Patients want to talk about their out-of-pocket costs – can real-time benefit tools help?

Imagine you are a primary care clinician seeing Ms. Smith, a 75-year-old woman who is retired and on a fixed income. She has a history of diabetes, heart failure, chronic obstructive pulmonary disease, and hypertension. She is enrolled in a Medicare Part D drug plan, but it is not very generous, with high copays for her medications. Despite taking 8 medications per day, her diabetes and blood pressure are not very well-controlled. So you tell her that you would like to prescribe two new medicines: one for diabetes, semaglutide and the other for blood pressure, amlodipine. “Ok, doc” she says. “But, how much will they cost me when I pick them up at the pharmacy?”

Until recently, the answer to that question would have been quite difficult to find. A clinician or their staff might call a community pharmacist to request coverage information and/or a cost estimate after sending in the prescription and before the patient leaves the clinic. But doing this takes additional time that clinic staff and pharmacists often cannot spare. So, as we described in a recent qualitative study, clinicians might instead “have the patient go back to the pharmacy, see how much that one costs, and then call us back.”¹ Alternatively, a motivated clinician could look up the price of each medication,² find a summary of the patient’s pharmacy benefits, determine each medication’s drug tier and associated cost-sharing requirements, and then calculate the patient’s out-of-pocket costs. But based on a national survey of US physicians, over three quarters would likely get some aspect of that calculation wrong.³

As shown by Mattingly and colleagues,⁴ many patients with chronic medical conditions want access to accurate cost information as well as compassionate cost-of-care conversations with their clinicians. This is an important patient population, with a significant need for accurate cost information. Approximately 70% of patients seen in primary care have multiple chronic conditions and take ≥4 medications on a regular basis.⁵ According to a 2019 Kaiser Family Foundation survey, 35% of patients taking ≥4 medications have trouble affording at least some of them.⁶ The result is predictable: adherence declines,^7,8 potentially leading to functional decline, hospitalization, or even death.⁹ So it makes sense that 84% of surveyed patients report wanting to discuss the financial tradeoffs of their medical decisions with their clinical providers.¹⁰ In fact, patients’ trust in their clinicians may increase when they are able to have frank conversations about costs during clinic visits.¹¹

Real-time benefit tools (RTBTs) are intended to make out-of-pocket medication costs more transparent and thus foster more informed cost-of-care conversations. Since January 2021, the Centers for Medicare and Medicaid Services (CMS) require that all Medicare Part D plans make RTBTs available to their enrollees via at least one electronic health record (EHR) system.¹²

As a result, when Ms. Smith asks you for the price of semaglutide and amlodipine, you now have the option to open up a tool that estimates her out-of-pocket costs, accounting for her insurance plan, drug tier, preferred pharmacy, and even preferred drug formulation (e.g., oral vs subcutaneous). RTBTs can also provide cost estimates for lower-cost medications in the same therapeutic class, when available. Health systems can tailor their RTBTs within certain constraints. At some institutions, clinicians must query the RTBT to obtain cost estimates for the drugs they intend to order as well as any lower-cost alternatives. At others, a window containing cost estimates alerts clinicians right after they click to sign their orders. Institutions can select the criteria that prompt RTBT alerts, including: price thresholds (e.g., any price above $10); potential savings (e.g., difference in price of $2 or more); estimates at pharmacies other than the one listed as the patient’s preferred pharmacy; and the order in which medications are listed.

So far, two published studies have evaluated the impact of RTBT use on patients’ medication fill rates and out-of-pocket costs. Bhardwaj and colleagues found that among 10,676 medication orders sent to a hospital-based pharmacy, patients were more likely to pick up prescriptions when an RTBT had been used (rate ratio 1.10; 95% confidence interval [95%CI] 1.06, 1.16).¹³ Desai and colleagues randomized clinics in one large academic health system to RTBT alerts vs no RTBT alerts and evaluated the out-of-pocket costs of 36,419 medication orders for which a lower-cost alternative was available. Costs were 11.2% lower (95%CI −15.7%, −6.4%) for medication orders sent from clinics randomized to RTBT alerts.¹⁴

The accompanying article by Mattingly and colleagues⁴ is the first to qualitatively assess patient perspectives of real-time out-of-pocket price transparency tools. The authors conducted qualitative interviews of a diverse group of patients to evaluate their views of cost-of-care conversations and the role that RTBTs might play in facilitating them. The findings from this article, as well as the same group’s previously published article on clinicians’ perspectives of RTBTs,^4,15 suggest that several important actions should be taken to ensure that RTBT use is practical and helps improve patient care, especially for complex patients like Ms. Smith.

