time prescription benefit technology has the potential to reduce the problem of cost-related nonadherence substantially. It integrates into EHR systems and with patients’ specific private insurers, allowing clinicians to access and discuss the costs of patients’ prescriptions, including individualized copayments. It also suggests lower-cost alternatives available if a patient cannot afford a drug. Real-time prescription benefit technology facilitates much-needed dialogue at the point of care to help clinicians ensure that their patients will be able to afford prescribed drugs. This technology has the added benefit of teaching clinicians to consider cost when prescribing.

A randomized trial involving nearly 900,000 patients in a large US urban academic health system found RTPB technology recommendations resulted in out-of-pocket reductions of 11.2% for general medications (95% CI −15.7 to 6.4) and 38.9% for high-cost drug classes (95% CI −47.6 to −28.7).⁸ If we consider that almost two-thirds of Canadians 65 or older were prescribed 5 or more different drug classes in 2016⁹ and apply the same reductions to Canadian data (keeping in mind that prices for brand-name drugs in the United States are more than 3 times those in Canada¹⁰), one might expect the savings due to RTPB technology to be quite substantial.

Implementing the link between EHR systems and the prices individual patients pay for medications does not guarantee cost-effective prescribing. Prescribing decisions are affected by many additional factors such as pharmaceutical company promotion of drugs; physician demographic characteristics; whether physicians are salaried, paid on a per capita basis, or bill fee for service; and patient expectations, but raising awareness of cost-effectiveness is a critical step in the right direction.¹¹ Combining a patient’s EHR with RTPB technology at the point of care to foster discussions about drug affordability has the potential to increase patients’ well-being, to lessen the consequences of cost-related nonadherence, and to reduce the need for additional health care services, emergency department visits, and hospital stays.⁶ The possible advent of a universal pharmacare plan in Canada, with accompanying public payment for most prescriptions, should further incentivize incorporating RTPB data into drug information systems to potentially lower the cost of such a plan.

Challenges

Integrating RTPB technology into EHR systems comes with challenges. First, in the United States, medical practices already have information about virtually every patient’s health insurance plan because it is needed for payment. Having this information would facilitate the use of RTPB technology, since practices do not have to ask most patients for additional details about drug coverage. In Canada, because physician and hospital services are publicly insured, asking patients for information about insurance coverage is not routine. Therefore, medical practices here would not necessarily know whether patients have private or public drug coverage.

Second, it is unclear who would pay the upfront costs of purchasing software and ongoing maintenance costs. Clinicians may be hesitant to implement new technology and may feel overwhelmed in learning how to use it. Clinicians may also resist using it because of time constraints and could believe that discussions around drug affordability would add to their burden of care. Finally, there may be privacy considerations that would need to be taken into account in implementing RTPB technology.

Additional research is needed to address the degree to which RTPB technology could lead to patients saving on drug costs, the impact it may have on drug adherence, and how clinicians’ end-user experiences with RTPB technology could be optimized with Canadians EHR systems. The overall impact of RTPB technology on cost savings also needs further investigation, as the aforementioned US study found alternative recommendations were provided for less than 5% of prescription medications.⁸ Finally, we cannot be sure that any money saved through more cost-effective use of drugs would be reinvested in other health care needs.