Some see it as an eternal struggle: the goodhearted doctor championing the best treatments, no matter the cost, while doing battle against the tightfisted insurance company denying claims for expensive but life-saving medications.
But when you get down to it, their goals often dovetail: the best care for patients at affordable prices.
After all, even if a plan sponsor or insurer picks up part of the tab, the cost of pricey medications may convince them to increase their deductibles or copayments, which will have an impact on future patients.
But at a time of increased concern about the sustainability of benefit plans, what’s the role of the doctor in helping to contain drug costs?
“I do think that physicians have a duty not just to the patient in front of them but to society at large,” says Dr. Peter Ubel, a professor of business, public policy and medicine at Duke University in Durham,
N.C. Just as he uses the strongest antibiotics only for the worst bacterial infections in order to protect public health, he’ll save expensive tests and medicines for occasions when cheaper alternatives aren’t successful. “I go right to an MRI rather than an X-ray, I’m burning through societal resources and that causes harm,” he says of the drawbacks of not keeping costs in mind.
Doctors should also consider the cost of drugs because unaffordable prescriptions lead to greater rates of non-adherence and, therefore, worse health outcomes. A 2016 study from Statistics Canada found that western Canadians with cardiovascular-related conditions who spend at least five per cent of their household income on drugs were three times as likely not to get the necessary medication as those who spend less than that amount.
“If patients can’t afford the medications, they don’t take them and then they don’t benefit from them,” says Dr. Yousuf Zafar, an oncologist and an associate professor of medicine at Duke University.
And that means they’re more likely to call in sick or, if they do make it to the office, work less productively.
While doctors wouldn’t prescribe a drug without making sure the patient understands the possible physical side-effects, they often don’t discuss the financial impacts with them. “To know what the best pill is for somebody, you need to know what they care about,” says Ubel. “And if they care about their out-of-pocket expenses, that might change what you prescribe.” But few doctors know how much their prescriptions cost, he notes.
Comparing drug prices in Alberta
To encourage family physicians to consider the cost of the drugs they prescribe, a group of Alberta doctors and pharmacists publish an annual price comparison guide for common medications. It compares costs for generic medications versus brand-name drugs and explains how much patients pay if they have coverage from Alberta Blue Cross, Indigenous and Northern Affairs Canada or none at all.
“We think there’s a lot of money that can easily be saved without any change in clinical outcomes,” says Dr. Michael Kolber, an associate professor of family medicine at the University of Alberta who co-authors the guide.
The report also points to pill splitting as an effective way to reduce drug costs. The diuretic spironolactone, for example, costs $25 for 90 days’ worth of 25-milligram pills. But the same amount of 100-milligram pills brings the price up to $40, so if patients can split them on their own, the cost would go down to just $10 every three months.
Kolber notes medical schools rarely teach much about drug pricing, something that was the case when he was a student and remains so today. “We actually give our pricing document to all our family residents in the University of Alberta and we’ve just sent them out to all of the University of Calgary residents as well,” he says.
“We are trying to educate our future prescribers. . . . Maybe, going forward, we’ll be a little more informed.”
How industry can educate
Insurers also have a place in the cost conversation. “As private carriers, we need to make sure that the health plans are sustainable,” says Theresa Rose, director of drug management solutions at Medavie Blue Cross.
“So when there are lower costs but equally effective treatments, we look to physicians to have that knowledge to be able to prescribe accordingly.
So it allows us to cover new therapies — and, a lot of the time, more expensive therapies — as we evolve with our private health plan.”
To help physicians understand drug costs, Medavie Blue Cross developed a mobile app called Drug Cost Compare. When doctors type in the name of a medication, they see a list of all drugs in that same therapeutic class, with the results colour-coded to reflect affordability based on the manufacturer’s list price and the province in which the physician works.
For its part, the Alberta School Employee Benefit Plan double-checks prescriptions for specialty drugs treating hepatitis C, multiple sclerosis, Crohn’s disease, rheumatoid arthritis and psoriasis. Those drugs have always required a special authorization form, but there was room for more rigour. “It was basically a check-box system,” says chief executive officer Jennifer Carson.
“If [the doctor] put yes on all of [the categories], then the prescription would be paid.”
Now, the plan asks physicians to explain the patient’s medical history. That way, the plan’s pharmacists can determine whether or not the doctor is prescribing the medication appropriately.
About 40 per cent of the time, the special authorization requests provide the wrong dosage, prescribe double the necessary amount or make other costly mistakes, says Carson. “They want the person to take 24 weeks, instead of 12 weeks, [of] Harvoni for hepatitis C. . . . And so it’s another $100,000 and it’s not what the drug manufacturer is saying is the best protocol and it’s not what notice of compliance was given on.”
