Prioritizing Patient Affordability: Enhancing Price Estimate Alerts for Optimal Medication Selection

January 26th, 2024

A unique but all too common situation is emerging in healthcare. Imagine, you, the patient, visiting your primary care physician for a follow-up on diabetes and blood pressure control. After discovering that their average blood sugar levels have been alarmingly high, your doctor recommends a new medication along with dietary modifications. However, your insurance coverage is limited, and you have been struggling to afford your copays. The fear of financial strain looms, forcing you to consider sacrificing other essential expenses. 

This situation is becoming all too common in the United States, where many patients are facing the burden of exorbitant medical costs. In fact, half of the American population has reported difficulties affording necessary medical care. 

What is the physician’s role in these situations? 

Usually in these situations the patient must bring up the issue of drug costs. Historically, the question of drug cost could only be answered for uninsured patients, but there were no direct methods of determining exact copay amounts. Fortunately, since 2021, clinicians in numerous large health systems have gained the ability to estimate medication prices for patients with private insurance or Medicare. These estimates are generated through Real-Time Benefit Tools, which consider factors such as pharmacy coverage, deductibles, copays, and preferred pharmacies. When these tools are integrated into electronic health records they allow physicians to access price information in real-time during patient consultations.

These tools can also alert physicians to lower-cost drug alternatives available. These alternatives could include medications within the same drug class, the same medication at a different pharmacy, a different supply duration, or even the same medication in a different formulation.. Previous research has shown that when clinicians are aware of their patients’ financial limitations, they actively seek ways to alleviate the burden, whether through financial assistance programs or by identifying more affordable medication options. Real-Time Benefit Tools have the potential to provide physicians with valuable insights into their patients’ medication expenses and allow them to minimize costs for patients.

Are Real-Time Benefit Tools actually saving patients money?

A recent study delved into the influence of implementing a real-time benefit tool, which provided clinicians with out-of-pocket price estimates and alternative medication options that were more affordable. Surprisingly, the findings revealed that clinicians were only notified of price estimates on less than 10% of medication orders. Even more interesting was the fact that clinicians were hesitant to switch to the suggested alternative, despite the potential for substantial cost savings. While physicians were more likely to change the medication when patients’ cost savings were greater (over $20) the study found that physicians still only did this around 16% of the time. 

These results shed light on the complexities surrounding clinician decision-making when it comes to medication selection. While the availability of real-time price estimates and alternative options may seem like a promising solution to address affordability concerns, it appears that there are underlying factors influencing clinicians’ actions.

Why aren’t physicians using Real-Time Benefit Tools more often?

One possible explanation for the low utilization of the real-time benefit tool and the reluctance to switch medications could be the ingrained trust in the initially prescribed medication. Physicians may have reservations about deviating from their initial choice, fearing potential adverse effects or a lack of efficacy with the alternative option. Prior studies have also shown that when physicians get too many alerts, they frequently ignore them or do not fully acknowledge them, and that most Real-Time Benefit Tool alerts (around 70%) only save patients a maximum of $5.  

Another aspect to consider is the influence of time constraints during patient consultations. Physicians are often faced with limited time to make decisions and may prioritize other aspects of care over exploring alternative medication options. While the initial study did not delve into the impact of time constraints, it is possible that this has played a role in the low adoption of using tools to reduce medication costs.

What should I do as a patient to get the most affordable price on my medication? 

The improved accessibility of medication price estimates for insured patients is a significant step forward in promoting transparency in healthcare. This development addresses the desires of both patients and physicians for information regarding medication costs, ultimately aiding physicians in determining the affordability of new drugs such as Trulicity. For now, we advise having a conversation with your doctor about medication costs and even ask them about how they use Real-Time Benefit Tools in their daily practice and if these tools may help you find more affordable alternatives. 

Since Real-Time Benefit Tools are relatively new to medicine they may take time to be adopted into everyday practice. To better promote their use and save patients from unnecessary costs, it is crucial we understand the factors influencing physicians’ decisions to adhere to or modify their medication orders following price estimate alerts. This will better inform electronic medical record developers and allow them to optimize the design and functionality of Real-Time Benefit Tools. It is imperative that we maximize the benefits of these tools to prevent patients from overpaying for healthcare without adding undue burden to physicians. 

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