Tools that help doctors calculate drug prices slowly

When Mary Kay Gilbert saw her doctor in May for a skin infection in her leg, she was not surprised to receive a prescription for an antibiotic cream.

But Gilbert, 54, a nurse and health consultant, was shocked when his doctor clicked on his office computer and told him that the drug would cost $ 30 a year on his Blue Cross and Blue Shield plan.

"I was like:" Wow – it's pretty cool that you knew this information ", she recalls telling Edina's doctor, in the news. Minnesota.

Allina Health, the largest hospital network based in Minnesota, is part of the growing number of health systems and insurers providing physicians with real-time information on the price of drugs so that they can help patients to avoid "sticky shocks" at the pharmacy.

The pricing tool, integrated with the electronic health records and prescribing system of each participating physician, indicates the amount that patients can expect to pay out of pocket, based on their insurance and the pharmacy of their choice.

This also allows the doctor to find a cheaper alternative, where possible, and begin the process of obtaining a drug's authorization, if the insurer allows it. required.

Soaring drug costs have been at the center of the growing national debate about the reorganization of health care in the United States.

Patients give up hundreds of thousands of prescriptions every year to the pharmacy, often because of high prices. Studies show that this can compromise their health and often lead to higher costs on the road.

Such a tool can help consumers – many of whom are also face rising costs and higher deductibles – discover cheaper options at the doctor's.

Yet doctors have been slow to adopt technology, sometimes because of fears of getting bogged down in lengthy discussions about the cost of drugs. Humana, for example, introduced its drug pricing tool to its network of doctors in 2015. Today, less than 10% use it, according to Humana officials.

These types of pricing tools have serious limitations. Because price negotiations between insurers, drug manufacturers and intermediaries are often highly competitive and secretive, the tools often do not have useful data for each patient.

For example, Allina works for only about half of her patients. The company says that this is because all pharmaceutical benefit managers do not share their cost information for members of a health care plan, and those who do so often only provide information about their health care costs. a fraction of their information.

"It's a chicken and egg thing where doctors do not use it because they do not have data for all their patients, and health plans do not pass it on to doctors because doctors do not have the technology in place, "Anthony Schueth, health information technology consultant in Jacksonville, Florida." This can be a powerful tool when it works, but for the moment, the determining factors are not widely adopted. "

At a hearing last month, Senator Martha McSally, R-Ariz, asked a senior Trump administration health official to explain why many patients had no access to information about the prices of prescription drugs at their doctor's office.

"It's America. Why can not we have this tool available now?" she asked. "Data is available, information is available, what does it take to make it happen?"

Technology has gained momentum last month when the Centers for Medicare & Medicaid Services have asked all Medicare drug plans to incorporate such a tool into the e-prescribing system of their doctors from 2021.

The details of what consumers spend out of pocket for drugs are provided by the Pharmacy Benefit Managers, or PIMs. It is the middlemen who negotiate with the drug companies about the prices that the insurers will pay for the drugs and what they will cover. Thus, the utility of a tool is compromised when key PBM modules are not included in the lists.

For example, a drug pricing tool sold by Surescripts, which partly belongs to the CVS Caremark and Express Scripts PBMs, includes data from these companies, but not from OptumRx, a PBM owned by United States. And the OptumRx drug pricing tool includes Optum data but not those of Express Scripts and CVS.

Demetrios Kouzoukas, who runs the Medicare for CMS program, hopes that the program's new mandate will encourage the industry to provide physicians and patients with a standard pricing tool, regardless of their insurance.

"What we hope and expect is that there is a standard developed by the industry … so that the tool is available in all electronic health records, for all." doctors and all patients, and that it is spreading even beyond Medicare, "he told McSally to the audience.

But cooperation does not seem to be on the horizon, say some health officials.

"I see no chance that there will be a centralized system that will connect all plans / PBMs to all currently used EHR systems," says Thomas Borzilleri, CEO of InteliSys Health, a technology-based company. the health. based in San Diego.

Nevertheless, the National Prescription Drug Program Board, a non-profit group that helps set guidelines for the pharmacy sector, has been working on standards for a drug pricing tool. John Klimek, vice president of the non-profit association, predicts that by next year, the country's doctors will be able to use the same drug pricing tool to consult the cost of drugs of their patients, regardless of the insurer.

Even in the absence of such a standard, doctors and hospitals are encouraged to use the tool that goes beyond the economics of their patients: such a tool can also be beneficial for the purse of the supplier.

For example, Allina, which owns or operates dozens of hospitals and dozens of clinics in Minnesota and Wisconsin, collects a fixed fee from some insurers to meet all of the health needs of the province. a patient. Thus, physicians and the health system all benefit when they can reduce costs and improve patient adherence to medication, says Dr. David Ingham, a family physician who also Edina. He is one of the 600 primary care physicians of Allina using this tool.

"When we prescribe a more expensive drug, we share less income from the insurance contract," he said.

For example, he notes that the tool has helped prescribe inhalers to asthmatic patients.

"I took a medication that I normally use, and it was said it would cost $ 240, but it suggested an alternative to $ 20 pharmacologically equivalent," Ingham said. "I sheepish asked the patient which one we had to choose."

Dr. Norman Rosen, a family doctor based in Orange, Calif., Who works for the Providence St. Joseph Health System, is one of 800 physicians who are testing Blue Shield's drug pricing tool. of California this year. Based on the first few months of use, the tool should save patients more than $ 100,000 in out-of-pocket expenses this year, according to businesses.

Without the tool, says Rosen, it would be impossible for him to know quickly which drugs are covered by which insurers and which are the copays. He says that he has already allowed patients to save several thousand dollars a year by altering their blood pressure and their diabetes medications.

"It does not take much time and it can be an important intervention," says Rosen.

Kaiser Health News is an independent non-profit editorial program of the Kaiser Family Foundation and is not affiliated with Kaiser Permanente.