Patients and pharmacists alike are feeling impacts of soaring medication costs
When Okwudili Ahiligwo opened Bidwell Pharmacy in 2007, the role of a pharmacist was a lot different than it is today. In fact, it’s probably the role you’d expect a pharmacist to play.
Ahiligwo is a native Nigerian who moved to Chico in 1999 with his wife, a Belgian he met while living in Europe. He spent his early years in the profession focused on medicines. He’d ensure patients received the correct drug and amount prescribed by the doctor; that a newly prescribed medication did not pose a risk of harmful interaction with something else the patient was taking, and that he was available to provide advice and information.
He still does all of that. Increasingly, though, he and other pharmacists also must play the roles of accountant, investigator, mediator and sometimes even benefactor.
Insurers vary wildly on which drugs they cover. Doctors rarely know whether the “formulary” for a patient’s health plan includes a particular medicine; these drug lists change, as do coverages. Even a doctor who wanted to make a medical choice incorporating economics would be hard-pressed to do so.
When arriving to pick up prescriptions, patients often don’t know what price tag awaits. The burden of explaining—or intervening with insurance companies—falls predominantly on the pharmacist.
“I will tell you the truth; that’s not what I came in for when I opened,” Ahiligwo said. “We have these different hats. The problem is the time that it’s taking—I can’t tell you how much time we put in. Most people don’t see it.
“It’s not the science of pharmacy anymore, it’s just dealing with the money part.”
Moments before saying that on a recent afternoon, Ahiligwo spent 10 minutes trying to help a patient who expressed surprise at the $75 cost of her medication. He already had tried to find a discount plan or manufacturer’s coupon. With neither of those available, he offered to reduce the price. Instead, she decided to ask her physician for free samples and left without her medicine.
“Most people don’t know what I did there: I cut down my own pay to accommodate that,” Ahiligwo said. Other customers have accepted his offer. “I would rather make less to make sure that somebody gets their prescription.”
The high cost of prescription drugs got national attention last month when news broke that the price for the EpiPen, an emergency injector prefilled with epinephrine to combat a serious allergic reaction, had skyrocketed after a corporate merger.
Fact is, Americans have been paying ever-increasing amounts for all sorts of medications.
As senior vice president for Connecture, a company that designs health information systems, including for PBM (pharmacy benefit manager) firms, Jim Yocum says that not only have prices exceeded the U.S. Bureau of Labor Statistics’ Consumer Price Index for the past two decades, many patients also pay more “because of the way that medical benefits are now structured with larger deductibles and higher percentages of cost-sharing specifically for prescription drugs.”
Unlike other countries, “by and large the government here does not set prices or negotiate prices,” he continued. “There’s less bargaining power here in the U.S. because our buyers of these drugs are fragmented compared to the negotiating power of a country.”
U.S. patent laws—particularly the Biologics Price Competition and Innovation Act of 2009, governing biological-based remedies—allow manufacturers to protect their brands for significant periods of time before generic alternatives can come to market. Moreover, Yocum said, the U.S. Food and Drug Administration accepts outside reports when making evaluations about a medication’s effectiveness, even from competitors, “so the other side gets a vote in this, which in most countries would be seen as unusual.”
Even when a generic drug becomes available, not every physician may wish to prescribe it.
“Some of the doctors like the brand names,” Ahiligwo said. “[They feel] some of the generics are not as good as the brand name; if you can get the brand name for the price of getting generic, why don’t you go for it?”
Indeed, not all generics are cheaper, or even priced equally. Insurers make contracts with drugmakers and may favor particular manufacturers over others.
What can patients do? Both the pharmacist and IT expert agree: Get informed.
Yocum suggests checking your insurer’s website. Whether your plan is public or private, chances are good that your insurer has a pharmacy benefit manager—a firm in charge of negotiating prices, etc.—associated with it. Connecture serves nearly half of the country’s PBMs with a drug-comparison interface; other PBMs offer online programs with differing amounts of data.
“Our tools are designed to help close the communication gap sometimes between the pharmacy, which is going to tell you what it’s going to cost, and the insurance company, which is going to tell you how much they’re going to cover and what you’re going to cover—and then what the doctor’s understanding of what these costs are,” Yocum said.
Connecture’s system allows a patient to research not just a medication’s cost and how it’s covered, but also if a specific pharmacy offers a lower copay and whether a cheaper alternative exists. Patients then can speak with their doctor or pharmacist.
Ahiligwo has those discussions. Even without consultation, when he finds a prescription is expensive or not covered, he’ll call physicians to inquire about switches.
The effort is intensive but worthwhile for everyone involved.
“Cost of drugs is one of the big determinants in adherence to a drug regimen,” Yocum said. “The cheaper the drug is, the more likely the patient is going to be able to afford it, stay on it and gain the benefit of that drug.”