Medication affordability: A new vital sign to screen for in primary care

Medication affordability is a major issue in the United States. CMS estimates that U.S. prescription drug expenditure was $335 billion in 2018, and recent studies have shown that the cost of prescription drugs is surging faster than any other medical service or good.

Access to affordable medicines is vital to the health of our communities and critical to improving our nation’s health outcomes. As primary care physicians, we work tirelessly in the clinic each day to care for our patients, and recurrently hear stories of our patients’ inability to afford their lifesaving medicines. This, unfortunately, is not unique. Patients routinely forgo filling prescriptions or skip doses because their medicines are too expensive. As physicians and members of the larger health care team, we must begin routinely asking patients if they have difficulty affording their medicines during each clinic appointment by establishing medication affordability as a new vital sign and having protocols in place to address this issue.

A Kaiser Family Foundation 2019 national poll revealed that nearly one in four people in the U.S. had difficulty affording their medications. Since then, many people have lost their jobs and employer-sponsored health insurance and are facing a number of other financial constraints due to the COVID-19 pandemic. This likely means that many more people cannot afford to pay for their medications.

In the primary care setting, insulin and inhalers represent some of the most commonly prescribed medications that patients have the greatest difficulty affording. According to an article from Kaiser Health News, one in four people with diabetes reports having rationed their insulin. This can result in patients developing severe complications of diabetes, which are much more costly for patients and the health care system to address. Even worse, rationing insulin can cause otherwise preventable deaths.

It is important to note that when insulin was discovered, the patent was sold to the University of Toronto for just $1 so that the drug would be available to everyone who needed it. Yet we have seen astronomical increases in different formulations of insulin over the past several years. For example, the cost of Humalog insulin (Eli Lilly) increased 700% from 1996 to 2016. Other forms of insulin have seen equally dramatic price increases.

Several states have moved to cap monthly out-of-pocket insulin expenses for people with diabetes. While at the direct patient level this appears helpful because it limits the amount of money patients pay out of pocket, it does nothing to lower the list price of the medication. Thus, this will not necessarily decrease overall prescription drug expenditure in the U.S. We must, therefore, develop comprehensive drug pricing policy reform so that all patients across the country can afford their medications, regardless of insurance or financial status.

Screening for medication affordability

As part of my current National Copello Health Advocacy Fellowship with Doctors for America working on prescription drug affordability, I had an opportunity to design a quality improvement project at a Connecticut community health center to screen patients for their ability to afford their medications. For this project, within our clinic, we designed a pilot intervention and, with the help of our medical assistants and nurses, routinely asked adult patients at the clinic whether they had difficulty affording their medication since their last visit or in the past year during the vital sign assessment. We also surveyed internal medicine residents and faculty physicians in the clinic to assess their clinical practice adjustments when treating patients unable to afford their medications, and then briefly interviewed local pharmacies on additional barriers patients face in affording their medications.

At our community health center, we found that of the 50 patients initially interviewed, 16% could not afford their medication since their last clinic visit, and 22% could not afford their medication within the past year. All our data were collected just prior to the start of the COVID-19 pandemic, so our findings likely represent an underestimate of those currently unable to afford their medications.

We also found that 100% of internal medicine residents and faculty physicians who were surveyed wanted to know whether patients could afford their medications during the clinic visit in order to address this issue during the appointment, building support for establishing medication affordability as a new vital sign.

In light of this — and because medication affordability is known to affect adherence — we need to start routinely asking our patients if they have difficulty affording their medications during the clinic intake process and normalize the collection of this information.

In addition, we need to integrate the medication affordability question into the electronic medical record (EMR), ideally within the medication reconciliation section of the chart. That way, if there is a positive response, the EMR will automatically alert the interprofessional care team, who can then act on this information during the visit. If it is not possible to develop an automatic alert, then there should be a system in place where the medical professional who conducts the intake process informs the physician directly that the patient is having a hard time affording their medications. Then medications can either be changed during the appointment, or the care team can help determine what drug pricing assistance the patient may be eligible to receive.

Since our clinic is a federally qualified health center, our low-income uninsured patients may qualify for 340B drug pricing assistance. To receive 340B pricing, patients must go to specific pharmacies participating in the program. However, not all patients are aware of this. For example, we had one patient who said he paid $700 to fill two prescriptions at his local pharmacy. If he had gone to a 340B pharmacy, the prescriptions would have cost only $16.

In the past, pharmacies were restricted by what was essentially a “gag rule” preventing them from telling patients if the cash price of a medication was cheaper than the insurance price. Congress recently banned that restriction; however, not all states require pharmacies to automatically tell the patient this information. A lot of pharmacies might do this, but not all do. It is, therefore, important for physicians to tell patients to always ask the pharmacy whether it would be cheaper to pay for the medication without going through insurance, as the price of a medication when going through insurance may vary depending on a patient’s deductible, co-pay and/or co-insurance. Physicians can also help patients access prescription discount cards and coupons. GoodRx is an excellent free resource for this.

During our work, we also found that pharmacies are charged a processing fee by insurance companies each time they run a prescription to check a patient’s out-of-pocket cost, often making it impossible for insured patients to determine what the cost of their medication will be prior to picking it up at the pharmacy. Working to abolish these fees and improve transparency by allowing pharmacies to check the insurance price of a medication for free so that a patient can decide if it is cheaper to use insurance or to pay cash or use a discount coupon for the prescription represents an opportunity for future advocacy.

