Value-based Rx: How physicians can manage affordability, adherence

For doctors, the price of prescription drugs used to be largely a medical concern: Patients wouldn’t get better if they couldn’t afford to fill their prescriptions. But with Medicare’s growing emphasis on value-based care, many physicians now also have a financial stake in ensuring that patients can pay for the medications they need.

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The specific catalyst for this development is the Merit-based Incentive Payment System (MIPS), Medicare’s payment program covering most small and solo medical practices that took effect at the start of 2017. MIPS-which was created as part of the Medicare Access and CHIP Renewal Act of 2015-links Medicare reimbursements to physicians’ performances on metrics in four broad categories, the most important of which is quality. And many of the MIPS quality metrics include outcomes for diseases and conditions routinely treated with prescription medications.

Hence medication affordability-or its lack-could spell the difference between a bump or drop of as much as 9% in a doctor’s Medicare reimbursements by 2022.

There are no data on the number of patients whose outcomes are affected by the cost of drugs. However, a 2013 study by the Centers for Disease Control and Prevention found that 8.5% of Americans between the ages of 18 and 64 did not take their medications as prescribed due to cost concerns.

Fortunately, despite the ever-rising cost of prescription drugs, physicians have numerous tools at their disposal to help patients fill the prescriptions they write. Moreover, experts say, a value-based payment system-which includes tying Medicare reimbursements to the thorny issue of drug affordability-has the potential to improve care.

“Until now there hasn’t been much incentive for physicians to learn that there are things they can do to help their patients [afford medications] because their payment wasn’t affected either way,” says Emmy Ganos, Ph.D., a program officer with the Robert Wood Johnson Foundation. “Now with this shift hopefully there will be more emphasis on patients getting what they need out of the [doctor-patient] interaction, because ultimately that’s everyone’s end goal.”

Communication is key

So what can doctors do to help patients afford prescription medications? Like so much else in medicine, the solution begins with good doctor-patient communication, experts say.

“That conversation [about prescription affordability] doesn’t come up as frequently as it should,” notes Eric Schneider, MD, FACP, senior vice president for policy and research at The Commonwealth Fund.

Schneider, who closed his internal medicine practice at Boston’s Brigham and Women’s Hospital in 2015, notes that the affordability issue had been coming up
increasingly over the years, with patients voluntarily acknowledging that they’re unable to pay for a prescription he has written.

“I think this performance payment system [MIPS] is probably going to drive these conversations to happen more frequently,” he adds. “In fact, if adherence is detected to be a problem for a patient, one of the questions that’s often asked now is ‘Are you having trouble affording your medication?’”

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Concerns about prescription drug affordability are not limited to patients who are poor, notes Damon Raskin, MD, an internist and addiction specialist in Pacific Palisades, California. Raskin treats patients with widely varying incomes, “but all my patients care about the cost of prescriptions, even those who are wealthy,” he says. “Especially for older patients on multiple medications, it’s a big chunk of their incomes each month.”

Focus on generics

Probably the most important step doctors can take to minimize affordability problems, say those who have studied the issue, is to prescribe lower-priced generics whenever possible. While that may seem obvious, not all physicians make it a priority, says John Rother, president and chief executive officer of the National Coalition on Health Care.

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“You’d be surprised by how many doctors are still writing brand-name prescriptions when much cheaper generic versions are available,” Rother says. “I think part of that is they’re not necessarily aware of what the true costs to their patients are. Or [doctors] assume insurance will cover it all.”

“Depending on the category [of medication] I do use a lot of generics in my practice because for most things they are just as good [as branded drugs],” Raskin says. “That’s especially true for common ones like blood pressure and cholesterol medications.”

Yul Ejnes, MD, MACP, an internist in Cranston, Rhode Island and a director of the American College of Physicians, routinely prescribes generics for his patients, but notes that even those have been getting more costly in recent years. Some generics now also require prior authorizations from payers. “That assumption of, ‘here’s a drug you only pay $10 for a 90-day supply isn’t a sure thing anymore,” he says.

