When Mary Kay Gilbert saw her doctor in May for a skin infection on her leg, she wasn't surprised to get a prescription to have an antibiotic cream.
But Gilbert, 54, a nurse and health consultant, was shocked when her physician visited the desktop computer and told Gilbert the medicine would cost $30 on her behalf Blue Cross and Blue Shield plan.
“I was like, 'Wow – that's pretty cool you know that information,'” she recalled telling a doctor in Edina, Minn.
Allina Health, a large Minnesota hospital network to which Gilbert’s doctor belongs, is among an increasing number of health systems and insurers providing real-time drug pricing information to physicians to allow them to help patients avoid “sticker shock” in the pharmacy.
The pricing tool, that is baked into physicians' electronic health record and prescribing system, shows just how much patients pays out-of-pocket according to their insurance and also the pharmacy. It enables the doctor to find a cheaper alternative whenever possible and start the process of getting authorization for any drug, if the insurer mandates that.
The soaring cost of drugs continues to be in the forefront in the growing national debate about revamping U.S. healthcare.
Consumers abandon thousands and thousands of prescriptions each year at the pharmacy, often because of high costs, jeopardizing their health and frequently leading to higher costs down the road, studies show.
Experts say the tool might help consumers – who are facing increasing copayments and higher deductibles – find out about cheaper options within the doctor's office.
Still, doctors happen to be slow to adopt we've got the technology, sometimes because of concerns about getting caught up in long discussions about drug costs. Humana, for example, introduced its drug pricing tool to its network doctors in 2021. Today, less than 10% are using it, company officials said.
But the tool has serious limitations too. Because price negotiations among insurers, drugmakers and middlemen in many cases are highly competitive and secretive, the tools often do not have data for everyone. For example, Allina's works for no more than half its patients. That's because not all pharmacy benefit managers share their data on health plan enrollee costs, and those that do often provide only a fraction of their information.
“It's a chicken-and-egg thing where doctors avoid using it because they do not have the data for those their sufferers, and health plans don't publicize it to physicians because doctors not have the technology in place,” said Anthony Schueth, a health it consultant in Jacksonville, Fla. “It could be a powerful tool if this works, but right now the drivers are not there overall for widespread adoption.”
At a hearing recently, Sen. Martha McSally (R-Ariz.) pressed a top Trump administration health official about why many patients lack access to info on prescription medication prices at their doctor's office.
“This is America. Why can't we have this tool available tool now?” she asked. “The data is available; the information is out there. What exactly is it going to take to achieve this?”
The technology got a boost recently when the Centers for Medicare & Medicaid Services mandated that all Medicare drug plans embed such a tool in their doctors' electronic prescribing system starting in 2021.
The information on what consumers spend out-of-pocket for drugs is provided by pharmacy benefit managers, or PBMs. They are the middlemen that negotiate with drugmakers around the prices insurers covers the medications and which ones the insurers will cover. So a tool's usefulness is undermined when key PBMs are not included in the listings.
For example, a drug pricing tool sold by Arlington, Va.-based Surescripts, that is owned partly by the PBMs CVS Caremark and Express Scripts, includes data from those companies, but not OptumRx, a PBM owned by insurance titan UnitedHealth. And the OptumRX drug pricing tool includes Optum data although not those of Express Scripts and CVS.
Demetrios Kouzoukas, who heads the Medicare program for CMS, said he hopes the program's new drug mandate will spark the industry to provide doctors and patients use of a pricing tool, no matter their insurance.
“What we're hoping and expecting is the fact that you will see a standard that's produced by the – so that the tool is available in all the electronic health records, for all the doctors and all sorts of patients, and spreads even beyond Medicare,” he told McSally in the hearing.
Given the competitive nature of the industry, cooperation doesn't seem to be on the horizon, some industry officials say.
“I don't see any chance that there is a centralized system that will connect all the plans/PBMs with all of the EHR systems currently being used anytime soon,” said Thomas Borzilleri, CEO of InteliSys Health, any adverse health technology company based in North park.
However, the nation's Council for Prescription Drug Programs, a nonprofit group that can help set guidelines for the pharmacy industry, has been working on standards for any drug pricing tool. John Klimek, a senior vice president, predicts that by the coming year doctors across the nation can use the same drug pricing tool to look up all of their patients' drug costs, whatever the insurer.
Even without this type of standard in position, doctors and hospitals have an incentive to use the tool beyond offering a cost-saving service to their sufferers: It can save providers money, too.
For example, Allina, which owns or operates in regards to a dozen hospitals and a large number of clinics in Minnesota and Wisconsin, gets a set fee from some insurers to care for all of a patient's health needs. Therefore the doctors and health system benefit whenever they can reduce costs and improve patients' adherence to taking their medication, said Dr. David Ingham, a medical professional also from Edina, one of 600 primary care doctors at Allina using the tool.
“When we prescribe a more costly medication, we share less revenue in the insurance contract,” he explained.
For example, he noted the tool helped him prescribe inhalers to asthma patients.
“I pulled up one medication I normally use, and it said hello would be $240 out-of-pocket, however it suggested an alternative for $20 that was pharmacologically equivalent. I sheepishly asked the patient which we ought to choose,” he said.
Dr. Norman Rosen, a family physician in Orange, Calif., who's utilized by Providence St. Joseph Health System, is one of 800 doctors at the hospital testing the Blue Shield of California drug pricing tool this season. Based on the first few months of use, the tool is expected to save patients a total of a lot more than $100,000 in out-of-pocket costs this year, based on the companies.
Without the tool, Rosen said, it might be impossible for him to quickly know what medicine is covered by which insurers and what the copays are. He explained he already has saved some patients several thousand dollars annually by changing their blood pressure and diabetes medications.
“It doesn't take a great deal of time, and this can be an essential intervention because one of the fears we've is a patient not implementing their medication since it is too costly,” Rosen said.