The complexities of switching
In the United States, the University of Pennsylvania Medical Center’s health plan worked with medication management and delivery company MedVantx Inc. to stock samples of generic drugs in doctors’ offices. “Our providers really do appreciate the ability to initiate patients on medications that they’ll ultimately be able to afford when they go to the pharmacy,” says William Shrank, the plan’s chief medical officer in Pittsburgh. “And we think that’s been a good strategy to reduce some of those barriers around getting started on generic drugs.”
While free samples of brand-name drugs are useful for a few weeks, patients — and their insurers — may face higher costs overall. That’s because while pharmacists can dispense a generic version of a branded medication, in most provinces, they can’t perform therapeutic substitution for a cheaper drug in the same therapeutic class because the active ingredients differ.
When it comes to generic substitution, Joe Farago, executive director of health-care innovation at Innovative Medicines Canada, emphasizes the importance of making the safest, most effective treatment decisions and considering patient preference.
Doctors also have a role in informing patients about cost options besides turning to generics, he notes.
“I think it goes beyond that because patients could also reduce the cost of their prescriptions by shopping around,” says Farago. “[Physicians should tell patients] that if they get their prescriptions filled at different pharmacies, they can actually find a lower cost, simply because some pharmacies have lower markups and lower dispensing fees, and it is one way to reduce their costs. I think physicians, in helping educate their patients, can significantly help reduce some of the costs.”
There’s also the question of biologic drugs versus biosimilars. When it comes to that issue, Jim Keon, president of the Canadian Generic Pharmaceutical Association as well as Biosimilars Canada, notes that while pharmacists can’t substitute prescriptions for a biologic drug with a biosimilar, “some insurance plans have made biosimilars the product of choice for new patients.” Keon expects that as more biosimilars enter the market, more plans will include such provisions.
Of course, drug replacement becomes more complex when dealing with biologics and biosimilars, says Zafar. “We suspect the effectiveness and safety of those drugs is the same, but I think the jury is still out in many cases,” he says, referring to questions about production and safety standards. “If there is a biosimilar available and we can be assured of the quality of production and we can be assured of the equivalent safety and effectiveness, it’s worth considering.”
Perceptions at play
Another issue at play is some doctors’ perceptions of generics. In a systematic review of randomized trials studying the efficacy of generic versus branded cardiovascular drugs, “we found no statistically significant difference . . .,” says Shrank.
“However, we also looked in those same journals at the editorials that were published, and the over- whelming majority of them raised concerns about generic efficacy and safety.”
In a 2011 study published in the Annals of Pharmacology, Shrank found a major source for physicians of information about drugs came from medical journals. It also determined that almost a quarter of U.S. physicians thought generics were inferior, with half of them expressing concerns about their quality.
At the same time, generic manufacturers may not necessarily have a relationship with doctors that allows them to counter those perceptions.
“It’s not that we ignore doctors, but when generics come to market, it’s 12 to 15 years after the original brand product has been introduced,” says Keon. “Doctors are very familiar with the product and don’t need the same level of detailing and education as they do when the product is brand new.”
What a young doctor should know
Of course, it’s not a physician’s role to know the cost of every pill and the coverage options of every plan. Family doctors already need to know a great deal about “an infinite number of conditions,” says Mike Sullivan, president of Cubic Health Inc. in Toronto.
“So you can’t blame them for, No. 1, not knowing what the cost of drugs are and No. 2, not knowing all the different drugs that are available in each different class. They’re not the drug therapy experts. They’re the diagnostic experts and the treatment plan experts.”
An ideal solution, he says, involves linking electronic health records with patients’ plan details so doctors can see what their benefits cover before they write prescriptions. But since such programs don’t yet exist outside of pilot projects, plans should provide members with apps and other technology-related tools in the meantime that allow them to explain their situation to their prescribers.
If both physicians and patients can find cost and eligibility information through provider or sponsor apps during their appointments, they can deal with any cost questions more easily. “It can create a dynamic conversation right in the physician’s office,” says Rose.
Karen Kristensen, senior manager of pension and benefits at EPCOR Utilities Inc. in Edmonton, agrees on the need to make information available. “We’re all in this together,” she says. Plan sponsors should make sure members understand the plan’s parameters, from drug exception forms to lifetime caps, and employees should flag any cost concerns with their doctor, she notes. “I do see it as a kind of triangle with the employer, the employee/patient and the physician.”
Sara Tatelman is an associate editor at Benefits Canada.
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