A second tool doctors and practices can use to help patients who are struggling to pay for medications-and thereby boost their quality score under MIPS-is to refer them to one of the patient assistance programs that many pharmaceutical manufacturers, and some nonprofit agencies, now operate. (Pharmaceutical companies often include them in their television and print advertisements for medications.) Such programs eliminate or deeply discount the patient’s copay, requiring patients to provide proof of income and an attestation from their physician that the medication is needed for the patient’s treatment.

“These programs aren’t really large enough to deal with the need, but for people who are able to get on them they can be very helpful,” Rother says.

Price comparison apps

A third step doctors can take to help patients is to recommend one of the growing number of apps and websites, such as GoodRx and OneRx, that let patients comparison shop their copays among pharmacies, and/or provide discounts for certain medications.

The latter is particularly useful, according to Schneider, because it allows patients to include their specific insurance plan, and thus know what their actual out-of-pocket cost will be when they go to fill a prescription.

That type of information, he adds, would be useful to provide in physicians’ electronic health records (EHRs). And while some EHR manufacturers are beginning to include prescription drug formularies in their software, Schneider says, they provide only the tier level of the prescription.

“The sort of system you’d really like to have is when you’re seeing Mrs. Jones you can pull up her medication list and say what each one will cost her if she fills that prescription today. But I don’t think that exists,” he says.

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Still another option for patients facing burdensome prescription costs is to purchase their medications from other countries, particularly Canada. While technically illegal, the practice is generally acknowledged to be widespread, and is rarely prosecuted. Moreover, the Food and Drug Administration makes some exceptions to the prohibition, which it outlines on its website.

However, buying drugs from abroad-even from Canada-does carry some quality-control risks, Rother points out. “The problem is, what may be advertised as Canadian drugs-which are just as safe as American drugs-they could be made originally in India or some other third-world country. So you have to do some homework to find out where the drugs are actually coming from,” he says.

Partner with pharmacists

Beyond these patient-focused strategies, many experts think practices can help address the cost issue-and boost their MIPS score through improved patient adherence-by working more closely with pharmacists. In Ejnes’s case, that takes the form of having a clinical pharmacist on his practice’s staff.

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“If I have a patient getting crushed by prescription prices I can refer them to the pharmacist, where they’ll go through the patient’s drug list and check them against the formulary, or see if there are any assistance programs they qualify for, and help them fill out the forms,” Ejnes says.

He acknowledges that an in-house pharmacist is a luxury that is generally available only to large, multi-specialty practices such as the one he’s part of.

“To me, it’s an argument in favor of being part of a bigger entity of some sort,” he says. “Information technology was supposed to make [drug pricing] easier, but we haven’t gotten to a place where I can be certain what the price to the patient will be when they get to the pharmacy.”

Practices that can’t afford to hire their own pharmacist can still derive some of the benefits by forging relationships with pharmacists in the community. Such relationships begin with a willingness to share a patient’s care plan with the pharmacist, says Joe Moose, Pharm. D., co-owner of Moose Pharmacy, a North Carolina-based chain of independent pharmacies.

Moose notes that the typical North Carolina patient sees their pharmacist 35 times annually, compared to 3.5 visits with their primary care provider. “That means we have 10 times more opportunities to reinforce that care plan,” he says. “That’s the real way you save on drug costs. The problem is, under the current model we usually don’t know what the care plan is.”

Some providers are reluctant to loop in pharmacists on a patient’s care plan, Moose acknowledges, but says those who do can find it helpful in improving patient adherence to medication regimens.

“The doctor can do everything right in terms of treatment and educating the patient. But then the patient never picks up the prescription, or stops taking it, and no one is calling the doctor to tell him. Then the patient has a follow-up appointment six months later and the numbers are still bad, and the doctor is left wondering what’s going on,” he says.

Pushing doctors to work more closely with others involved in patient care may prove to be an important benefit of Medicare’s payment reform initiative, says the Robert Wood Johnson Foundation’s Ganos.

“I don’t think this [improving patient health] has to be all on the physician’s shoulders to solve,” she says. “If doctors are going to take some financial hits because patients aren’t getting better, then that incentivizes finding other ways to help patients get access to what they need, which ultimately
I think is a good thing.”