Editor’s Note: The cost of medication nonadherence is high for all stakeholders involved in the healthcare system. It’s also an issue that is highly complex, multifaceted, and personal. The reasons for nonadherence vary amongst patients and medications. However, one common and growing trend across the spectrum is the ability of patients to afford their medications. As patients increasingly find themselves being prescribed innovative, branded medications to improve their health, it’s become more difficult for them to apply their insurance benefits as payers have introduced measures designed to combat growing pharmacy spend. Moreover, transparency into the process for applying benefits and accessing available patient support resources is generally murky at best. Life sciences manufacturers marketing branded therapies should look to ensure that patients seeking access to their therapies have the best chance at getting their prescriptions covered by insurance, have multiple options for fulfillment, and can easily access any available support programs. The PhilRx Patient Access platform offers patients full transparency into every stage of the prescription journey and offers patients the option for local pickup or home delivery of their prescriptions. Check out our recent blog post transparency-is-critical-in-the-patient-access-journey/ explaining why transparency should be a critical component of any patient access program.
Medication non-adherence is a persistent and complex issue that presents ongoing difficulties for patients and providers alike. When patients can’t or don’t take their medications as prescribed, they can experience a variety of negative health outcomes, including increased hospitalizations, disease progression, and higher healthcare costs. The average cost of medication non-adherence in the U.S. ranges from $5,271 to $52,341 per person, according to one estimate.
The healthcare industry has tried various strategies to address the issue of medication non-adherence and its myriad causes, including medication reminders, education programs, and financial assistance programs. While these initiatives have shown some success, they have not been able to fully solve the problem. This is partially because providers often don’t have the time or information needed to properly support a patient when they prescribe a medication. It’s also because of misaligned incentives: Manufacturers have an incentive to promote new higher-cost drugs, while health plans create friction to encourage patients to take lower-cost medications first.
The complexity that results leaves patients and providers guessing at the “right” decision. Mired in that complexity, patients often just give up. What we need to overcome these challenges is a digitally enabled marketplace of options that can be personalized to the patient and the context of their specific condition, pharmacy preference, and ability to pay.
Imagine a tech platform that could—in real-time—generate price, formulary, benefit design, and total cost of care information to equip providers with insights they need to make prescribing decisions with the patient at the point of care.
Let’s say, for example, a doctor wants to prescribe a brand-name heart medication for a patient. With knowledge of a patient’s insurance plan, a tech-enabled platform could tell them how much the drug would cost in total, what the patient’s insurance would cover, and what the patient’s out-of-pocket costs would be. The provider could then have a candid discussion with patients about their ability to afford the drug (considering the costs of other drugs they may be paying for, as well as non-healthcare-related expenses). The tool could also identify available and compliant financial assistance programs based on any patient’s insurance. Commercially insured patients could be connected to co-pay assistance, and Medicaid patients to the Heart Failure Foundation, for example. The technology could also alert patients to coupons from places like GoodRx, Optum Perks and SingleCare—saving them the hours it would take to comb all these sites individually; it could even text them the coupons for easy redemption.
Equipping a provider with this information would enable them to better care for their patients. With real-time insights, they could find out that cost will be a barrier to adherence and engage in proactive problem-solving with the patient—while they’re still sitting together.
Currently, many providers send prescriptions to the pharmacy without discussing any of the details with the patient, and the patient doesn’t discover they can’t afford it or that insurance does not cover it until they try to pick it up. In these cases, it’s not that the patient didn’t want to take the drug, it’s that they didn’t know what to do next or what their options might be. The provider also may not find out about the issue until the patient calls them from the pharmacy or comes in for their next appointment.
Why is providing cost information earlier in the process so important? Because high or unaffordable out-of-pocket costs is the primary reason many patients don’t take medications as prescribed. In fact, up to 37% of prescriptions are never filled due to cost. In other cases, patients may fill their prescription but split pills in half or quarters to make them last longer, skip doses, or delay refills—cost-saving strategies that can reduce effectiveness of the medication, potentially worsen the condition, and increase risk of complications and adverse events.
In a perfect world (or hopefully just a future state), patients would have access to a dashboard where they could view their prescription options from start to finish. For example, after being assessed by their provider, a patient could receive a list of appropriate medication options to review. The patient could then select among those options, considering factors such as whether and how much their insurance will pay, whether there are any restrictions, and whether they even want to use insurance (sometimes it’s cheaper to pay cash). They could then choose how it’s fulfilled—low-cost pharmacy, home delivery program, via a home health system that will help them, etc. Afterward, they could text their care team or pharmacy with questions or concerns and resolve any issues quickly. This approach would give patients the tools they need to actually have consumer choice.
Given the number of clinicians, organizations, and advocates working to improve adherence, clinical outcomes, and access to medication, it can be frustrating to see how slow and fragmented those efforts can be without the right tools and technologies to introduce consumer choice in healthcare. Technology—when deployed strategically—really does have the potential to create a more connected, transparent, and responsive healthcare system that makes sense for patients, providers, payers, and pharma.
Our consultants will work with you to analyze your current channel strategy and make recommendations for how to improve patient access and increase the percentage of scripts getting covered by insurance.