1. Clinicians should be trained to discuss costs with patients.

Everson and colleagues found that clinicians have positive views of RTBTs and envision switching to lower-cost medications when possible and appropriate.¹⁵ Cost estimates could be useful even when lower-cost alternatives are not available, because they might help patients and clinicians have more informed discussions of the financial implications of their decisions.¹⁵ Mattingly and colleagues’ findings illustrate that RTBT use and cost-of-care conversations should be tailored to each patient’s circumstances, including their desire to discuss costs, their financial situation, the importance they place on costs when making medical decisions, and prior positive and negative experiences with cost-of-care conversations.⁴ Clinicians could be given access to scripted language or training modules that would help them incorporate out-of-pocket costs into complex clinical decisions when appropriate.¹⁶

2. Clinicians should have additional time for cost-of-care conversations.

Both patients and clinicians worry that RTBT use will prolong clinical encounters and/or take time away from other important clinical matters.^4,15 Prior analyses of audio-recorded encounters have found that cost-of-care conversations typically last only one or two minutes,¹⁷ but these analyses were conducted prior to the existence of RTBTs. Now that real-time cost information is available, cost-of-care conversations may take longer and may be more nuanced, as clinicians and patients discuss the tradeoffs of various medications with varying cost, efficacy, and side effect profiles. Clinicians should be given dedicated time to review out-of-pocket costs with their patients during clinic visits. While this goal may not be currently feasible in most settings, reimbursement structures could be altered to provide additional time. For example, billing codes for cost-of-care conversations could be introduced, similar to those used for advanced care planning.

3. RTBT estimates must be accurate.

Inaccurate cost estimates could damage patients’ trust in their physicians.⁴ Only one study so far has evaluated the accuracy of RTBT cost estimates. In that study, Bhardwaj and colleagues compared RTBT estimates in one health system to the amount that patients actually paid for their medications.¹⁸ RTBT estimates were accurate for 98% of prescriptions. The sample was limited to medications that were sent to the health system’s pharmacy, however, so the accuracy of RTBT estimates at outside pharmacies is unknown. Further research is needed to ensure that patients and clinicians can trust the estimates they see during clinic visits.

4. RTBTs should provide a monthly estimate for the full medication regimen.

In their current format, RTBTs do not provide cost estimates for medications that patients are already taking. In addition to providing estimates for new medications, RTBTs should provide estimates of total monthly medication costs, so that patients can put their new medication costs into context and adjust their monthly budgets accordingly.

5. RTBTs should provide an annual cost estimate for each medication.

Out-of-pocket costs may fluctuate widely throughout the year. A medication that is estimated to cost $500 in January may cost $20 once the deductible has been met and $0 after the out-of-pocket maximum has been met. With the passage of the Inflation Reduction Act, patients enrolled in Medicare Part D plans will soon pay a maximum of $2,000 per year for their medications. In 2023, roughly 1.4 million Medicare enrollees are expected to meet this threshold.¹⁹ If RTBTs provided an estimate of total annual costs for each medication, patients would be better equipped to plan for the year ahead.

6. Health systems should engage clinicians and patients to find the most intuitive RTBT workflow.

Clinicians have expressed concern that RTBT alerts may interrupt their workflow too much or at inappropriate times, decreasing their utility and causing alert fatigue.^15,20 As the main users and beneficiaries of RTBTs, patients and clinicians should have a seat at the table when health systems decide what information their RTBTs present and when that information is presented.

Access to point-of-care out-of-pocket price transparency has the potential to remove what has long been a major barrier to informed cost-of-care conversations.²¹ As Mattingly and colleagues illustrate so well, much more work needs to be done to ensure that RTBTs are as useful as possible for patients with chronic illnesses and as usable as possible for the clinicians who care for them.