Software May Help Determine a Drug's Cost Before It Is Prescribed

'How much does this cost?,' followed by, 'My doctor said it would be [Insert free/cheaper response]' is a conundrum faced many times throughout the week in the pharmacy. After all, in an era with changing formularies, rising drug costs, and other issues plaguing the health system at large, predicting how much a drug will cost a patient is just 1 other item that is hard to address. Pharmacy companies are coming up with internal systems to combat costs, and then we have companies like GoodRx and Blink Health that have drug lowering software, but it is not really inclusive to most patients. But hey, that's why it's become an attractive topic as of late, and of course, some companies want to solve that issue.

One example to hit the news recently was Gemini Health, a California based startup focused on offering solutions to reduce drug pricing for patients.¹ They have recently paired up with Blue Shield of California to provide services for 4 million BSC patients. This entails an online tool that can predict the cost of a drug that a provider may be thinking of prescribing for a patient.² The tool will generate a list of drugs (which I assume are in the same or similar classes of pharmacological action), and give cost comparisons. The tool will work by taking information from multiple databases. This entails looking at the cost from the insurance health plan (BSC), and the pharmacy data, along with EHR data.

Why hasn't a tool like this come about before? Why don't doctors see how much what they are prescribing cost? What it boils down to is the multiple issues facing the drug supply chain, coverage, and sales of medications. Take for instance, what are the negotiated coverage of drugs from the insurance or PBM, how much is the acquisition cost and markup for a pharmacy, and what does a clinician want to use. In a way, the price has always been part of the evidence-based medicine path, as far as I am concerned. I use the STEPS method when thinking of medication to utilize clinically, which breaks down to:

S—Safety

T—Tolerability

E—Efficacy

P—Price

S—Simplicity

The price component, especially in the United States, I feel, really is a big lynchpin of care. For example, there is a big argument that Glucagon-like peptide-1 receptor agonist (GLP-1 agonist) should be first-line therapy in diabetes management. The evidence is building in recent trials, and it seems to be a good drug for mortality benefit. But, in comparison to metformin, the cost is staggering. We are talking a difference of cash price, where metformin runs $4 (generic list) compared with up to $800. For some patients, the insurance coverage mitigates this, but for others, it may not be possible.

In any event, the golden goose many seem to be pursuing is making a tool that is built into the EHR or e-prescribing system for a provider that when they go to send a prescription, it tells them what the out-of-cost expenditure will be for the patient. The previous example? A patient may balk at the co-pay and ask for another recommendation. After all, there is no point in prescribing something if a patient will not take it, due to it being unaffordable.

Now several other companies, besides Gemini Health, are tackling this issue. Surescripts has created a tool launched this year that can be built into several EHRs (Cerner, Epic) to deliver such a service, called their Real-Time Prescription Benefit program.³ When a provider creates a prescription, the program uses the EHR to check insurance coverage, and then compares the costs with up to 3 pharmacies nearby, and up to 5 different drug alternatives. This can then be discussed with the patient for a joint decision on care. But this system isn't built into every EHR, and some issues will be present if Surescripts doesn't have access to see the billing cost.

Another example is Kareo, who has started to integrate GoodRx into their platform to give the cash price and coupon (from GoodRx) to a patient for the drug they are prescribing.⁴ While this isn't extensive, as say Surescripts or Gemini, I feel that it is in the right step, and at least it's built into the user interface.

These programs, I am sure, will develop further in the future. Some issues that strike me, which I am not able to determine, is how their programs work for say patients with dual-eligibility, or if it would be possible to identify patients with access to patient assistant programs, cost prediction across the year for Medicare Part D patients (e.g. coverage gap [Donut Hole]), or issues with prior authorization. Nonetheless, the benefit would hopefully streamline workflow for providers, and lead to fewer patients that have price shock at the counter.

References

• Gemini Health website. www.gemini.health/. Accessed May 8, 2018.
• Prescription drugs are costly. This startup helps doctors find cheaper ones. San Francisco Chronicle. April 24, 2018. https://www.sfchronicle.com/business/article/Prescription-drugs-are-costly-This-startup-helps-12861674.php. Accessed May 8, 2018.
• Surescripts. Real-Time Prescription Benefit. Surescripts website. http://surescripts.com/enhance-prescribing/benefit-optimization/?modal=real_time_prescription_benefit. Accessed May 8, 2018.
• E-Prescribing Overview. Kareo website. https://www.kareo.com/e-prescribing. Accessed May 8, 2018.