More than a decade after the Affordable Care Act was signed into law, U.S. healthcare costs continue to spiral at rates unseen in the rest of the developed world.
But while healthcare costs overall are escalating, there are some signs of hope in the world of prescription drugs. Patients can often save significant amounts of money on prescriptions, but many are either unaware of that fact or don’t know where to look for the savings. Real-Time Prescription Benefit (RTPB) tools are now available to providers nationwide, supporting conversations about affordability and access – all while the patient is still in the exam room. These technologies surface pricing information, coverage restrictions, and lower-cost alternatives on millions of prescription transactions every year.
When enabled by RTPB, electronic health records can provide doctors the ability to see drug costs and alternative options as they’re talking with patients, and there is often a wide range of prices for the same or comparable drugs. It’s striking how often there are opportunities to save significant amounts of money — even get prescriptions for free. Recently, an in depth analysis of 78 million prescription transactions that took place across 2022 found that in 47% of the cases, there was a no-cost option available to the patient.
Uncovering lowest-cost medication options is important for patients because sticker shock causes individuals to skip taking meds altogether. To get a sense of the wide price variations in what are often comparable medications, take insulin, a drug that millions of Americans need to survive. Thanks to legislation passed earlier this year that caps insulin prices (at $35 for seniors), insurance companies now must provide low-cost options for those with diabetes. But it’s not that simple. If a doctor prescribes insulin covered by a patient’s insurance, it likely costs tens of dollars each month. But if it’s out of coverage, the price can quickly balloon to thousands. And there’s nothing from the patient’s perspective that would explain or justify this discrepancy in prices.
Price transparency has come a long way over the past couple of years, with insurance companies and hospitals now required to publicly disclose their prices. The more pressing issue is that there is no mechanism in place to make this information easily digestible, personalized to each patient, and placed in context with competitors’ prices. Insurance plans publish long lists of what their services cost, without structuring the information in a way that is useful to patients. The result is trillions of lines of data that nobody wants to sort through to get the one thing they need to know: what their care will cost and whether there are cheaper options available.
Sadly, the vast majority of Americans can’t afford high-cost medications they need for life-saving care, and are unable to find lower-cost options. The Robert Wood Johnson Foundation and Urban Institute conducted research last year which found that an estimated 13 million adults either didn’t fill a prescription or delayed it due to high costs – a damning indictment of how difficult our healthcare system is to understand and navigate.
There are a number of price transparency tools in the market that doctors can tap into. But in many cases, the pricing information they show is either inaccurate or not in a usable form. With other transactions, these tools are unable to surface any information on price at all. This has soured many doctors on pricing tools in general, which means that usage has faltered and opportunities to save patients money on their drugs have been missed.
It doesn’t have to be this way. RTPB solution providers must put a significant emphasis on data quality and accuracy. By standardizing error messages, translating quantity inputs and drug codes, and filtering erroneous noise, RTPB can present actionable information to providers in every patient interaction. And accurate, actionable data means more patient savings are possible.
The results so far have been eye-opening—and provide hope when it comes to our ability to control spending on drug prescriptions. In some cases, providers can literally find the same exact medication for half the price by changing a quantity, a pharmacy, or a form (capsule vs pill). There may, in some situations, be a less expensive heart drug available delivered via the mail instead of being available for pickup at the pharmacy.
There’s no silver bullet for addressing the many challenges in our healthcare system. But we must embrace new tools in order to offer a more comprehensive snapshot of prescription costs, availability, and restrictions to patients. The ultimate effect will be more affordable care for patients – and for providers, a return to the basic mission that drew many to the field to begin with: helping to deliver effective care and restore health.
Written by Kyle Kiser, CEO of Arrive Health.
As seen on MedCity News.