The last few weeks have seen a flurry of activity with several congressional committees holding hearings in an effort to address the crisis of high drug costs for patients. As the debate intensifies around drug pricing, it is easy to get lost in the rhetoric and lose sight of finding meaningful solutions that will bring down costs for patients where it hurts the most — at the pharmacy counter.
Each year, patients forego needed medications due to cost. In fact, surveys have shown that nearly 50 percent of patients have abandoned a prescription at the pharmacy counter because of affordability. This can lead to poorer health and significant increases in cost to the health-care system. It is critical that we do all we can to address high patient out-of-pocket costs, and we urge policymakers to consider the following policy ideas to provide greater predictability, affordability and access for patients.
In a recent survey, 57 percent of Americans said that, most of the time, they don’t know how much a prescription will cost or whether they can afford it before they reach the pharmacy counter. Efforts to provide doctors with access to real-time cost and benefit information at the point of prescribing are critical so that doctors can prescribe an effective drug that the patient can afford - increasing the likelihood that the patient will fill the prescription they need to get better or stay healthy.
Many employers and government programs have achieved significant savings using pharmacy benefit manager (PBM) tools and services that provide real-time benefits information at the point of prescribing. Through one PBM’s real-time benefits tool, physicians have prescribed a different, lower-cost drug about 20 percent of the time when an alternative was available — and consumers saved on average $80 per prescription fill.
Last year, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule to advance the implementation of these practical cost-saving tools by requiring Part D sponsors to implement a real-time benefits tool by 2020. The expanded use of these PBM tools in Part D and the commercial market can play an important role in reducing costs.
Seniors enrolled in Medicare Part D and Medicare Advantage plans remain the only insured population in the U.S. without an out-of-pocket maximum for their pharmaceutical costs. Between their coinsurance and their responsibility to pay five percent of costs once they reach the catastrophic phase of their coverage, they could potentially face unsustainable costs. The Kaiser Family Foundation estimates seniors taking just one specialty drug can expect to pay thousands of dollars in out-of-pocket costs in 2019.
Establishing an out-of-pocket maximum in Part D could help protect seniors from high drug costs and improve access to needed medicine and better health outcomes.
A third goal should be to ensure that patients in high deductible health plans (HDHPs) can access needed medications. More than 22 million Americans rely on HDHPs for their medical coverage, which requires them to pay for 100 percent of the costs of their medications not defined as preventive until their deductible is met. Because of this, patients with chronic conditions enrolled in HDHPs are at significant risk for non-adherence — and often choose to change dosing schedules or skip needed medications until their deductible is met.
For patients enrolled in a HDHP with a health savings account, allowing coverage of preventive medications for the treatment of chronic disease, regardless of whether the deductible has been met, should help increase adherence and reduce costs incurred from patients not taking their medications as intended.
As Congress and the administration continue to discuss options to help patients afford their medicine, we encourage them to turn their attention to these policy solutions that can meaningfully bring down costs for patients.
Debra Barrett is the executive director of the Coalition for Affordable Prescription Drugs (CAPD).