It used to be so easy to prescribe. Decide what I wanted to do, grab a pad from my pocket, scribble about six to 10 words and numbers in cryptic language, hand the paper to the patient and move on to the next patient.
That was the way my colleagues and I wrote prescriptions when we were trained, not all that long ago. Of course, that approach had many challenges and often led to downstream rework, poor outcomes and frustrated, ill-informed patients. While some of those challenges have been solved with e-prescribing, the actual process of choosing the best prescription for the patient has become significantly more complex.
Today, with advances in science that have created highly effective but costly drugs and the empowerment of patients to participate in a shared decision process, there are four forces to consider when choosing the optimal medication:
- The provider’s clinical judgment
- The patient’s choice
- The cost to the patient
- The administrative burden on the provider and practice.
While this adds more complexity to the medication process, a provider and a patient can efficiently choose the right prescription at the point of care with the right information and technology.
The provider’s clinical judgment
The moment when a physician analyzes information from the patient’s chart, the diagnostic tests and the patient’s care history to make a treatment decision during the visit is sacred. Today, that moment should be supported by complete information and advanced decision tools yet unencumbered by the worry of commercial influence that may not be in the patient’s best interest. This is the crucial moment that provides the best choice or choices of therapies to the patient with the goal of delivering the highest probability of an optimal outcome.
This force is unchanged from the beginning of medicine, albeit today there is far more information to digest and more potential options for therapies. Furthermore, the provider cannot simply end the involvement when a therapy is chosen; with value-based care and a focus on outcomes, the provider and that provider’s support team must remain vigilant about the patient’s fulfillment of the prescription and the ongoing adherence to the treatment plan, especially for diseases with high morbidity and mortality.
The patient’s choice
In virtually every medication decision, there is a choice — a choice balancing risk and benefits, a choice between treatment and watchful waiting, or a choice between two or more therapeutic options. Often, the choice is not obvious — a powerful therapy may have significant risks, an infection may or may not resolve without treatment. With shared decision-making, a patient should be fully informed and work with his or her provider to make an optimal choice. Fortunately, unlike during my training, there is a wide range of resources available to educate patients before and after their interaction with their provider,1 and the concepts of shared decision-making are adopted by most providers as a foundational approach to deliver care.
Case study: Charlotte Dermatology
Practice leaders at Charlotte Dermatology, with 50 employees in the practice, knew their patients wanted medications they can afford, says Gary B. Slaughter, MD. “They’d find out how much their prescription cost at the pharmacy level, which is thankfully changing,” Slaughter says. “We had patients who would have sticker shock at the pharmacy counter if the cost was too high — they’d either abandon their prescription or they’d change the prescription at the pharmacy counter.”
The problem could go unnoticed because doctors know cost is important but “it’s challenging to navigate how much it will cost or where the patient should go to fill their prescription,” Slaughter says.
Toward the end of 2018, the practice began using a prescription pricing tool built into the EHR it uses.
“Now we can see how much the prescription costs right … at the point of prescribing,” Slaughter says. “It saves both time and money for the patient.”
Slaughter says the practice has had a positive experience with this EHR tool, and that it has the potential to influence how patients choose a provider. “For patients who can pick Dr. A, who uses a prescription price transparency tool, or Dr. B, who doesn’t … the patients are picking Dr. A,” he says. To that end, Slaughter says he’d like there to be greater awareness that a prescription price transparency tool exists for providers. “It trumps dealing with prior authorization at the pharmacy counter,” Slaughter says.
The cost to the patient
The cost of medications today ranges from a few dollars a month to tens of thousands of dollars per year. Medication cost increases have required payers to enact checks and balances to minimize the economic impact while maintaining quality outcomes. For providers, the formulary flag in most EHRs has helped indicate prescriptions best aligned with the patient’s insurance plan; however, that flag is a coarse indicator that does not take into consideration the patient’s deductible or different delivery options.
When the most economical choice is not selected, at best the patient pays a little more money than an alternative; at worst, the patient goes to the pharmacy, hears the price and simply chooses to not fill the prescription. This is often a source of rework for the physician and the provider’s practice. When the patient is surprised with the cost, the pharmacist may call the practice back to ask for an alternative. Many studies have shown a direct correlation between medication cost and prescription abandonment. For example, prescriptions over $50 in copays were 4.7 times more likely to be abandoned compared to prescriptions with no copay.2
Today, real-time price transparency tools can help providers and patients make an optimal choice by displaying the out-of-pocket cost to the patient as soon as enough information — typically the drug, dose, quantity and days’ supply — is captured in the EHR. With these tools, there are three factors to consider:
- What is the source of the information? The ideal source for pricing information is directly from the patient’s pharmacy benefit manager or insurer. Only through that model can the price displayed take into consideration the patient’s deductible and personal out-of-pocket spend to date, so it can have the most up-to-date information sourced in the same manner as when the pharmacy runs the claim.
- Where is the information presented in the provider’s workflow? The best decision support tools are in the EHR as part of a pre-existing workflow. Any time a provider must be trained to leave a current process or leave the EHR, the likelihood that the provider will use a tool dramatically decreases. The ideal approach presents the information immediately and directly in the prescribing process in the context of the EHR’s prescribing workflow.
- What are the alternatives available to the provider? While the cost of the prescription is helpful, the real value is derived when alternatives are easily chosen that achieve the same therapeutic outcome at a lower cost. The alternatives may be a different quantity (e.g., 90 days versus 30 days), a different delivery mechanism (mail order or retail), or a different medication in a similar drug class. Importantly, those therapeutic options should be vetted with evidence-based evaluations and have full transparency in terms of how those alternatives were selected and presented.
Price transparency tools also enhance the shared decision-making process; providers can show the options displayed on the EHR screen to the patient in the exam room and allow the patient to provide input into the best choice. While early, these tools have shown savings of tens to thousands of dollars on a single prescription.3
With the cost of certain medications, the prescription is not complete when the prescriber completes the prescription in the EHR. Costly prescriptions often require prior authorizations — additional questions that add time and cost to the practice. Using price transparency tools, providers can often see options that achieve the same therapeutic outcome but do not require prior authorization. With patient-specific information, the uncertainty of the need for prior authorization is eliminated — for example, if prior authorization exists, the price transparency tool does not display a prior authorization required icon. If prior authorization is still necessary, it can be triggered in the EHR for the staff to complete immediately, prior to the patient arriving at the pharmacy.
Making the complicated simpler
For many good reasons, there is no going back to the days of paternalist decision-making and paper prescription pads. The shared decision-making process is essential to patient care, and the high cost of advanced medications requires checks and balances. Every practice is looking for ways to improve patient and provider satisfaction while eliminating rework and waste. Optimizing the four forces for prescribing can serve as a powerful framework to improve care processes and satisfaction and to assist the provider with impactful decision support tools.
- “Shared decision making.” National Learning Consortium. December 2013. Available from: bit.ly/2yBIKYK.
- Shrank WH, Choudhry NK, Fischer MA, Avorn J, Powell M, Schneeweiss S, et al. “The epidemiology of prescriptions abandoned at the pharmacy.” Ann Intern Med.; 153: 633–640. doi: 10.7326/0003-4819-153-10-201011160-00005.
- “2018 impact report: Prescription price transparency.” SureScripts. February 2019. Available from: bit.ly/2I92pai.