Advocating for change

Medicare is one of the largest payers for prescription medications in the U.S., but it is currently not allowed to negotiate drug prices. This is a major issue, and it is essential that we advocate for legislation supporting Medicare drug price negotiation, such as the “Elijah E. Cummings Lower Drug Costs Now Act” (H.R. 3 – 116^th Congress), which has thus far only passed the U.S. House of Representatives, as well as the House-introduced “Medicare Negotiation and Competitive Licensing Act of 2019” (H.R. 1046 – 116^th Congress).

More recently, the “Make Medications Affordable by Preventing Pandemic Price gouging Act of 2020” (H.R. 7296 – 116^th Congress) was introduced to protect patients from being price-gouged on COVID-19 treatments developed through taxpayer-funded research. The federal government has poured enormous amounts of money into the development of potential COVID-19 treatments since the start of the pandemic. These are all taxpayer-funded research initiatives and trials, and so it is important to ensure that taxpayers are not charged a second time when they actually need the medication. It is also important to advocate for the affordability of other medications currently on the market that were developed through taxpayer-funded research and later sold to pharmaceutical companies.

All physicians — regardless of specialty — have an obligation to support patients by advocating for comprehensive prescription drug pricing policy reform at all levels of government so that our patients are able to access the medications they need.

PCPs are particularly equipped to advocate on behalf of patients for affordable medications. We, as PCPs, hear our patients’ stories every day. We know the challenges our patients face and what is happening in our clinics and on the ground. As physicians, we hold positions of power in society. We must give voice to our patients by developing strong relationships with policymakers and communicating our patients’ stories to those developing legislation at the federal, state and local levels, so that we may promote policy reform to comprehensively meet the needs of our patients and improve health outcomes.

Addressing the issue of the high costs of prescription medications in the U.S. is a bipartisan issue, and the stakes to make medications affordable have never been higher. In the United States, we know that when we call the fire department, they will show up in an emergency, will not demand payment before providing life-saving assistance, and will not send a financially catastrophic bill to a family after saving their home from a fire. But at the same time, we have come to accept that when a child of a single parent working two jobs without benefits to support the family requires expensive lifesaving medications, sometimes that parent will need to foreclose on their home to pay for the medications that will save their child. We must stop this acceptance and change our nation’s expectations.

References:

Cleary EG, et al. Proc Natl Acad Sci USA. 2018;doi:10.1073/pnas.1715368115.

Congress.gov. H.R.1046 — Medicare Negotiation and Competitive Licensing Act of 2019. https://www.congress.gov/bill/116th-congress/house-bill/1046/text. Accessed Oct. 26, 2020.

Congress.gov. H.R.3 — Elijah E. Cummings Lower Drug Costs Now Act. https://www.congress.gov/bill/116th-congress/house-bill/3. Accessed Oct. 29, 2020.

Congress.gov. H.R.7296 - MMAPPP Act of 2020. https://www.congress.gov/bill/116th-congress/house-bill/7296/text. Accessed Oct. 26, 2020. 

CorpWatch. Eli Lilly Raised U.S. Prices Of Diabetes Drug 700 Percent Over 20 Years. https://corpwatch.org/article/eli-lilly-raised-us-prices-diabetes-drug-700-percent-over-20-years. Accessed Oct. 29, 2020.

GoodRx. Prices for Prescription Drugs Rise Faster Than Prices for Any Other Medical Good or Service. https://www.goodrx.com/blog/prescription-drugs-rise-faster-than-medical-goods-or-services/. Accessed Oct. 29, 2020.

Healthline. Pharmacists Will Now Be Able to Help You Save Money on Prescriptions. https://www.healthline.com/health-news/how-your-pharmacist-can-now-save-you-money-on-prescriptions. Accessed Oct. 29, 2020.

Indivisible. H.R. 1046: Act Now to Bring Drug Prices Down. https://indivisible.org/resource/hr-1046-act-now-bring-drug-prices-down. Accessed Oct. 26, 2020.

Kaiser Family Foundation. Poll: Nearly 1 in 4 Americans Taking Prescription Drugs Say It’s Difficult to Afford Their Medicines, including Larger Shares Among Those with Health Issues, with Low Incomes and Nearing Medicare Age. https://www.kff.org/health-costs/press-release/poll-nearly-1-in-4-americans-taking-prescription-drugs-say-its-difficult-to-afford-medicines-including-larger-shares-with-low-incomes/. Accessed Oct. 26, 2020.

Kaiser Health News. Insulin’s Steep Price Leads To Deadly Rationing. https://khn.org/news/insulins-high-cost-leads-to-deadly-rationing/. Accessed Oct. 26, 2020.

Kuwahara RK, Marhatta A. “Prescription Drug Affordability as a New Vital Sign: Strategies to Routinely Assess Medication Affordability at a Federally Qualified Health Center.” Presented at: The American College of Physicians Connecticut Chapter Meeting; Oct. 18, 2020.

U.S. News & World Report. Why Are Insulin Prices Still So High for U.S. Patients? https://www.usnews.com/news/health-news/articles/2019-11-07/why-are-insulin-prices-still-so-high-for-us-patients. Accessed Oct. 29, 2020.